Patterns and predictors of laparoscopic complications in pediatric urology: The role of ongoing surgical volume and access techniques

Purpose: Laparoscopic surgery in children has evolved to include complex reconstructive procedures. While complication rates are low, they can have significant consequences. In this study we define the incidence and risk factors for complications in children undergoing laparoscopic urological surgery. Materials and Methods: We conducted a retrospective analysis of all conventional and robot assisted laparoscopic urological procedures performed at our institution from 1995 to 2005. Complications were graded based on Clavien's classification. Statistical analysis was performed using the t test and Fisher's exact test. Results: A total of 806 laparoscopic procedures were evaluated. Overall, there was a 2% complication rate, including 1.6% for access related and 0.7% for procedural complications (in 440 nondiagnostic cases). Complications related to access occurred in 9 of 396 cases (2.3%) using Veress access, compared to 3 of 389 cases (0.8%) using open access (p = 0.14). The incidence of grades III and IV complications was identical between techniques (0.8%). Complications included preperitoneal insufflation sufficient to necessitate conversion to an open procedure (0.7%), vessel injury (0.4%), small bowel injury (0.4%), bleeding requiring conversion (0.1%), bladder perforation (0.1%) and vas deferens injury (0.2%). Surgeons performing more than 12 laparoscopic cases annually had a significantly lower complication rate (p = 0.024). Conclusions: The low risk of complications demonstrated in this series confirms that laparoscopic procedures are safe, although there remains a risk of significant injury. Determinants of surgical outcome include laparoscopic activity, and to a lesser extent access technique. Most if not all complications are preventable with proper adherence to technique and ongoing education.