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Review Article

Minimally invasive surgery in management of renal tumours in
children
Kathrine Olaussen Eriksen, Navroop Singh Johal, Imran Mushtaq

Department of Paediatric Urology, Great Ormond Street Hospital for Children NHS Trust, London, UK
Contributions: (I) Conception and design: All authors; (II) Administrative support: All Authors; (III) Provision of study materials or patients: NS Johal,
I Mushtaq; (IV) Collection and assembly of data: None; (V) Data analysis and interpretation: None; (VI) Manuscript writing: All authors; (VII) Final
approval of manuscript: All authors.
Correspondence to: Imran Mushtaq, MD, FRCS (Paeds). Department of Paediatric Urology, Great Ormond Street Hospital for Children NHS Trust,
London, UK. Email: mushti@gosh.nhs.uk.

Abstract: Minimally invasive surgery (MIS) in the management of malignant and benign renal tumours
in children is gradually becoming more common. Experience is limited and restricted to case reports,
retrospective chart reviews and a few cohort studies. There are currently no randomized controlled trials
or controlled clinical trials comparing the laparoscopic and open surgical approach for the management of
renal tumours in children. MIS may offer the same oncologic outcome in malignant renal tumours whilst
providing the advantages associated with MIS in correctly selected cases. The technique for tumour resection
has been shown to be feasible in regards to the recommended oncologic principles, although lymph node
sampling can be inadequate in some cases. Preliminary reports do not show an increased risk of tumour
rupture or inferior oncologic outcomes after MIS. However, the sample size remains small and duration of
follow-up inadequate to draw any firm conclusions. Implementation of MIS is lacking in the protocols of the
major study groups, and standardized recommendations for the indications and contra-indications remain
undefined. The objective of this article is to present a review of the literature on the role of MIS in the
management of renal tumours in children, with the main focus on Wilms’ tumour (WT). Further studies on
MIS in renal tumours are required to evaluate the incidence of oncological complications such as complete
tumour resection and intra-operative tumour spillage. A long-term follow-up of patients managed by MIS is
essential to compare recurrence rates and overall survival rates.

Keywords: Laparoscopy; paediatric; renal; tumour; minimally invasive surgery (MIS)

Submitted Sep 12, 2016. Accepted for publication Sep 21, 2016.
doi: 10.21037/tp.2016.09.04
View this article at: http://dx.doi.org/10.21037/tp.2016.09.04

Introduction developing WT. Syndromes associated with WT include
Beckmann-Wiedemann, Denys-Drash, Li Fraumeni and
Renal tumours account for about 7% of all tumours in
neurofibromatosis (4), and patients with these syndromes
children before the age of 15 years. Wilms’ tumour (WT), are required to undergo periodic screening with renal
or nephroblastoma, is the most common primary renal ultrasound. Other less common renal neoplasms in children
neoplasm in childhood with an incidence of 1 in 10,000 (1-3). include clear cell kidney sarcoma (CCKS), renal cell
The most common presenting sign is an asymptomatic carcinoma, malignant rhabdoid tumour of the kidney and
abdominal mass in a child between 2 and 4 years old. mesopblastic nephroma. Metanephric adenoma is a benign
Most WT occur as solitary lesions, but 6% present with renal tumour that can occur in children (2).
bilateral disease and 12% with multifocal disease within The survival rate in children with WT has increased
a single kidney. Some children have a predisposition to dramatically over the past 5 decades, and is now around

© Translational Pediatrics. All rights reserved. tp.amegroups.com Transl Pediatr 2016;5(4):305-314

are removed if achievable. Minimally invasive surgery (MIS) has been utilized staging system used by COG is based on findings of primary for decades in the adult patient group.amegroups. The guidelines for management of WT are shown to occur during open radical nephrectomy (ORN) well established.com Transl Pediatr 2016. The tumour and the adipose capsule.306 Eriksen et al. localized tumours. low. however lagging surgery. facilitating the introduction and tumour histology.8) and increased risk factors of the histology type. The on the general management of WT and other solid chemotherapy induces a pseudo-capsule that is important in tumours. Large multi. operative Vincristine and Actinomycin D in patients with with all surrounding structures. Other options for tumours of higher conditions such as pyeloplasty and nephrectomies for non. Arguments for the strategy in are continuing improvements and developments in every this protocol are risks associated with the chemotherapy. or other malignant tumours than WT. The essential difference in the COG [which includes the former National Wilms’ Tumor Study protocol is that most patients are treated with immediate Group (NWTSG)]. groups have not yet investigated the role of MIS within the guidelines and recommendations. Four weeks pre. Laparoscopic management of renal tumours in children 90% for patients with low stage (I and II) disease and a in cases of metastatic tumours. Low-dose radiation Despite the increasing utilisation of MIS in paediatric therapy (RT) may also be indicated in selected groups with surgical oncology. recommended surgical technique is defined by the SIOP 2001 protocol. Tumour rupture has been study groups. radiotherapy. functioning kidneys and polycystic kidney disease (9. redirecting the attention towards treatment options which the oncologic outcomes are excellent regardless of utilized may minimize the surgery related morbidity without protocols (13. including urological D and Doxorubicin.8% of the cases in the SIOP-9 protocol (14). Neo-adjuvant chemotherapy is the gold standard in which increases the intratumoural pressure. modification of The great success achieved in reducing mortality is histology and loss of staging information. Cyclophosphamide and Etoposide (13). tp. impacting the event-free survival. treatment aspects.7. Two major groups that have contributed greatly preventing intra-operative tumour rupture and subsequent in the successful management of WT are the European spillage. Range of conditions successfully operative chemotherapy include Vincristine. chemotherapy is down staging. The with the traditional open nephrectomy. Acitomycin managed by MIS is rapidly growing. risk/stages include different combinations Carboplatin. 6 weeks and the addition of Doxorubicin Inspection of the entire abdominal cavity is performed. laparoscopy has risk. Radical open nephrectomy is fundamental in 2. assuring regular update of the treatment protocols. and is especially of advantage in cases of larger International Society of Paediatric Oncology (SIOP) and tumours and where nephron-sparing surgery (NSS) may be the North American Children’s Oncology Group (COG) indicated (7. The risk stratification has proved to be prognostically gained widespread popularity in standard as well as complex more important than the stage. © Translational Pediatrics. The tumours are then behind in the paediatric patient group.6).5(4):305-314 . Nevertheless. Open radical nephrectomy The aim of this article is to review the existing literature on the experience of MIS for renal tumours in children. The abdominal cavity is opened using a long transverse abdominal incision or a Chevron incision. Open radical nephrectomy is the gold standard in unilateral the advantages and concerns. and the risk treatment of WT in the SIOP protocol. Common protocols for post- operations in children. The system used by SIOP is based on of new instruments and techniques to almost all surgical staging following pre-operative chemotherapy. With development separated into one of three groups depending on prognostic of new and smaller instruments (1. of tumour rupture.10). intermediate or high experience among surgeons in the field. and also includes five stages. both in combination and within each including administration to patients with benign tumours field. the international multi-centric trial higher stage disease or higher risk (5. shrinkage of tumour centric randomized controlled trials have been published and reduction of surgery-related complications. All rights reserved.16). The aim of the neo-adjuvant favourable histology of the tumour (5. Surgical technology is Post-operative treatment is based on histological staging constantly in development. and to compare the outcomes cases of malignant renal tumours in children.11-13). There has been and still NWTS-4 protocol (15). There are also independent national surgery and then chemotherapy. The current fields.13). The Current management of WT renal vessels are ligated early to avoid swelling of kidney. compared in management of WT in combination with chemotherapy to 11% of the patients treated with upfront ORN in the and in some patients.

5% in the SIOP- avoid tumour rupture and spillage. No 4 October 2016 307 including the renal veins and vena cava. Kinahan et al.5(4):305-314 . and mass to the abdominal cavity through breakage of the compared the answers with 4. as small (11. Limitations of MIS endoscopic single site surgery (LESS) and robotic surgery] are tactile deficit and limited visualization of lesions not and included 69 patients in their study. but the numbers are small.20).27). Studies have shown tumours in children.25).17).18).19. Another study showed significantly reduced mean aortic lymph nodes are sampled for histology. This has been survivors of childhood cancer through self-reporting on associated with increased the risk of disseminating tumour scarring and disfigurement and persistent hair loss. Vol 5. The incision is smaller and literature so far. and radiotherapy post-operatively. however duration of post-operative narcotics MIS is increasingly being used to treat malignant renal were not significantly different (12). Complete surgical resection is one of the the additional benefit of an earlier start of chemotherapy strongest predictors of outcome in WT (19). an inferior oncological outcome is the main partially attributed to learning curve factors (9). obstruction and intussusception have also been shown to be Three or four trocars are commonly utilised. The risk of wound infection is reduced. short-term advantages of a quicker recovery in MIS may though cases are reported utilising the retroperitoneal be less in children when compared to adults. survivors reported a significantly higher rate of scarring/ The advantages of MIS are well known.358 and remove the tumour by morcellation. underwent ORN. potentially improving LN in renal tumours in children is more commonly the prognosis for patient following MIS (1. A systematic review and meta-analysis recover faster following an open procedure. the open surgical approach. outcomes in the paediatric population in relation to recovery There are several possible disadvantages of MIS in and surgical morbidity (12. Distinguishing tumour from invasive modalities were associated with shorter length unaffected tissue can be very difficult. The cancer endoscopic bag and is generally not recommended (20). the outcomes of these two approaches and there were no Post-operative complications such as adhesive bowel differences in safety and efficacy of these two methods (23).com Transl Pediatr 2016. and rupture of tumour. compared the management of renal tumours. The basic better pulmonary function. compared to the open approach. The other option for specimen removal is to extend incisions result in reduced scarring on the abdomen than the incision of one of the port sides. This reduces the risk of rupture and allows adequate no cases of intussusception or bowel obstruction after inspection of the tumour margins and accurate histological LN for renal tumours in children have been reported in staging of the tumour (8. Negative impact on event-free survival and © Translational Pediatrics.20).12).22). with good disfigurement for chest/abdomen (29). The surgical technique different surgical approaches to paediatric nephrectomy in is considered to be technically more challenging when children [open surgery. reviewed 14.Translational Pediatrics. The rapid recovery that follows MIS has sampling (12. ORN in the SIOP-2001 study (15. Hilar and para. tp. times than open surgery. 5. usually the umbilical. earlier return of bowel function tenets of MIS must adhere to oncological principles. as children approach (21.24.4% and 2.9 days) compared with 32 patients whom or MRI indicates bilateral tumour (14. and the incidence of intussusception 1.26). The bag containing the 9 trial.20. The specimen reduced (20. assess the entire abdominal cavity to a ten-fold decreased risk of incisional hernias has been detect metastasis and to perform adequate lymph node reported (24. laparo. Laparoscopy is of available publications in the adult literature compared also associated with lower hospital costs (25. but were noted to have slightly longer surgical and damage of healthy organs (19). concern. located in a more concealed area compared with ORN Another advantage is the cosmetic outcome. The difference in surgery time was Clearly. The performed via the trans-abdominal approach (11. Kim et al.24).9 vs. Incidence of bowel obstruction following is usually placed within an endoscopic retrieval bag to ORN in the NWTS-3 was 5. All rights reserved.27).1% in after specimen is then removed through a pfannenstiel incision. Almost all the patients in the ORN group received epidural block versus none in the Laparoscopic nephrectomy (LN) LN group. The opposite hospitalization in thirteen patients that underwent LN for retroperitoneal space must be assessed if pre-operative CT WT (2.amegroups. and significantly shorter duration of nasogastric tube in the LN group. This and more rapid normalisation of the immune function includes the ability to completely remove neoplasm without after MIS. To our knowledge.28).023 siblings. transperitoneal laparoscopy. with the potential of hospitalization and reduced post-operative analgesic consequence of incomplete resection of neoplastic tissue requirements. The minimally located on the organ surface.

compared ORN and LN over Duarte et al. neo-adjuvant chemotherapy was Fearsome oncologic complications are tumour rupture with not given. follow-up is lacking (32). The long-term reported in patients treated with MIS for WT. To our adjuvant radiotherapy and increase the chance of cardiotoxic knowledge. adult population and led to concerns regarding long-term Operative time has been reported to be longer in survival (11). have reported on MIS for WT resection in a 5-year period. There was no evidence of regarding death. Post-operative (15. lymph node sampling was not performed and subsequent spillage.27).27). Statistical analysis showed no difference pre-operative chemotherapy. LN has commonly been performed after pre-operative especially at higher stages (27). described a case of peritoneal diffusion with applied to both radical and partial nephrectomy in various port-site and peritoneal metastasis after laparoscopic NSS procedures (34).7% chemotherapy according to the WT SIOP protocol in the SIOP-9 protocol (19) and 4. Of note. The authors highlighted the magnifying view Port-site metastasis is another feared complication. intra-operative tumour rupture at the time of the surgery. relapse and the need for radiotherapy. without anaplasia.amegroups. Guidelines for laparoscopic oncology were LN for WT. Robotic techniques for renal cell carcinoma in adults are Chui et al. Pre-operative chemotherapy management of renal tumours. also who underwent LN for WT in the SIOP 2001 trial. the trocars and excision of the trocar edges if doubt (27). one patient had a local recurrence and a possible group (11). They examined 13 patients with renal Brazil. tumour recurrence and event-free survival at invasive approach.27). Recurrence rates analysed oncological and surgical outcomes in 24 patients were similar in both patient groups (12). Recent technological advances have led for WT in a 2-year-old girl.18. Romao et al. no other cases of port-site recurrence have been chemotherapy to the patient (12. In this retrospective study 17 patients were included tumours managed by LN and only two patients underwent in the LN group. Among the shown (11. were no tumour spillage and no other complications (33). in particular the ability to remove multiple small procedures were performed on abdominal neoplasms in the tumour implants in the deep pelvis (26). and the rate reduced dramatically. up at 47 months. from 97 (20) to retrieval bag for specimen extraction. Incomplete resection is an independent risk chemotherapy using the COG protocol have also been factor for local recurrence in WT (30). of favourable histology successful outcome in WT managed by the open approach.5(4):305-314 . Other renal mass. Javid et al. lymph node sampling considered to be a contra-indication for MIS. Nevertheless.19). and local recurrence is associated with poor prognosis. The SIOP Renal Tumour Study Group (RTSG) cause was a tear in the retrieval bag. and incomplete resection of the tumours it was unknown if a retrieval bag was used. Interestingly. and add chemotherapy was commenced 6 weeks post-operatively the burden and possible long-term morbidity of intensive and no radiotherapy was given to the patient (31). Barber et al. though no significant difference has been developed.3% in the NWTS-4 (11. The surgeons in the trial had above-average highly selected group of patients. and reports consequences are the increased risk of local recurrence of the are not indicative of port-site recurrence in laparoscopic disease and peritoneal metastasis. peritoneal seeding in pelvis and disseminated studies have also reported on LN as safe and feasible in pulmonary metastatic disease. Cases undergoing LN without preoperative protocol (18).308 Eriksen et al. The recurrence rate was 2.com Transl Pediatr 2016. CO2 exsufflation by 282 minutes (12).12.20.17. however long-term in a six-fold increase in local recurrence in abdomen (18). All rights reserved. at follow-up at 4. with no incidents if tumour successfully reduced the sizes of the lesions. reported. and metastasis is generally experience with WT. tp.12). The patient is disease-free at 19-month follow-up compared with open surgery (1. The tumour size was 10 cm to an introduction of options for urological procedures © Translational Pediatrics. These events would upstage the tumour. treatment results were comparable to those of open surgery aged 14 months and 16 years. Laparoscopic management of renal tumours in children overall survival would be unacceptable due to the already (significantly larger for her age). The presented two patients undergoing upfront LN for WT.3 years compared with the ORN However. was performed in only 15 of the 24 children and in only two described a case of WT in a 2-year-old child with a large patients were more than six lymph nodes sampled (7). surveillance. Tumour spillage results procedure in paediatric malignancies. and there were no intra-operative tumour Most studies have focused on the utilization of MIS in a ruptures. mean operative time of the recommendations were the introduction of impermeable procedures varies greatly among studies. with visualization of tumour and metastatic disease as a great which was discovered after the initial laparoscopic advantage. and all remaining ruptures. The results were similar in regards to surgical lesions were removed in the same surgery by minimally complications. with 8-cm lesions. There in terms of event-free and overall survival at median follow.

NSS for non-syndromic unilateral WT. All rights reserved. © Translational Pediatrics. Information on outcome amenable T1 renal tumours (the tumour is confined to at follow-up was not included (35). bilateral Wilms’ or in case surgical difficulties requiring high expertise and experienced of concurrent contralateral urological and nephrological surgeons (22.com Transl Pediatr 2016. Firstly. Secondly. Very few cases of the robotic oncologic outcomes in patients treated off-protocol with approach in paediatric oncology have been described. Pre- first introduced to children with benign conditions with operative chemotherapy is commonly administered prior the aim to preserve renal function. The authors highlight the suturing of performed for malignant tumours in children. population. The largest tumour measured 67 mm in diameter.. and she was later diagnosed of the patients (40). Another recent introduction to the minimal invasive and laparoscopic nephron-sparing resection was performed approaches is the LESS. Advantages are magnified three-dimensional 5 years). to reduce risk of tumour rupture. Piché et al.41).28.e.Translational Pediatrics. no case reports utilising follow-up (22). No 4 October 2016 309 in children.9% found on 6 months surveillance. due to increased risk of metachronous WT. before COG and SIOP to NSS for WT. favourably against ORN. by sparing non-cancerous renal parenchyma.30. and NSS required angiographic embolization for complication with Data in adult patients has demonstrated that NSS is pseudo aneurysm in the renal parenchyma (30). Wilde et al. with sizes of tumours possibly amenable for more intensive adjuvant treatment. 93. but only in localized disease (no assisted surgeries in renal tumours in the adolescent invasion of renal vessels or surrounding organs) (16). as the successfully performed. A problem occurs in case of positive disorders (16.amegroups. a renal cell the kidney and less than 7 cm) in adults (34). the remaining renal tissue or vascular injury as particular described a case of a small polar WT in 2-year-old girl with advantages of the robotic approach (36). associated with improved renal morbidity and has a Proposed inclusion criteria include a small tumour that significant advantage with reduced postoperative CKD is well circumscribed. reviewed reconstructive procedures (9). have presented two separate cases on robotic. preferably with a polar location and when compared with radical nephrectomy (37). tp. and only 3% of the that facilitates in particular intracorporeal suturing and patients in the study had NSS (39). A lesion of the pancreatic head was most important urological complication.38). Selection of patients is crucial. 10 and 14 years old who underwent laparoscopic NSS for metanephric adenoma. 5%). showed that nephron-sparing resections Sampling of lymph nodes in unilateral WT had oncologic outcomes comparable to patients after ORN (100% OS. Suggested Disadvantages for laparoscopic NSS in WT are tumour candidates include patients with increased risk of recurrent spillage. occurred in 2. BWS in Canada. Resection margins approach. which would upstage the tumour and require earlier stage. syndromic Wilms’). risk of peritoneal and port site metastasis. Cost et al. Surgical complications were more common (11% visualization and improved wrist-like instrument control vs. risk of renal impairment is increased (16). There are only a few reports on LPN with MEN type 1.5(4):305-314 .30).5% event-free survive at Sampling of lymph nodes is essential for accurate staging. a pre-chemotherapy robotic-assisted Laparoscopic partial nephrectomy (LPN) is increasingly radical nephrectomy was described in a 14-year-old patient performed in benign conditions in paediatric urology (9) with WT. and disease (i. Radiotherapy would NSS. laparoendoscopic single stage through retroperitoneal approach. Neo-adjuvant chemotherapy was given. reported on two patients aged LESS in renal paediatric oncology have been published. Also. Cases of successful nephrectomy have been were negative and she was recurrence-free at 6 months reported (9).375 adult patients that underwent LPN in Japan with robotic-assisted NSS. Ozden et al. Partial nephrectomy and an demonstrated that LPN was successfully completed in extended full aortic and hilar lymph node dissection were 93% of the patients. Vol 5. Ultrasound screening of patients with surgical margins or neoplasm in sampled lymph nodes after increased risk of WT facilitates detection of disease at an NSS for WT. A review carcinoma measuring 1 cm in a 14-year-old was managed of 1. the counteract the functional benefits of NSS (14). NSS was without any vascular involvement or metastasis (30). More included NSS as a surgical option in a highly selected than 50% of renal tissue should be spared in the surgery to group of patients with bilateral malignant renal disease give protection against hyper perfusion (14. NSS compared Cost et al. To our knowledge. without intra-operative tumour rupture and and considered to be the treatment of choice for most with negative surgical margins.16. One re-attended on day 8 post-operatively. Post-operative haemorrhage.

There has been a controversy if A Cochrane review was published in 2015 on MIS compared the number of lymph nodes resected is associated with with open surgery in treatment of solid abdominal and thoracic 5-year survival rate. There are concerns regarding inadequate lymph in general. reviewed available lymph node controlled clinical trials were identified and thus the evidence data in 1. adults is high. As with other literature on laparoscopic surgery approach.340 patients. Patients with WT. hence amendable to either NSS surgery or Absence of lymph node sampling is associated with LN. and experience staging purpose. concluded however been published on the laparoscopic approach for tumour that number of lymph node sampled did not change 5-year biopsy. All rights reserved. Laparoscopic approach is described as feasible without The recommended number of lymph nodes might be violating the general surgical principles in tumour clearance. whereas 85% had more than 5 years of experience in MIS. undefined. and resections of a selection of thoracic. though consensus is that sampling of periaortal however liberality in conversion to the open approach is lymph nodes must be sampled regardless of surgical highlighted. WT is among the four conditions that scored highest on Comparison with renal tumours in adults negative recommendation for MIS. In comparison. countries completed an anonymous web-based questionnaire. The success nevertheless. Kieran et al. as there are differences in Discussion tumour biology. pelvic and abdominal found that only patients with anaplastic tumours had greater tumours have been described (25. 51 technique. treatment as stage III disease to avoid under treatment (8. The incidence of small renal tumours in treatment approach to minimize the risk of a local relapse (24). One hundred and explanations for lack in sampling have been described in seventeen paediatric surgeons in Australia and the Pacific these studies (7. Zhuge et al. The study demonstrated results in cases of adrenal neuroblastomas (47).27). often have large increased risk of abdominal recurrence. No randomized clinical trials or conclusions. size of patients. with equivalent recurrence rates as for open cholecystectomy and undescended testicles respectively (48).19). Studies have reported that have been observed (8.5(4):305-314 . Nevertheless. tp. Only five surgeons LN for stage T1/T2 renal cancer (tumour confined to the would perform MIS in WT and ten would recommend. Comparison with the paediatric population is controversial in many cases. rapid recovery time and good cosmetic results node sampling in MIS (18). laparoscopy is performed in management sampling (87%) versus patients with more than ten lymph of solid tumours in children. Laparoscopic management of renal tumours in children risk stratification and in choosing the correct adjuvant on presentation.com Transl Pediatr 2016. surgery (46). Lymph node metastasis and local residual disease Comparison with other paediatric solid tumours have a negative impact on overall and event free survival in WT patients (42). and should mandate tumours on presentation (12).12. exploration and for tumour resection (45). the sample sizes lymph node sampling is feasible utilizing the laparoscopic remain too small to generate reliable conclusions. The reasons opinion of minimally invasive paediatric surgery in common for this remain unclear. Ninety-seven surgeons (87%) did not has surpassed open surgery as the most frequent surgical think MIS would be indicated in management of WT.409 patients.40). Reports including more than surgeons (<20 years of experience). Both LN and robotic-assisted techniques are of these classified as “senior” paediatric surgeons (>20 years utilized in partial and radical nephrectomy of procedures of experience) and 46 were classified as “junior” paediatric also of complexity (34. only one 100 cases in a multi-institutional study prove LN to be safe and eight surgeons considered MIS not to be indicated in and efficient.45). approach. however compared to open surgery the number Jones and Cohen performed a survey on surgeons’ of lymph nodes sampled tends to be lower. Several small case series have node sampled (95%) (43). and no specific comments or paediatric conditions in Australia. as two large studies have had different neoplasms in children. on the other hand. recommendations on radical lymph node dissection (44).amegroups. and reported a significantly lower was insufficient to draw any conclusion on the topic (25). size of instruments and prognosis (25). 5-year overall survival for patients with absent lymph node Nevertheless. and not perform MIS.17. Tumour survival variation in their review of 3.310 Eriksen et al. though not evidence that would justify with MIS in metastatic disease remains highly limited. but kidney) in adults has gained widespread popularity. Another important aspect is the tumour size MIS is a surgical option in the management of carefully © Translational Pediatrics.45). the importance of lymph node sampling for rate seems higher in cases of smaller tumours. including successful effect on lymph node positivity.

the selection criteria in patients. The limited number of cases in renal The role of MIS in paediatric solid tumours remains tumours in the paediatric field will prolong the learning unclear. Older children and tumours.5(4):305-314 . adolescents have proportionally larger working space similar suboptimal results and unacceptable rate of complications to that found in adults. and there are curve (25). Furthermore. MIS has not played a role principles (18). it seems likely that utilisation of adjuvant radiotherapy and chemotherapy is the use of laparoscopy in the treatment of renal tumours often lacking (7). suggested inclusion of patients with tumour are not blinded.Translational Pediatrics.com Transl Pediatr 2016. most complications occur during study. techniques. imaging and increased technical laparoscopic Important data including information about surgical experience among paediatric surgeons have been decision making in choice of MIS. in the management of benign conditions the number of new approaches in children mirror adult developments MIS procedures performed for renal tumours is also likely albeit with a delay in its introduction. The length of follow-up is also inadequate will further increase as it has done in the management of in the vast majority of cases with respect to oncological benign conditions in children.27). Controversy continues to remain as to whether the Indications or recommendations for MIS in renal laparoscopic approach is an alternative to the open tumours remain undefined (26. The risk of rupture increases with larger of surgical complications that are comparable the open tumours. fourth or fifth trocar could facilitate laparoscopic removal The published studies have several limitations worth of a larger tumour. The SIOP should have adequate experience in both laparoscopy and RTSG have also reported on a lack of relevant data making open oncological surgery. One can rightfully raise concerns over the still several questions that are unanswered. The approach must valid conclusions. number of trocars.33). the challenges (13). groups. No 4 October 2016 311 selected paediatric renal tumours. and the initial approach to renal vessels without approach. or the patients undergoing MIS have a better prognosis as tumour size <10 cm (12). Vol 5. Inclusion criteria used is often different and dimension/height ratio <10% (50). There are to this date no randomized be converted to open if the tumour mass cannot managed clinical trials comparing MIS with open approach in laparoscopically. It is however of great importance that the not been able to incorporate the rapid development of emphasis of surgery in these children is not the feasibility. the number of patients is too small to draw any mobilisation of the kidney is essential. As often observed when utilising comparisons difficult between the patients included in the new surgical techniques. Most studies have to increase. tp. Although the literature reports on a low incidence important factor. The age and the size of the patient these carefully selected cases tend to have smaller localised are also important factor to consider. The choice of impact of an experimental process through a learning curve.amegroups. sampling of lymph nodes and management of oncological patients. Improvements in length of stay is affected by the surgical modality (12). Although surgical feasibility is not the main focus modality if specimen removal. including small sample sizes and lack of control prolonged and procedure could become more unsafe (20. however operative time would likely be mentioning. surgical technique. It is suggested however. instrumentation. All rights reserved. Others have focused on utilisation of neoadjuvant chemotherapy varies. if studies are either not submitted or spectrum shifts from WT to renal cell carcinoma that tends publications not accepted (49). that adding a WT. nasogastric tube and The location of the tumour is important. the may be underreported. technical innovations and surgical advances making MIS but management in accordance to the strict oncological in solid tumours more feasible. details of surgical important factors that have allowed this development (24). surgical trainees are exposed to higher volumes of MIS As commonly seen in paediatric surgical subspecialities. Patient selection seems critical. insufflation parameters. and polar © Translational Pediatrics. From a pathological perspective. The majority of studies approach in the surgical management of paediatric renal published have naturally included size of the tumour as an tumours. In general the distance from lateral aspect of vertebra on CT (7. in particular due to vulnerability retrieval method are just a few of the aspects that need and life expectancy. and experience is required to overcome the time (7). The patients are not randomized. As the new generations of consideration (7. and thus outcomes will be biased. Post-operative management to present as a tumour of smaller size (2). and the studies Duarte et al. as is the case in other paediatric solid tumours (25). in relation to narcotic medication. considered to be because MIS played a small role at the learning curve. A surgeon performing these operations in paediatric urological oncology until recently.27). if pre- There is a higher threshold for safety and experience for the operative chemotherapy should be mandatory and the paediatric patient group.27). further clarification.

Laparoscopic approach for Wilms tumor. the multimodal approach 6. Suita S. Kelsey A. as well as Conflicts of Interest: The authors have no conflicts of interest providing intensive treatment for high-risk patients (17). Jones PM. Improvement in identification of tumours amenable to NSS and MIS. Another important question that will need to be indication for MIS in renal tumours. The growing interest in MIS for renal tumours cannot 4. The overall survival rate. Mitchell C. The treatment of trials or controlled clinical trials. Collaboration between cancer study group (UKCCSG) second Wilms' tumour specialized centres is needed to accomplish this. both oncology and laparoscopy. Age be denied and the increasing numbers of publications prove distributions. Open partial nephrectomy or None.101:417-20. Unfavourable events were registered in 8% if the 1. Guerrero Ramos F. et al. and were statistically more likely in right-sided Vázquez F. Laparoscopic management of renal tumours in children tumours are easier to treat surgically and more amenable to concerning indications and contra-indications. The surgical MIS. Kinoshita Y. could potentially increase Acknowledgements the number of patients eligible for minimally invasive partial nephrectomy (30). All rights reserved. et al.83:602-8. however a case of WT addressed is where these procedures should be performed. A proposed reason for this is Evidence for a delay in diagnosis of Wilms' tumour in the less therapeutic options in cases of relapse after a more UK compared with Germany: implications for primary intensive primary treatment (14). care for children. as evaluation to be undertaken for the next trial based on these post-operative radiotherapy is likely to be required (27). which were usually classified as or treated as malignant tumours. preferably randomized clinical 5. Japan. The aim is for prospective data acquisition and large lymph nodes observed on the abdominal CT scan. exist in the rarity of these tumours. although able to offer the treatment. The influence on 5-year event-free survival did not 2. Challenges study. larger tumour volume at surgery and an older Surg Laparosc Endosc Percutan Tech 2014. laparoscopic radical nephrectomy should not compete. Randomization of patients Wilms' tumour: results of the United Kingdom Children's however. birth weights. Malkan AD. Bahrami A. which could be explained by effective masses in pediatrics. tp. Beckwith JB.14).774 patients from SIOP 9301 with unilateral WT evaluated clinical factors and how it influenced the References rate of intra-operative tumour rupture and incomplete resection.47:260-7. patient. Breslow NE. Loh A. et al. Arch Dis Child 2016. Footnote Challenges continue to remain to reduce morbidity from over-treatment of low-risk patients. Pediatrics 2015. López patients.24:22-5. 3. Pritchard-Jones K. An approach to renal reach significance. Pediatr studies comparing MIS to open surgery in renal tumours Blood Cancer 2006. Close collaboration between the procedure is well accepted in adults. and current recommendations favours PN (7. Study protocols are in and outcome of Wilms tumors with a favorable histology the process of being renewed and these will implement the in Japan: a report from the Study Group for Pediatric role of MIS in renal tumours. guidelines (7). Perlman EJ. J © Translational Pediatrics.312 Eriksen et al. Additional heterogeneity in the pathogenesis of Wilms tumor. and that the strategy needs further assessment. adjuvant therapy.5(4):305-314 . et al. in children are required. benign renal tumours. Findings of locally advanced tumour and metastatic panel in the SIOP RTSG has planned to develop guidelines disease will usually exclude the option of MIS. Vena caval thrombus is generally considered a contra. was significantly lower. A review of 1. and define recommendations Solid Malignant Tumors in the Kyushu Area. van Tinteren H. et al.com Transl Pediatr 2016. Graf N. tumours. Cabezalí Barbancho D. however. only high-volume centres The potential of laparoscopic nephron-sparing approach with surgeons sub-specialized in the field of MIS may be to renal tumours in children is highly uncertain. MIS in NSS every centre involved in the management of renal tumours could be an alternative approach however in a highly in children would be needed in order to select patients with selected patient group.135:142-58. with renal vein thrombus has been successfully treated with With the emphasis on a high level of surgical experience in a 3-port retroperitoneal laparoscopic technique (21). Br J Cancer 2000. nephrogenic rests. It has been for MIS in nephroblastoma in the upcoming new treatment argued however that MIS could be indicated if there are protocol. may prove to be difficult.amegroups. Tajiri T. to declare. et al. Clinical characteristics and differences between protocols.

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