Division of Urology

Minimally Invasive Surgery for Urologic Conditions in Children

The Division of Urology is a world leader in minimally invasive surgery, a type of surgery done through small incisions no larger than a grain of rice.

We have performed thousands of these minimally invasive procedures ranging from diagnostic endoscopy to laparoscopic/robotic reconstruction for obstruction, reflux and poorly functioning kidneys. We also treat certain kidney stones with endoscopy, laser and shockwaves depending on the stone size and location.

What are laparoscopy and endoscopy?

Laparoscopic and endoscopic procedures are types of minimally invasive surgery that enable surgeons to operate on very precise areas of the body. Patients experience less pain, disability and scarring and experience faster recovery as compared to standard "open" surgery, where a large incision is made.

Endoscopy can best be described as one of the vehicles for laparoscopic surgery. An endoscope is a probe with a tiny camera and bright light that is inserted into natural body openings such as the anus, urethra or vagina. The surgeon looks at a video screen, which displays the magnified images of the body's internal structures. He or she moves the endoscope in the organ system and operates with thin, precise instruments.

How is laparoscopic surgery done?

The surgery is usually done under general anesthesia. The surgeon makes a small incision about 5 mm long at the navel. Gas composed of carbon dioxide is injected through the cut to slightly expand the abdominal wall. This makes it easier to see the internal organs with the laparoscope, which is gently pushed through the incision into the abdominal cavity. The surgeon looks down the laparoscope or looks at images on a TV monitor connected to the laparoscope.

One or more additional and separate small incisions are made in the abdominal skin. They are typically 5 mm or less. The incisions allow thin instruments to be pushed into the abdominal cavity. The surgeon can see the ends of the instruments with the laparoscope to perform the required procedure.

In certain instances that require complex reconstruction, a surgical robot is used to facilitate the procedure. The robot uses very fine movements resulting in minimal trauma to tissue. When the surgeon is finished, the laparoscope and other instruments are removed, the incisions are stitched and dressings are applied.

What are the benefits of laparoscopic surgery?

Because the overall trauma to the skin and muscles is reduced, post-operative pain is less — allowing patients to get out of bed sooner. Patients are often able to walk and move around within a few hours following their operations.

In addition, during laparoscopic surgery, delicate tissues are not exposed to the air of the operating room over long periods of time, as they are when the body is wide open in traditional operations; therefore, there is a reduced infection rate.

Video magnification also offers surgeons better exposure of the diseased organ and its surrounding vessels and nerves. As a result, delicate maneuvers can be performed to protect these vital structures during the removal or repair of target organs.

The documented benefits of laparoscopic surgery compared to traditional open surgery include:

For what conditions is laparoscopy most appropriate?

Laparoscopy is established in the mainstream of urologic surgery. Many aspects of urologic surgery for the kidney, ureter, adrenal gland, prostate, bladder or lymph nodes can now be achieved laparoscopically with far less injury and pain to the patient. Minimally invasive surgery is superseding open surgery at major medical centers throughout the world.

When should minimally invasive surgery not be performed?

Minimally invasive surgery should not be performed in patients with uncorrectable coagulopathy (bleeding disorders), intestinal obstruction, abdominal wall infection or suspected malignant ascites (excess abdominal fluid).

Minimally invasive surgery is not recommended for patients who are obese, have had extensive prior abdominal or pelvic surgery, have ascites, are pregnant, have severe chronic obstructive pulmonary disease (COPD), severe cardiac arrhythmias or heart disease.

What are the complications of minimally invasive surgery?

Complications are decreased with experienced surgeons who perform the procedures on a routine basis. Laparoscopic procedures are generally more difficult to perform than open surgery. Pediatric urologists who perform these procedures must have highly specialized training in this technique. Our urology team has extensive experience, both in performing these procedures and as innovators of the procedures, and is committed to remaining at the forefront of research and development of this emerging technology.

The estimated complication rate of laparoscopic surgery is less than 5 percent with an associated mortality rate of about 0.3 percent and a conversion rate to open surgery between 1-5 percent worldwide.

Risks of surgery include bleeding, infection and injury to adjacent organs such as the liver, bowel, spleen or pancreas, as well as possible conversion to open surgery. Most intra-operative complications are vascular and bowel injuries, while post-operative complications are predominantly blood clots and wound infections. Conversion to open surgery might be necessary to safely complete the planned procedure, which occurs less than 2 percent of the time  — even in experienced hands.

How do we prepare for the surgery?

Within one week prior to your surgery, your child will be scheduled for pre-admission evaluation with our anesthesia staff. Testing may be performed; it generally consists of a complete blood count, electrolyte panel and possibly urinalysis and urine culture when indicated.

Operative phase

The evening before surgery, your child will not be permitted to eat or drink after midnight or later depending on age. Specific instructions will be given regarding time limits. This ensures that no food is in the stomach prior to induction of anesthesia.

Before the procedure, an anesthesiologist will give your child medication to decrease anxiety and induce relaxation. Once in the operating room,  the anesthesiologist will give your child general anesthesia. This medication will prevent your child from feeling any pain during surgery. The surgical team then performs the procedure.

A bladder catheter will be inserted to facilitate the recording of urine output during the operative and post-operative periods. The catheter will also assist with urination after the procedure since normal urination may be delayed by the anesthesia.

Small skin incisions, 3 to 5 mm,  will be created to perform the procedure. After the operation, the wounds will be closed and covered with a transparent dressing. There is no need for removal of any stitch in the future.

Post-operative phase

After the procedure is completed, your child will be wheeled into the recovery room where he will be monitored by the recovery room nurses. They will check his blood pressure, pulse, respirations, temperature and drainage from tubes. When your child is awake and in stable condition, he will return to his room and the floor nurses will then take over the care.

Your child may still be drowsy from the anesthesia, but as it begins to wear off, there might be some discomfort from the incisions. We will give your child pain medication upon request and monitor the effectiveness of the medication. The pain should begin to decrease each day and medication dosages will be adjusted accordingly. The intravenous medication will eventually be changed to pills when your child is tolerating fluids and food, usually within four to 48 hours.

What should my child expect after laparoscopic surgery?

Your child may feel a little sore around the incisions and have some pain in the shoulder tip. This is caused by the gas used during the procedure, which irritates the diaphragm; this area has the same nerve supply as the shoulder tip. The pain passes quickly. The length of time to recover can vary, depending on why the procedure was done and what operation was performed.

What should I know before my child goes home?

Your child will probably not have any tubes in place when you go home. The urethral catheter is always removed on the first day after surgery. A clear liquid diet will be allowed on the first post-operative day. The draining tube will be removed according to the daily amount and quality of the drained fluid. This will usually happen on the second to fourth day after surgery.

Upon release from the hospital, usually one to two days after surgery, we will give you printed discharge instructions and ask you to make an appointment to see your child's urologist within four to six weeks following discharge. During your follow-up appointment, we will discuss future care with you and your child.

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