title: What's the best minimal invasive approach to pediatric nephrectomy and heminephrectomy: conventional laparoscopy (CL), single-site (LESS) or robotics (RAS)?
abstract: BACKGROUND
  Conventional laparoscopy (CL) using 3-5 mm ports has become the goldstandard for pediatric nephrectomy (N), heminephrectomy (HN) and heminephrecto-ureterectomy (HNU) for many years now. Recently the spectrum of minimal invasive surgery (MIS) has been extended by variants like laparoendoscopic single-site surgery (LESS) or robot-assisted surgery (RAS). However such technical developments tend to drive surgical euphoria and feasibility studies, but may miss adequate academic research about function and proven patients' benefits. This article delivers a comprehensive analysis of present pediatric studies comparing at least two MIS approaches to N, HN and HNU.
  
  
  METHODS
  A systematic literature-based search for studies published between 2011-2016 about CL versus LESS or RAS for pediatric N, HN, and HNU was performed using multiple electronic databases and sources. The level of evidence was determined using the Oxford Centre for Evidence-based Medicine (OCEBM) criteria. Single arm observational studies about N, HN or HNU using CL, LESS or RAS as well as publications including adult patients were excluded.
  
  
  RESULTS
  A total of 11 studies met defined inclusion criteria, reporting on CL versus LESS or RAS. No studies of OCEBM Level 1 or 2 were identified. Performing CL for N and HN limited evidence indicated reduced analgesic requirements and shorter hospital stay over open surgery, but longer operating time. Preservation of renal function of the remaining moiety after CL-HN was 95%. Importantly, of patients losing their remaining moiety, median age at surgery was 9 months (range, 4-42 months), and all except 1 (6/7) had an upper pole HN. Several authors compared TNP versus RPN access for CL and confirmed a longer operating time for RPN versus TPN-NU. Moreover one study reported a longer ureteric stump in RPN versus TPN-HNU (range, 2-5 cmvs.3-7 mm). Disadvantages of LESS or RAS over CL were longer operative time and higher total costs (RAS). There were no differences regarding complications, success rates, or short-term outcomes between pediatric RAS versus CL. No long-term studies about preservation of renal function or length of ureteric stump using LESS or RAS could be retrieved.
  
  
  CONCLUSIONS
  Several approaches to MIS-NU and HNU are available today. CL represents the method of choice for any age group. TPN or RPN can be chosen according to age of the patient. LESS and RAS offer distinct advantages, but also lack evident patients' benefits over CL at present. Hopefully, as pediatric MIS advances over the next decade, larger studies comparing CL, LESS or RAS directly for pediatric NU and HNU will be published to gain a higher level of evidence what's really best for the child.
authors.affiliation: Department of Paediatric and Adolescent Surgery, Medical University of Graz, Graz, Austria.
authors.forename: Holger
authors.initials: H
authors.lastname: Till
authors.affiliation: Department of Paediatric and Adolescent Surgery, Medical University of Graz, Graz, Austria.
authors.forename: Ali
authors.initials: A
authors.lastname: Basharkhah
authors.affiliation: Department of Paediatric and Adolescent Surgery, Medical University of Graz, Graz, Austria.
authors.forename: Andras
authors.initials: A
authors.lastname: Hock
keywords: Paediatric; laparoendoscopic single-site surgery (LESS); laparoscopy; nephrectomy; urology