Laparoscopic approach for gonadectomy in pediatric patients with intersex disorders

Abstract

The birth of a child with a disorder of sex development (DSD) prompts a long-term management strategy that involves a myriad of professionals working with the family. There has been progress in diagnosis, surgical techniques and in understanding psychosocial issues related to this condition. However, since these kinds of disorders are rare and have many anatomical variations, individual care is necessary, especially regarding surgical management. Gonadectomy is indicated in a number of intersex disorders with a Y chromosome to reduce the associated risk of cancer. Recently, laparoscopy has gained wide acceptance in pediatric urology. Laparoscopy is also reported to be a useful tool for diagnosing and treating DSD because of its minimal invasiveness and favorable cosmetic outcome. However, reports of evaluation and management using laparoscopy for large numbers of DSD patients are limited and debate is still open about indications and timing of gonadectomy. In this study, we reviewed the literature of the last 10 years about the role of laparoscopic gonadectomy in patients with DSD. In the analyzed papers, all the procedures were accomplished successfully using laparoscopy. No conversions to open surgery neither intra-operative complications were reported in all series. Post-operative complications were reported only in one series and included 1 umbilical port infection [2% (1/50)] and 1 pelvic abscess [2% (1/50)], both treated with antibiotic therapy (grade I Clavien-Dindo). Of the analyzed series, 7/10 reported postoperative diagnosis of gonadal tumors. The histopathologic examinations revealed 15 cases of gonadoblastoma, 7 cases of dysgerminoma and 2 cases of seminoma. Analyzing the single series, the incidence of these tumors varied between 10% and 33%. The results of our review confirmed the safety and efficacy of laparoscopic gonadectomy in DSD patients. In our mind, laparoscopic gonadectomy should be accepted as the treatment of choice in children and adolescents with these rare conditions. It thereby eliminates the risk of malignancies of gonadal origin with the advantages of a minimally invasive procedure, with lower morbidity, quicker postoperative recovery and excellent cosmetic results.

The role of laparoscopy in paediatric and adolescent gynaecology.

“…Gonadectomy is indicated in many gender differentiation disorders associated with the Y chromosome to reduce the associated cancer risk [ 29 , 30 ]. In patients with intra-abdominal gonads, laparoscopy plays a very important diagnostic role in locating the gonads and determining the pelvic anatomy, while assuming a therapeutic role in the removal of dysgenetic gonads and residues from Mullerian ducts.…”

“…Before the era of laparoscopy, the localisation of intra-abdominal gonads was difficult because various imaging methods (including ultrasonography, computed tomography, and even magnetic resonance imaging) had low diagnostic sensitivity. Thus, laparotomy and bilateral gonadectomy were the traditional procedures for people with impaired gender differentiation [ 29 , 31 ]. At present, laparoscopy provides good visualisation of the surgical field, which enables accurate pelvic control and accurate location of gonads.…”

“…In cases when the location of gonads is difficult to identify, their situating is aided by revealing the vessels supplying gonads and then the gonadal tissues. The gonadectomy is performed after the ureter is revealed and the precise localisation of the course of the ureter and fallopian tubes is provided, to reduce the risk of their damage [ 29 ].…”

“…Postoperative complications were demonstrated only in one study, where the umbilical port infection was present (2% (1/50)) in one case and pelvic abscess (2% (1/50)) in the other. Both cases were treated conservatively with antibiotics [ 29 ]. In the material presented, the authors emphasise the advantages of a minimally invasive procedure, which is associated with lower risk of mid- and postoperative complications, faster recovery, and good cosmetic results.…”

“…In the material presented, the authors emphasise the advantages of a minimally invasive procedure, which is associated with lower risk of mid- and postoperative complications, faster recovery, and good cosmetic results. The latter aspect is particularly important for patients with gender differentiation disorders, who require confirmation of their good body image and self-esteem [ 29 ].…”