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Retroperitoneoscopic partial nephrectomy for duplex kidneys: 20 years of experience, from lateral to prone approach
Marc-David LECLAIR, MD, PhD, Caroline CAMBY, MD, Sébastien FARAJ, MD, Etienne SUPLY, MD, Stephan DE NAPOLI COCCI, MD, Yves HELOURY, MD.
Children University Hospital, NANTES, France.

Laparoscopic retroperitoneal partial nephrectomy in children remains a challenging technique with limited diffusion among paediatric surgical community. We aimed to report on our experience with retroperitoneoscopic partial nephrectomy for duplex kidneys, and compare outcomes using lateral vs prone approach.
92 consecutive children underwent retroperitoneal laparoscopic partial nephrectomy at a single institution between 1993 and 2013 : 74 upper-pole nephrectomies (ureteroceles (n=30) or ectopic ureter (n=44)) and 18 lower-pole nephrectomies (high grade reflux (n=16) or non functioning hydrophrotic lower moiety (n=2)) were retrospectively included in this study. Median age at surgery was 18.5 months (range 1.5-142.5), including 49 infants under 12 months of age. Retroperitoneoscopic procedure was performed using lateral position (n=32, 1993-2004) or prone in the last 60 cases (2005-2013).
We assessed intraoperative and postoperative morbidity.
Follow-up was based on clinical review and renal ultrasound with Doppler-colour assessment of remaining moiety vascularization.
Mean duration of surgery was 106 min (43-215). Ten procedures (11%) were converted into open surgery, mostly at the begining of the experience (8 among the first 20 cases, as compared to 1 conversion in the last 50). Most converted procedures were related to difficulties of exposure in small infants (n=5, 1.5 to 8 months) or bleeding during parenchymal section (n=3) before availability of sealing devices (<2000). The two remaining conversions were necessary to ensure adequate closure of calyceal breach.
The mean length of hospital stay was 1.9 days (1-13).
There were 5 complications (5%) : Clavien grade III-a (urinoma requiring drainage, n=2), III-b (eventual laparoscopic removal of symptomatic ureteric stump, n=1), or IV-a (functional loss of the remaining moiety, n=2).
On the last US follow-up post-operative assessment performed at a mean of 50 months (range 3-155), an asymptomatic fluid collection (“cyst”) could be seen in contact to the parenchymal cut on the on renal US in 10/92 cases, but never required further procedure. Doppler-colour showed normal renal vascularization, and normal cortico-medullary renal differentiation in 90/92 cases.
When comparing lateral to prone approach, there was no difference in the complication rate. The conversion rate (9/32 vs 1/60), and duration of surgery (127 ±36 vs 96 ±33min.) was highly in favour to the prone approach , but very likely related to the learning curve and experience developed during the first procedures, all performed in lateral position retroperitoneoscopy.
Retroperitoneoscopic partial nephrectomy remains a challenging procedure in children, especially in small infants with dilated collecting systems requiring a learning curve of >20 cases. With experience, the prone approach allows to achieve very low complication rates with minimal operating time and short hospital stay.

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