Retroperitoneoscopic renal surgery in children: our experience.

BACKGROUND: Laparoscopic renal surgery has become an accepted approach for benign disease in adult and pediatric urology. We present our experience in renal laparoscopy in infants during the past 5 years and evaluate our series to establish the safety and efficacy of such procedures in children. MATERIALS AND METHODS: From August 1999 to December 2004, we performed 32 renal laparoscopic procedures on 31 children aged 12 months to 16 years (mean, 42 months). Twenty-seven patients underwent unilateral retroperitoneal nephrectomy; 1 child with Denis Drash syndrome underwent transperitoneal bilateral nephrectomy; 2 children underwent renal cyst unroofing; and 1 child with lymphoma underwent retroperitoneal laparoscopic renal biopsy. Indications for surgery were: renal function <9% in cases of unilateral nephrectomy; the prevention of renal neoplastic changes in the patient with Denys-Drash syndrome; symptomatic large renal cysts; and suspected lymphoma not diagnosed with a previous percutaneous biopsy. RESULTS: All procedures were completed laparoscopically. In 6 cases, the accidental opening of the peritoneum did not require conversion to open surgery. Intraoperative blood loss was minimal. One patient who underwent a retroperitoneal nephrectomy required a blood transfusion for postoperative bleeding into the retroperitoneal space. Twenty-four of 27 unilateral retroperitoneal nephrectomy patients were discharged on postoperative day 2. Mean follow-up was 30 months (range, 6-64 months). Cosmetic results were excellent in all patients and no long-term complications have been encountered so far. CONCLUSION: Laparoscopic urologic surgery may be performed in children with minimal morbidity, minimal postoperative discomfort, improved cosmetic results, and a short hospital stay.

Natural history of vesicoureteral reflux associated with kidney anomalies.

OBJECTIVES: To evaluate the cystographic follow-up of patients with multicystic dysplastic kidney (MCDK), renal agenesis, and renal ectopia with associated primary vesicoureteral reflux (VUR). METHODS: Patients with primary associated VUR (grade 2 or more) and with a minimal follow-up of 24 months were included in this study. RESULTS: Of the children with renal agenesis, 24% had VUR. The median grade of VUR was significantly greater in the boys than in the girls (4 versus 2, respectively; P < 0.05). All girls and 34% of the boys experienced spontaneous resolution 1 year after diagnosis; 66% of the boys required operative treatment. Of the patients with MCDK, 16% had VUR. The median grade of VUR in the kidney contralateral to the MCDK was greater in the boys than in the girls (3.5 versus 2, respectively; P = 0.06). All girls and 60% of the boys had spontaneous resolution 1 year after diagnosis; 40% of the boys underwent operative treatment. Of the children with renal ectopia, 30% had VUR. The median grade of VUR for the refluxing unit was significantly greater in the girls than in the boys (3 versus 2, respectively; P < 0.05). Spontaneous resolution of VUR was observed in all boys (66% at 1 year) and in 40% of the girls; 60% of the girls required operative treatment. CONCLUSIONS: Spontaneous resolution of VUR can be anticipated in girls with MCDK or renal agenesis and in boys with renal ectopia. These data can be used in planning the proper follow-up schedule for babies with a kidney anomaly detected by ultrasonography.

Long-term outcome of vesicoureteral reflux associated chronic renal failure in children. Data from the ItalKid Project.

PURPOSE: The nephropathy associated with vesicoureteral reflux (VUR) is one of the leading causes of chronic renal failure (CRF) in children. We describe the clinical course of the disease based on information available in the ItalKid Project database, and analyze the predictive value of baseline renal function, age at VUR diagnosis and urinary protein excretion in relation to the risk of progressive renal failure. MATERIALS AND METHODS: As of December 31, 2001 the registry included a total of 343 patients (261 males) with a diagnosis of primary VUR, which was the leading single cause of CRF, accounting for 25.4% of all patients with CRF. RESULTS: The estimated risk of end stage renal disease (ESRD) by age 20 years was 56%. The patients with a creatinine clearance (Ccr) of less than 40 ml per minute at baseline had an estimated 4-fold greater risk of ESRD developing in comparison with those whose Ccr was 40 to 75 ml per minute. No significant difference in probability of disease progression to ESRD was found between subjects diagnosed with VUR at age 6 months or less and those diagnosed later (older than 6 months). Furthermore, children with normal urinary protein excretion (a urinary protein [uPr]/urinary creatinine [uCr] ratio of less than 0.2 in 36 patients) and low grade proteinuria (uPr/uCr 0.2 to 0.8 in 34 patients) at baseline showed a significantly slower decrease in mean Ccr than those with moderate proteinuria (uPr/uCr greater than 0.8 in 34 patients). Hypertension and/or antihypertensive treatment (including antiprogressive drugs) were reported in 29.1% of patients. CONCLUSIONS: The results of the present study define the long-term risk of ESRD in a large population of children with CRF and VUR, and provide some critical information for identifying the prognosis.