Radical nephrectomy has long been considered the gold standard surgical treatment for renal cell carcinoma. In the past two decades, nephron sparing surgery has become the standard for treatment of small localized renal masses 4 cm or smaller, with similar oncologic outcomes being achieved. Recently, focal ablative therapy is gaining acceptance as a viable alternative for poor surgical candidates. However, for larger tumors and in carefully selected cases with metastatic disease, radical nephrectomy is still the procedure of choice.
The first reported case of laparoscopic nephrectomy was in 1991. Since then, the technique has been refined to allow surgeons to remove kidneys with tumors larger than 10 cm and tumors with renal vein involvement. Laparoscopic radical nephrectomy can be performed by either a transperitoneal or a retroperitoneal approach. Hand-assisted technique is also an option. This chapter describes the more widely used transperitoneal approach.
Indications and Contraindications
Indications for laparoscopic radical nephrectomy include clinically staged T1 and T2 kidney tumors. Some patients with T3 disease including renal vein involvement may be candidates for the laparoscopic approach. Laparoscopic cytoreductive nephrectomy can also be performed in carefully selected patients with metastatic disease.
Absolute contraindications to the laparoscopic approach to radical nephrectomy are diminishing, though there are several important factors to consider before proceeding. Anatomically, extremely large tumors (>15 cm) may make the procedure difficult because of limited working space. Also, patients with tumor thrombus extending beyond the renal vein may be best served with an open approach for optimal control of the great vessels. Tumors that extend beyond the Gerota fascia, prior history of ipsilateral renal surgery, extensive intra-abdominal surgery, and perinephric inflammation may increase the chance for the need to convert to open surgery.
Patient Preoperative Evaluation and Preparation
The preoperative evaluation of a patient undergoing laparoscopic radical nephrectomy involves routine laboratory studies. Cross-sectional imaging with either computed tomography (CT) scan or magnetic resonance imaging (MRI) is required to delineate the anatomy. Renovascular anatomy can be better defined with three-dimensional reconstruction of the contrast-enhanced CT scan.
A chest radiograph is also necessary to assess for metastatic disease. In cases of cytoreductive nephrectomy, careful patient selection with Eastern Cooperative Oncology Group (ECOG) performance score of 0 or 1 and a brain MRI to rule out metastasis are essential to ensure optimal outcomes. If there is suspicion for a renal vein tumor thrombus, MRI is preferred to evaluate the extent of vein involvement preoperatively.
Contralateral renal function should be assessed before proceeding with a radical nephrectomy. Estimated glomerular filtration rate should be calculated, and appearance of the contralateral kidney on contrast-enhanced CT should be noted. In equivocal cases, a functional nuclear medicine scan can be considered.
The adrenal glands are also carefully evaluated. In general, attempts are made to spare the adrenal gland unless it is involved by local invasion of an upper pole tumor or by a metastatic deposit.
As with any surgical procedure, patient preparation begins with a thorough informed consent. In particular, patients undergoing laparoscopic radical nephrectomy should be informed of the risk for need to convert to an open procedure, although the risk is less than 5%.
Many surgeons prefer their patients to undergo a modest bowel preparation the day before the procedure. It helps by decompressing the colon during the transperitoneal approach. Type and screen is generally sufficient, although obtaining autologous or crossmatched blood before the procedure may be prudent in difficult cases.
Operating Room Configuration and Patient Positioning
In the operating room, there should be at least two monitors available to allow visualization of the procedure by all members of the surgical team. The surgeon and the camera holder face the patient’s abdomen; the scrub nurse and any other assistant face the patient’s back. The primary monitor should be placed across the table from the surgeon at an appropriate height for optimal ergonomics ( Fig. 17-1, A ).
After the induction of general anesthesia and endotracheal intubation, an orogastric tube and a bladder catheter are placed. The patient is then positioned in a 30-degree modified decubitus position with the ipsilateral side up. The iliac crest overlies the break in the table. The ipsilateral arm is placed at the patient’s side, secured, and padded. This arm can also be placed across the chest in a “praying” position. The bottom leg is bent slightly and pillows are placed between the legs. All potential pressure points are carefully padded, including the contralateral wrist, the elbow, and both legs and ankles. An axillary roll may be needed to prevent brachial plexus injury ( Fig. 17-1, B ).
The table is then flexed (optional) approximately 30 to 45 degrees to widen the space between the ipsilateral costal margin and the iliac crest. The patient is also placed in a slight reversed Trendelenburg position so the great vessels are in the horizontal plane. The patient is then secured to the table with wide tape over the chest, hips, and legs. Rotation of the bed is tested to ensure the patient is safely secured before surgical preparation and draping. The skin is prepared from the nipples to the pubis and from the paraspinal muscles to the contralateral rectus muscle.
Trocar Placement
Intraperitoneal insufflation to 15 mm Hg is achieved with a Veress needle at the umbilicus with the table rotated slightly from the surgeon. In morbidly obese patients, the Veress needle can be inserted in the midclavicular line just off the costal margin.
In most cases three ports are sufficient to perform the procedure safely. On the right side, an additional port for the liver retractor is needed. For larger upper pole tumors, an additional port placed laterally may be helpful for upper pole and hilar dissection.
The first 10/12-mm port is placed through a periumbilical incision. An optical trocar is preferred to allow for endoscopic visualization while the trocar is introduced. The table is then rotated toward the surgeon such that the patient is at a flank position, 90 degrees to the floor. This will move the bowels medially and allow for better traction of the kidney later in the procedure. A second 10/12-mm port is then placed along the ipsilateral midclavicular line just caudal to the first port. A third port is then placed below the costal margin about one third of the way between the xiphoid and the umbilicus. For right-sided nephrectomies, a port is placed below the xiphoid for a liver tractor. The umbilical port is for the camera; the other two ports are for the surgeon. In obese patients, the ports need to be moved laterally to ensure that the instruments can complete the dissection ( Fig. 17-2 ).
Procedure (See )
After successful port placement, the following steps are followed to complete the operation:
- 1.
Incise the white line of Toldt to mobilize the colon medially.
- 2.
Identify the gonadal vessels and the ureter.
- 3.
Develop the posterior plane between the Gerota fascia and the psoas muscle.
- 4.
Secure the hilum.
- 5.
Dissect the upper pole, with or without the adrenal gland.
- 6.
Divide the ureter.
- 7.
Divide the lateral attachments.
- 8.
Entrap the specimen.
- 9.
Remove the specimen by extending the inferior trocar incision or the periumbilical trocar incision.
- 10.
Fascial closure and skin closure.
Exposing the Retroperitoneum
A 5-mm atraumatic forceps and electrosurgical scissors are used to identify and incise the ipsilateral white line of Toldt. On the right side, this is carried from the hepatic flexure down to the right common iliac artery. The colon and mesentery need to be mobilized medially to expose the Gerota fascia and the retroperitoneum ( Fig. 17-3 ). The right triangular and anterior coronary ligaments of the liver may need to be divided as well. The colonic mesenteric fat has a more pronounced yellow hue that is easily distinguishable from Gerota fascia and retroperitoneal fat. Be alert for the possibility of a retrocecal appendix that can be injured inadvertently during this portion of the procedure. The duodenum is then sharply mobilized until the vena cava is clearly visualized ( Fig. 17-4 ).
