Results

Table 1 presents outcomes of six series of transperitoneal laparoscopic radical nephrec-tomy. Tumor size and stage and perioperative parameters including blood loss and length of stay are presented.

Results of laparoscopic radical nephrectomy are similar if not better than traditional open radical nephrectomy.

As with any relatively new procedure, most authors describe a learning curve, with results improving over time. Comparative series show a trend with experience to shorter operative times and less blood loss. In addition, the indications for this procedure continue to grow as surgeons treat more complex presentations including larger tumors. Nevertheless, there is a growing enthusiasm for laparoscopic nephron-sparing surgery to treat smaller lesions.

Complications associated with laparoscopic radical nephrectomy are similar to those associated with open surgery (Table 2), including injury to adjacent organs, bleeding, infection, port site or wound herniation, peritonitis, and postoperative ileus (9,22-27).

The incidence and severity of intraperitoneal adhesions associated with transperitoneal laparoscopic surgery have been shown to be significantly less than noted after open abdominal surgery (28). However, specific vascular complications associated with the dissection and ligation of the renal vessels may occur, e.g., clip misfire during renal artery ligation due to significant atherosclerosis may lead to vessel

TABLE 1 ■ Laparoscopic Radical Nephrectomy Series

Author

No. of pts

Transperitoneal

Retroperitoneal

Conversion to open (%)

Blood loss (mL)

Tumor size (cm)

Comp major

Comp minor

stay (day)

OR time (min)

T1

Stage T2 T3

T4

Wille

125

125

None

2 (1.6)

210

5.1

6

NA

I

6

200

78

12

28

0

et al. (19)

Ono

103

85

18

4

254

3.1

10

3

M

NA

282

102

0

1

0

et al. (5)

Gill

100

27

73

2

212

5.1

14

3

I

1.6

179

63

11

4

1

et al. (4)

Dunn

61

58a

3

NA

172

5.3

2

21

M

3.4

330

9

32

1

0

et al. (3)

Janetschek

73

73

None

0

170

3.8

5

3

I

7.2

142

59

0

9

0

et al. (20)

Barrett

72

72

None

6

NA

4.5

6

2

M

4.4

175

8

61

3

0

et al. (21)

aThree cases were intentionally combined retroperitoneal and transperitoneal. Abbreviations: OR, operating room; I, intact; M, morcellated.

The contents of Gerota's space, including all the adipose tissue surrounding the kidney, should be developed and removed en bloc.

Specimens can be extracted either by extending the umbilical trocar site incision or with a small suprapubic incision. Transvaginal extraction has also been reported.

Results of laparoscopic radical nephrectomy are similar if not better than traditional open radical nephrectomy.

Complications with laparoscopic radical nephrectomy are similar to those associated with open surgery, including injury to adjacent organs, bleeding, infection, port site or wound herniation, peritonitis, and postoperative ileus.

TABLE2 ■ Complications Associated with Laparoscopic Radical Nephrectomy

Intraoperative bowel injury Small bowel Duodenum Colon Splenic injury Liver injury Vascular injury Bleeding

Clip misfire and/or slippage EndoGIA misfire Abdominal wall hematoma Intraperitoneal abscess Peritonitis

Complications occurring during transperitoneal laparoscopic nephrectomy are slightly different compared to retroperitoneal laparoscopic nephrectomy. During dissection of the renal hilum, the renal vein, may require retraction to allow adequate visualization of the renal artery. Aggressive retraction, particularly on the left side, may lead to bleeding from venous tributaries. This is usually not an issue when employing a retroperitoneal approach.

crush injury proximal to the clips and hemorrhage. In addition, EndoGIA misfire can occur if a dense structure (i.e., fibrotic or calcified vessel, adjacent metal clip, etc.) is inadvertently caught within the jaws during engagement. Precise dissection of accessory vessels minimizes intraoperative blood loss.

The complications occurring during transperitoneal laparoscopic nephrectomy are slightly different compared to retroperitoneal laparoscopic nephrectomy. In fact, during dissection of the renal hilum, the renal vein, which is commonly anterior to the renal artery, may require retraction to allow adequate visualization of the renal artery. Aggressive retraction, particularly on the left side, may lead to bleeding from venous tributaries (including the adrenal vein). This is usually not an issue when employing a retroperitoneal approach. There is also a decreased risk of trauma to intra-abdominal organs when using the retroperitoneal approach.

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