Preoperative Preparation Specific Investigations

Preoperative evaluation includes full history and physical examination, routine blood tests, including group and save, and anesthetic assessment. It should be appreciated that despite the many advantages of the laparoscopic approach to the patient, laparoscopic nephrectomy is a major procedure with significant mortality. Abdominal contrast computed tomography provides information regarding the size of the kidney and renal pelvis, the presence of stones or inflammation, vascular anatomy, and the state of the contralateral kidney. A nuclear renogram and diethylenetriaminepenta-acetic acid scan provides important functional information to determine whether ablative surgery is appropriate. Ultrasound performed immediately prior to surgery, to re-assess the size of the renal pelvis and renal movement with respiration (as a marker of perirenal fibrosis) may also be helpful.

Upper Urinary Tract Drainage

A grossly enlarged hydronephrotic kidney, especially in the presence of infection should be drained, either with stent or preferably nephrostomy tube placement, at least 4 weeks prior to ablative surgery. The resulting reduction in size facilitates dissection. A delay of at least six weeks in the infected kidney will permit much of the associated inflammation to settle, thus facilitating the dissection. Urine from the obstructed kidney, collected at the time of drainage, should be sent for culture, and antibiotics commenced as appropriate. Mid-stream specimen of urine test is unreliable as a predictor of upper urinary tract infection in the presence of upper urinary tract obstruction (8). Uncomplicated hydronephrosis may be drained with a ureteric catheter at the time of laparoscopic nephrectomy to decompress the kidney and facilitate ureteric identification (9), however this maneuver is not essential (10).

Bowel Preparation

This is not performed routinely for laparoscopic nephrectomy for benign diseases. If preoperative imaging is suggestive of xanthogranulomatous pyelonephritis, full bowel preparation is recommended in case bowel injury occurs or bowel resection is required.

Informed Consent

Patients must be warned of the (small) risk of conversion to open surgery, particularly those with inflammatory conditions in which the risk is even greater. The kidney to be removed should be confirmed with the patient, and the patient is marked with indelible ink. Side should be indicated clearly on the operating list and the patient's consent form.

TECHNIQUE Description

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