BACKGROUND: Laparoscopic retroperitoneal nephrectomy is a known treatment for nonfunctioning kidneys in children. This approach affords the benefit of avoiding the intra-abdominal space, in which many patients receive peritoneal dialysis. This approach has been extended to treatment of conditions which affect horseshoe kidneys as well, although only reported in adults and limited to unilateral procedures. One downside to performing bilateral renal procedures is the need to reposition the patient. One way to eliminate this step is to employ a prone approach to patient positioning, which is routinely done at our institution. Here we report on a case of laparoscopic retroperitoneal nephrectomy of a horseshoe kidney in prone position in a patient with end stage renal disease with severe nephrotic syndrome. To our knowledge, this is the first report of this approach in the literature.
METHODS: Our patient is a 10year old female with a medical history including mosaic Turner’s syndrome, horseshoe kidney, nephrotic syndrome resulting in significant proteinuria and generalized edema. She is followed by the nephrology team who recommended bilateral nephrectomy in preparation for renal transplantation. Patient will undergo simultaneous hemodialysis catheter placement for renal replacement therapy while she awaits transplantation. Given known aberrant vasculatures associated with horseshoe kidneys, the patient underwent a preoperative MRI to characterize her anatomy. In addition to horseshoe kidneys with poor parenchymal enhancement and loss of corticomedullary differentiation, her MRI revealed hypoplastic single renal arteries arising from the aorta and two left renal veins with the inferior one being retro-aortic.
RESULTS: The patient was placed in prone position with all pressure points well padded. Two large gel rolls were placed beneath the chest and the hips to allow for a space for the abdominal wall to drop downward and create working space in the retroperitoneum. Three ports were placed as outlined in the video. Using a combination of a Ligasure and a kitner, we first mobilized the left kidney entirely, taking care to spare the hilar vessels. Once we crossed the isthmus, we walked over to the right side, placed the trocars which mirrored the left side and mobilized the right kidney in the same manner. Once the entire kidney was freed, the vessels were individually ligated with clips and the isthmus was divided using ligature. We then placed one kidney into a specimen bag and morcellated it using Mayo scissors and ring forceps. The same steps were repeated on the contra-lateral side. Surgery time was six hours. The patient did well from a surgery standpoint. At one week post-operatively, her incisions were healing quite well as detailed in the video.
CONCLUSIONS: Laparoscopic retroperitoneal nephrectomy for a horseshoe kidney for a pediatric patient in prone position is safe and effective approach to sparing the intraperitoneal space for dialysis, reduce positioning, and allow for small incisions in a cosmetically favorable location.
