Patient Positioning and Trocar Placement

For most transperitoneal renal surgery, the patient is initially positioned supine for intravenous (IV) access, the induction of general anesthesia, and endotracheal intubation. A bladder catheter and orogastric tube are placed for decompression of the bladder and stomach during insufflation, trocar placement, and dissection. Sequential compression stockings are placed for deep venous thrombosis prophylaxis. When performing transperitoneal procedures, including robotic and LESS surgeries, patients are positioned in a 30- to 45-degree flank-up position. Care is taken to pad all pressure points. The patient is secured to the operating table to allow lateral tilting of the table (Fig. 55–1). Tilting the table away from the affected kidney will help move bowel out of the operative field. There is no need to flex the table or use a kidney rest as there is with open surgery. The equipment in the operating room is situated to maximize the use of space and allow all members of the surgical team to view the procedure (Fig. 55–2). During the skin preparation and draping, the entire flank and abdomen are included in case conversion to an open procedure is required.

Figure 55–1 The patient is placed in a modified flank position, with the operative side tilted up 30 to 45 degrees using a gel roll or a rolled blanket supporting the back. The lower arm is placed on a padded armrest, and the other arm is flexed at the elbow and rested over the chest. Wide cloth or silk tape is used to secure the patient to the operating table to allow for table rotation during the surgery.

Figure 55–2 The operating room configured for left nephrectomy. Two monitors allow the assistant to follow the procedure. The scrub tech is positioned to easily assist with instrument passage and exchange.

Once a pneumoperitoneum is established, three to five trocars are initially placed to complete the dissection (Fig. 55–3). There are a variety of trocar configurations that are effective for each procedure.

Figure 55–3 Trocar sites for left-sided (A) and right-sided (B) procedures. A 12-mm trocar is placed lateral to the rectus at the level of the umbilicus, a second 10-mm trocar is placed at the umbilicus, and a 5-mm trocar is inserted in the midline between the umbilicus and the xiphoid process. C, In obese patients, all trocars are shifted laterally. Optional accessory subcostal, subxiphoid, and low midline trocar positions, which may be helpful for retraction, are also shown.

A 12-mm trocar is placed lateral to the rectus at the level of the umbilicus; this trocar is used for instrumentation and the passage of sutures, bulldog clamps, or staplers to secure and divide hilar vessels. In short patients, this may be placed in the midline, halfway between the umbilicus and pubis. A 10-mm trocar is placed at the umbilicus for the camera, and a 5- or 10-mm port is inserted in the midline 2 cm below the xiphoid process. In obese patients, all trocar sites are moved laterally (see Fig. 55–3C). Additional trocars for retraction may be needed for visualization or assist with organ entrapment (Fig. 55–4).

Figure 55–4 Options for additional trocar placement and instrumentation. A, Additional retraction during left-sided procedures can be accomplished with the use of a blunt instrument passed through a 5- or 10-mm trocar placed above the symphysis pubis, or a 5-mm instrument and retractor passed through a subcostal incision. B, In right-sided procedures, the liver and bowel can be retracted through a 3- or 5-mm trocar placed in the midline. C, In right-sided procedures, the liver and bowel can be retracted through a 5-mm trocar with a 5-mm instrument. An optional 10-mm lower midline trocar may also be placed for retraction, freeing the two other working hands for dissection.

Patient Positioning and Trocar Placement

Using this approach, patients are placed in a full-flank position. Modest table flexion can help increase the distance between the ribs and iliac crest to facilitate trocar placement. An axillary roll is required, as well as care in securing the patient to the bed. Arms may be secured on pillows or a purpose-built armrest. A 15-mm transverse incision is made in the posterior axillary line, midway between the tip of the 12th rib and the iliac crest (Fig. 55–5A). After deepening the dissection downward through the lumbodorsal fascia, the retroperitoneum is entered, and a working space may be developed using blunt dissection with the tip of a finger in the space between the psoas muscle and the kidney (Fig. 55–5B). A simple balloon created from two fingers of a size-8 or -9 glove may then be inserted and filed with CO₂ or saline to further develop the retroperitoneal working space (Fig. 55–5C). A blunt tip trocar is then passed through the incision, and the trocar cuff is expanded and cinched to the skin to prevent leakage of CO₂ (Fig. 55–5D). An alternative entry approach involves entry with the 0-degree lens and visual obturator through the initial incision (Fig. 55–6A). Entry into the retroperitoneum may be confirmed by the appearance of the characteristic yellow retroperitoneal fat, insufflation is initiated, and blunt dissection using only the laparoscope is performed to develop a working space (Fig. 55–6B). Caution must be used not to enter too anteriorly because inadvertent peritoneal entry or colon injury may occur; entering too posteriorly may result in bleeding from the quadratus lumborum or psoas muscles. Once the working space is established through either approach, pertinent structures may be identified for orientation and additional trocars placed. Typically, a 5-mm trocar is placed just off the tip of the 12th rib, and a 12-mm trocar is placed posteriorly and superiorly relative to the camera port (see Fig. 55–5A).

Figure 55–5 Trocar placement for retroperitoneal kidney surgery. A, With the patient in the full lateral position, the hips flexed, and the kidney rest elevated, a 15-mm incision is made 2 cm below the tip of the 12th rib, between the rib and the anterior superior iliac spine. B, The index finger is inserted through the incision and used for blunt dissection to create a hole from the skin through the muscle into the retroperitoneal space. If the finger is in the correct position, the surgeon should feel the smooth surface of psoas muscle and the lower pole of the kidney covered by Gerota fascia. C, To quickly create the working space, insert a balloon created from the finger of a size 8 or 9 glove, secured with silk suture over a simple red rubber catheter. The balloon is then filled with 600 to 800 mL of saline. D, A Blunt Tip Trocar (U.S. Surgical, Norwalk, CT) is used to seal the trocar site. Because of its low profile, it will not obstruct the view or take up useful space in the retroperitoneum. The balloon/collar configuration eliminates the need for sutures and allows 360-degree rotation.

Figure 55–6 A, Standing behind the patient, the surgeon initially develops a space bluntly between the psoas muscle and the kidney using the visual obturator with the 0-degree laparoscope through it. B, Together, they are used to bluntly push the peritoneum medially, creating a working space large enough to allow placement of additional trocars.

The greatest limitations of the retroperitoneal approach are the limited working space and more subtle anatomic landmarks. The smaller working space limits the distance between trocars, potentially leading to awkward hand positioning. Also, the pathology is much closer to the lens, and frequent smudging of the tip may occur. If additional space is needed during the procedure, initial retroperitoneal access can be expanded to a transperitoneal approach through opening the peritoneum under direct vision. Despite these limitations, the retroperitoneal approach may be preferred in some cases, and with adequate experience, a wide variety of laparoscopic renal surgery may be performed.

Patient Positioning and Trocar Placement

The patient is positioned just as for pure laparoscopic kidney surgery. The initial incision is for the hand port that is made through the skin and fascia and into the peritoneal cavity. Location will depend on handedness of the surgeon, operative side, and body habitus of the patient (Figs. 55-7 and 55-8). Care must be taken to avoid making the incision too large, because gas may escape, making the procedure more difficult due to decreased working space. Once the hand-assisted device is placed, the peritoneum is insufflated, and the additional trocars may be placed under direct vision by placing the camera through the hand port.

Figure 55–7 Port placement for a right-handed surgeon for hand assistance. A, For a right-sided kidney, the hand-assisted device is placed in the right lower quadrant for insertion of the left hand, and dissection is performed with instruments in the right hand placed through an umbilical trocar. The camera is placed several centimeters above the umbilicus in the midline. On the right side, retraction of the liver is usually necessary to allow visualization and dissection of the renal hilum. A liver or bowel retractor can be placed through a subcostal trocar to assist with visualization or irrigation/aspiration. B, For the left kidney, the hand-assisted device and left hand are placed though a periumbilical incision and dissection is performed with the right hand using an instrument placed in the subcostal margin just medial to the nipple. The camera is placed several centimeters lateral to the edge of the actual hand-assisted device (not the edge of the incision). Additional assistance can be delivered through the most lateral trocar site.

Figure 55–8 Port placement for a left-handed surgeon for hand assistance A, When operating on the right kidney, a left-handed surgeon places the hand-assisted port in the periumbilical location for insertion of the right hand. The working port for the left hand is placed lateral to the rectus muscle, in line with or just inferior to the level of the umbilicus. The camera is placed through a lateral trocar in the anterior axillary line. Additional assistance with retraction of the liver can be accomplished through a subcostal trocar. B, For a left-handed surgeon operating on the left kidney the hand-assisted port is placed in the left lower quadrant for insertion of the right hand. The left hand works with the instrument passed through an umbilical trocar, and the camera is placed midway between the umbilicus and the xiphoid process. Additional assistance with retraction or aspiration can be accomplished through a fourth trocar placed at the subcostal margin.

There are some limitations in location of port placement, and the hand may potentially get in the way of visualization or dissection instrumentation. Some leakage of gas may occur about the device, resulting in difficulty in maintaining the pneumoperitoneum. These devices exert 30 to 100 mm Hg of pressure on the arm, which may account for surgeons developing tingling, numbness, or pain in the forearm or hand (Monga et al, 2004).

Patient Positioning and Trocar Placement

Patient positioning will depend, in part, upon tumor location if partial nephrectomy is to be undertaken. In addition, the timing of docking the robot must be considered because with the robot docked, table rotation will not be possible. The entire procedure may be performed with the aid of the robot, or the initial part of the operation may be performed using standard laparoscopy, with use of the robot only for tumor excision and renorrhaphy.

Most authors prefer a flank position with the table modestly flexed (Aron et al, 2008; Deane et al, 2008; Benway et al, 2009). As the robotic procedure requires more trocars than standard laparoscopy, this allows more adequate spacing of instruments and less clashing of the robotic arms. Inclining the table may provide additional space at the back of the patient for the robot and other equipment (Fig. 55–9).

Figure 55–9 Operating room configured for left-sided robotic-assisted laparoscopic partial nephrectomy.

Robotic trocars plus the additional assistant and camera ports are typically used for the procedure. A port-in-port technique of robotic-assisted partial nephrectomy (RaPN) has also been described, wherein the righthand and lefthand working ports are actually standard 12-mm laparoscopic ports (Aron et al, 2008). The robotic 8-mm ports are inserted through these 12-mm ports to perform RaPN. This arrangement can be advantageous in event of an intraoperative complication or robotic malfunction, wherein emergent conversion to pure laparoscopic surgery is necessary. The robot can be undocked expeditiously and standard LPN performed in the usual fashion without requiring additional time to insert new ports or working through 8-mm robotic ports that preclude passage of the necessary CT-1 or CT-X needles.

A three-arm configuration includes four to five total trocars, a 12-mm periumbilical camera port, an 8-mm subcostal robotic trocar in the anterior axillary line, an 8-mm robotic trocar in the posterior axillary line placed above the iliac crest, and one 12-mm assistant trocar in the low midline to allow passage of sutures, bulldog clamps, suction, or retraction. An additional 12-mm subxiphoid trocar may be used, if necessary, for additional retraction or passage of bulldog clamps if the angle is more optimal (Fig. 55–10A). A four-arm configuration involves five to six total trocars, using the same general configuration as the three-arm technique, but shifting the robotic trocars slightly to avoid clashing of the arms (Fig. 55–10B).

Figure 55–10 Trocar placement for robotic-assisted laparoscopic renal surgery. A, Three-arm system configuration. B, Four-arm system configuration. A, assistant trocars, R, robotic trocars, C, camera port.

The shortcomings of the device include the initial capital investment and ongoing disposable expenses that make robotic procedures more expensive than other laparoscopic approaches. In case of instrument malfunction, the surgeon must either have laparoscopic skills or abort and perform the surgery in an open manner. Robotic cases also require a skilled bedside assistant and use more, and potentially larger, port sites, whereas most laparoscopic renal procedures can be completed in a solo fashion using a mechanical endoscope holder and two working trocars.

Patient Positioning and Trocar Placement

Because LESS surgery remains a procedure in evolution, there is no widely accepted method of positioning or gaining access. Modified and full-flank positioning have been described and are identical to standard transperitoneal or retroperitoneal kidney surgery, respectively. Once pneumoperitoneum has been established, one may cluster multiple traditional low-profile trocars close together within a single, small extraction incision (Fig. 55–11). Alternatively, newer purpose-specific access devices (Fig. 55–12) may be used in combination with conventional laparoscopic or flexible instrumentation. The devices are secured using preplaced fascial sutures or with an inner and outer ring drawn together with a cylindrical sleeve. Characteristics of single-site access options are described in Table 55–1.

Figure 55–11 Laparoendoscopic single-site surgery performed using three low-profile trocars inserted through a single small extraction incision. A flexible laparoscope and flexible instrumentation may be used.

(From Tracy CR, Raman JD, Cadeddu JA, Rane A. Laparoendoscopic single-site surgery in urology: where have we been and where are we heading? Nat Clin Pract Urol 2008;5:561–8.)

Figure 55–12 Purpose-specific devices for laparoendoscopic single-site surgery. A, The TriPort system (Advanced Surgical Concepts, Bray, Ireland). B, The Uni-X system (Pnavel Systems, Cleveland, OH). Both allow for passage of multiple instruments through a single incision.

Table 55–1 Access Options for Laparoendoscopic Single Site (LESS) Surgery

These approaches are technically challenging and the most difficult of the minimally invasive techniques. To date, no differences in postoperative morbidity or recovery have been reported (Raman et al, 2009). Advances in instrumentation may increase applicability and dissemination into mainstream urologic practice.

NOTES involves using a natural orifice to perform the entire operation. In the gastrointestinal (GI) and surgical literature, the mouth, vagina, and rectum have been used to remove organs such as the appendix and gall bladder (Rao et al, 2006; Zorron et al, 2007; Palanivelu et al, 2008). In urology, to date experience with pure NOTES surgery in humans is limited (Kaouk et al, 2009). Several authors have reported hybrid approaches with NOTES and standard laparoscopic techniques, using the vagina as an access and extraction site for nephrectomy (Branco et al, 2008; Alcaraz et al, 2010; Sotelo et al, 2010).

Reflection of the Colon

For a left nephrectomy and all renal surgery, the line of Toldt is incised from below the lower pole of the kidney inferiorly to above the spleen superiorly (Fig. 55–13). The inferior limit of this incision may be extended inferiorly, if the bowel does not move sufficiently. The lienocolic ligament should be incised to allow the spleen to fall medially along with the pancreas and the colon (see Fig. 55–13). Care must be taken to avoid injuring the diaphragm with this maneuver. The thin colorenal attachments are incised and the colon is swept medially (Fig. 55–14). Care should be taken to avoid making a hole in the mesentery. Mesenteric fat has a brighter hue of yellow compared with the retroperitoneal or Gerotas fat, which allows for identification of the correct plane of dissection. If the operative field is not adequately visualized, a paddle retractor may be placed in an additional lower midline trocar to aid in retracting the colon, pancreas, and spleen medially (see Fig. 55–4A). Blunt and sharp dissection is necessary to move these structures off the anterior surface of the kidney and hilum.

Figure 55–13 Incision of the white line of Toldt with endoshears, bipolar cautery, or ultrasonic energy allows reflection of the colon. Continuing superiorly allows incision of the lienocolic ligament, facilitating reflection of the spleen, pancreas, and colon.

Figure 55–14 Medial traction on the colon helps identify additional colorenal attachments and assists in differentiating the undersurface of the large bowel mesentery. Care must be taken at this step to avoid creating a mesenteric window.

During a right-sided nephrectomy, the peritoneal incision is carried medially and parallel to the lateral border of the venacava and duodenum. A lateral (anterior axillary line) or high midline port may be needed to retract the liver anteriorly (see Fig 55–4B and C). Care must be taken to avoid thermal injury to the duodenum and gall bladder during incision of the peritoneum. Medial traction on the colon reveals colorenal attachments that must be divided to complete the colon dissection. Again, a low midline retractor may be helpful for visualization. A Kocher maneuver may be required to fully expose the medial portion of the kidney and the connective tissue overlying the renal hilum (Fig. 55–15).

Figure 55–15 On the right side, the colon is reflected, and a Kocher maneuver may be performed to completely expose the kidney and the renal hilum.

Dissection of the Ureter

Once the colon has been adequately mobilized, the psoas muscle and tendon should be identified. Following this structure medially, the gonadal vessels are usually first encountered. These should be swept medially and the ureter is usually located just deep to these vessels. Peristalsis of the ureter can help differentiate between these two structures. Once identified, the ureter is elevated and followed proximally to the lower pole of the kidney. The ureter is not divided at this time, because it can be used to help elevate the kidney (Fig. 55–16). The tissue posterior to the ureter and lower pole of the kidney is swept anteriorly to further expose the psoas muscle. Care should be taken to try and stay above the psoas fascia to minimize postoperative thigh numbness. The instrument in the subxyphoid trocar is used to slide under the kidney all the way to the sidewall. This allows the surgeon to lift the kidney and place medial lymphatic and vascular attachments on stretch.

Figure 55–16 A curved dissector, in the left hand, is placed beneath the ureter and used to provide anterolateral elevation. On the right side the angle of insertion from the gonadal to the vena cava can be a source of significant bleeding if torn during elevation.

Identification of the Renal Hilum

Safe dissection of the renal hilum requires medial retraction of the colon and bowel by gravity or an additional retractor, as well as anterior retraction of the kidney, lifting it out of the renal fossa. With the ureter and lower pole of the kidney elevated, vessels entering the renal hilum can be identified and bluntly dissected using the tip of the irrigator-aspirator. Firm elevation of the lower pole assists in identification and dissection of the renal hilar vessels (Fig. 55–17). This is accomplished by gently placing the lateral grasper under the ureter and kidney until it abuts the abdominal sidewall. It is important to be sure that the grasper is against the muscle and not into the renal parenchyma. A gentle, layer-by-layer dissection is performed with the irrigator-aspirator until the renal vein is uncovered. There is usually an anterior bundle of connective tissue that needs to be incised in order to fully expose and visualize the vein. Gonadal, lumbar, and accessory venous branches can be clipped and divided as necessary.

Figure 55–17 The lower pole of the kidney and ureter are firmly retracted anterolaterally, placing the hilum on stretch. The left gonadal vein has been ligated and divided.

Securing the Renal Blood Vessels

By clearing off inferior attachments and lymphatics, one can identify the renal artery. If the irrigator-aspirator tip is not precise enough for meticulous dissection, a hook electrode can be used to dissect the lymphatic vessels free of the vein and artery. With an endovascular gastrointestinal anastomosis (GIA) stapler, the artery is divided first, followed by the vein (Fig. 55–18). We prefer to use staples in this area because three rows of staples will be left on the vessel stump and are unlikely to be dislodged during subsequent dissection. In some instances clips may be needed. We prefer to use at least five clips on the patient side, when possible.

Figure 55–18 A, First, the renal artery is stapled using an endovascular gastrointestinal anastomosis (GIA) stapler. B, The renal vein is secured lateral to the adrenal vein with the GIA stapler. If clips are used on the gonadal or adrenal vessels, the surgeon must be careful to exclude them from the jaws of the stapler.

Isolation of the Upper Pole

Once the hilar vessels have been divided, the dissection continues posteriorly and superiorly to the upper pole. The adrenal gland is preserved in cases of simple nephrectomy by staying close to the upper pole (Fig. 55–19). This is accomplished by incising the Gerota fascia anteriorly, just above the hilum. Gerota fat is then gently peeled off circumferentially above the upper pole of the kidney. At this point during the dissection, it may be necessary to clip and transect the ureter. This allows the kidney to be rotated anteriorly above the liver (right) or spleen (left) to facilitate incision of the uppermost attachments under direct vision. In cases of extreme fibrosis, a subcapsular nephrectomy can be performed once the artery and vein have been controlled (Moore et al, 1998). Long, blunt instruments, such as the closed stapler or the 10-mm Ligasure Atlas (Valleylab, Boulder, CO) are particularly well suited for reaching and freeing the upper pole attachments.

Figure 55–19 The adrenal gland can be preserved during simple nephrectomy or radical nephrectomy as indicated by dissecting it from the superior pole of the kidney.

Organ Entrapment and Extraction

The kidney can be removed intact or through morcellation. When morcellation is performed, the specimen should be placed into a sturdy entrapment sac (Urban et al, 1993). This minimizes the risk of rupture during mechanical morcellation of the tissue (Landman et al, 2000; Pautler et al, 2002). Using ring forceps and a Kocher clamp, the kidney and collecting system can be morcellated and removed in small pieces (Fig. 55–20). Alternatively, the kidney can be removed intact through an incision after placement into a sac (Fig. 55–21). The kidney can be worked out of an extended trocar site or Pfannenstiel incision. For trocar sites greater than 5 mm, it is helpful to place the closure sutures before removing the kidney. Once the sutures are placed, trocars can be reinserted for kidney entrapment and removal.

Figure 55–20 Removal of the morcellated specimen. A, The LapSac (Cook Urological, Spencer, IN) entrapment sac is introduced through the lateral 10-mm trocar site after passing a hydrophilic wire through the opening of the LapSac. The entrapment sac is then released within the abdomen. The wire facilitates opening the bag and placement of the specimen. A lateral 5- or 3-mm port may be necessary to assist with holding placement of the specimen inside the LapSac. B, Once the specimen is within the LapSac, the wire is removed, the bag cinched closed, and the opening withdrawn through the 10-mm trocar site. C, The entrapment sac is pulled tightly up against the abdominal wall, with two hands pushing part of the specimen to appear through the opening of the LapSac. After the site is carefully draped, manual morcellation with ring forceps or a Kelly clamp can be used. D, The entrapment sac is removed once the remaining specimen fragments are small enough to be extracted through the trocar site. Only the tissue visible from the opening is grasped. Blind passes into the bag may injure surrounding bowel segments.

Figure 55–21 Removal of the intact specimen. A, The camera is moved to the lateral port site and an EndoCatch device is placed through the umbilical trocar site to entrap the specimen. B, Alternatively, the specimen may be extracted through a Pfannenstiel incision. To accomplish this, the EndoCatch device is brought in through a separate 10-mm suprapubic incision. C, The trocar is then removed, bringing the EndoCatch device with it through the trocar site, and the suture is cut and clamped. D, A 4- to 6-cm incision is made including one of the trocar sites. The surgeon’s finger protects the specimen and underlying structures from injury.

Procedure

Access and trocar placement are similar to what has been described for simple nephrectomy. With larger masses, caval involvement or organ invasion, additional trocars or a hand port may be needed. The procedure for laparoscopic radical nephrectomy (LRN) is essentially identical to laparoscopic simple nephrectomy. The main distinguishing feature is that Gerota fascia is left intact during dissection. The adrenal may be removed en bloc with the kidney when indicated (Fig. 55–31A). Alternatively, this fascia is opened over the upper medial aspect of the kidney when adrenal-sparing nephrectomy is performed (Fig. 55–31B). Suspect lymph nodes may be removed, and a full hilar or retroperitoneal dissection can be carried out if deemed necessary. Excision of part of adjacent muscle or involved organs, such as the pancreas, liver, spleen, and bowel, has also been reported (Molina et al, 2004).

Figure 55–31 A, Inclusion of the adrenal gland during right laparoscopic radical nephrectomy can be readily accomplished using ultrasonic or bipolar shears to control the multiple arterial branches to the adrenal gland. Inferior retraction of the specimen facilitates exposure of this surgical plane. B, Adrenal-sparing, right radical nephrectomy. Use of a blunt instrument above the hilum to put anterior and inferior traction on the kidney helps to expose the correct plane and place the connective tissue on stretch. Ultrasonic or bipolar shears are again useful to avoid any bleeding that may be encountered in this plane.

Results

Long-term cancer-specific survival data is now widely available from multiple centers around the world that perform laparoscopic radical nephrectomy (Table 55–3). Five- and 10-year outcomes show oncologic equivalence to open radical nephrectomy in treatment of renal cancer. Indeed, LRN has become the standard of care for most renal malignancies.

Table 55–3 Oncologic Outcomes of Laparoscopic Radical Nephrectomy

A multi-institutional study from centers performing LRN compared the surgical and disease-specific outcomes between open and laparoscopic radical nephrectomy, with long-term follow-up (Portis et al, 2002). Median follow-up was 54 months, and recurrence-free survival was 91% and 92%, respectively, for the two groups at 5 years. The 5-year cancer-specific survival was 98% for the laparoscopic cohort and 92% for the open cohort.

A comparative analysis of 67 patients undergoing LRN, with 54 patients undergoing open radical nephrectomy, evaluated perioperative and oncologic outcomes (Permpongkosol et al, 2005). The LRN group showed a longer mean operative time (256 vs. 193 minutes). However, this finding likely reflects the learning curve for laparoscopy, because the first 34 patients and last 33 patients in the LRN group had a significant operative time difference. Complications occurred in 15% of patients in the LRN and open groups, and blood transfusions were required in 6% and 20% of the patients, respectively. Most importantly, the calculated disease-free survival rates for laparoscopic and open radical nephrectomy were 95% and 89%, respectively, at 10 years. The actuarial survival rates for laparoscopic and open radical nephrectomy were 87% and 75%, respectively, at 10 years. These differences were not found to be statistically significant.

Most recently, 10-year oncologic outcomes data following LRN were reported. Recurrence-free, cancer-specific, and overall survival rates were 86%, 92%, and 65%, respectively, at 10 years postnephrectomy (Berger et al, 2009). Of 73 patients undergoing LRN, no patient developed local recurrence, and 6 (8.2%) developed metastatic disease at a mean time to recurrence of 74 months. Although outcomes in this study were not compared with an open radical nephrectomy cohort, results are quite comparable to those for open surgery.

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