Indications

Laparoscopic simple nephrectomy is indicated in benign renal diseases where complete loss of the renal unit has occurred or is desired. Such conditions include but are not limited to:

Renovascular hypertension,

■ Obstructive or reflux nephropathy,

■ Chronic inflammatory/infection conditions including xanthogranulomatous and tuberculosis pyelonephritis (these are technically challenging),

■ Symptomatic ADPKD,and

■ Posttransplantation hypertension.

Simple nephrectomy is most commonly performed for symptomatic (pain, hypertension, and infections) and nonfunctioning renal units. The etiology of functional loss may be due to calculi, obstructive nephropathy, reflux nephropathy, poly-cystic kidney, pyelonephritis, and others. Laparoscopic nephrectomy for benign conditions has gained wide acceptance and has become the standard of care in many institutions.

Benefits of laparoscopic simple nephrectomy over open nephrectomy include decreased need for pain medication, shorter hospital stay, and quicker convalescence time (2-6).

Complication rates are equivalent or, as some reports suggest, less than the rates commonly associated with open nephrectomy.

Gill et al. reviewed 185 cases of laparoscopic nephrectomy from five centers (7). Overall, 83% of cases were performed for a benign cause. Complication rate was 16% and conversion rate was 5.4%. Fornara et al. reported a retrospective single center study of 249 patients; open simple nephrectomy was performed in 118 patients and laparoscopic simple nephrectomy in 131 patients (3). The laparoscopic group experienced decreased pain medication requirement (12 mg vs. 20 mg morphine), shorter hospital stays (4 days vs. 10 days), and shorter time to convalescence (24 days vs. 36 days). Complication rate was 20.6% for the laparoscopic group and 25.4% for the open group, respectively. Open conversion rate during laparoscopy was 6.1%. In another comparison study in which 92 patients underwent open nephrectomy and 92 underwent laparoscopic nephrectomy, the laparoscopic group had shorter hospital stay (3.9 days vs. 5.9 days), shorter time to convalescence (12 days vs. 33 days), and lower complication rates (13% vs. 31%) (5). Open conversion rate during laparascopic nephrectomy was 0.8%. Other studies have supported these findings (2,4,6).

Care must be taken when approaching patients who have undergone prior abdominal surgeries. Veress needle placement should be as far from the previous incision site as possible.

In patients with a history of prior open abdominal surgery, an open Hassn trocar placement or a retroperitoneal approach should be considered.

Obesity is not a contraindication for laparoscopic nephrectomy. Laparoscopic nephrectomy is both feasible and efficacious in the obese patient.

Recommendations for operating upon obese patients include the use of higher insufflation pressures (20 mmHg) and repositioning of the midline trocars lateral to the rectus to improve visualization and dissection. The retroperitoneal laparoscopic approach for nephrectomy is particularly advantageous in the obese patient because of avoidance of pannus and direct access to the renal hilum.

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