LAPAROSCOPY ON UPPER URINARY TRACT IN CHILDREN1568

as they are indeed avoidable, and to report com-plications honestly to permit our community tocontinue learning from our shared experience. Theauthors should be congratulated for sharing thesefindings with us and focusing our attention on the

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kidney based on reflux nephropathy due to urethral

our cases. That is a critical first step in preven-tion.

Craig A. Peters

Division of Pediatric UrologyUniversity of Virginia

fact that such occurrences are possible in any of Charlottesville, Virginia

Surgery was performed by 3 pediatric surgeons whoalso perform all other open and minimally invasiveurological operations on the upper and lower urinarytracts. Furthermore, these surgeons have broad exper-tise in laparoscopic and thoracoscopic surgery coveringthe complete field of minimally invasive pediatric sur-gery. Operative times did not change relevantly dur-ing the 74-month study period mostly because of pre-vious experiences with operations in older children.

We agree that the indication for surgical proce-dures in pediatric urology must be critically as-sessed. Thus, we precisely described the indicationsfor surgery in the patient cohort. The conservativetreatment serves as the main approach for childrenwith hydronephrosis in the first year of life. Treat-ment strategies for duplex collecting systems varyfrom isolated ureterocele incision to simultaneoustotal correction of the upper and lower urinary tracts.Nephrectomy is justified in cases of a functionless

valves. We also recommend use of a 5 mm opticallens because it gives a superior overview comparedto a 3 mm lens, minimizing the risk of intestinalinjuries when using the transabdominal approach.

A major objective was to share our experienceswith the cited complication, which did not occurduring the learning curve of the operating surgeonwho had performed more than 50 minimally inva-sive pyeloplasties previously. A heated monopolarhook caused an unnoticed 2 mm lesion in the colon.In our opinion the risk of this complication was notdecreased by using a mesocolic approach. Intestinalinjury is a general risk of transabdominal minimallyinvasive surgery, particularly with the retroperito-neal approach when working space is relevantly lim-ited. Future devices such as a 3 mm harmonic knifemay help minimize the occurrence of such complica-tions. We hope that our report will remind surgeonsthat laparoscopy is still associated with significant

operative risks.