Introduction
Since the first report of laparoscopic nephrectomy in 1991, minimally invasive nephrectomy has become the procedure of choice for most benign pathologic conditions of the kidney and malignant renal tumors, including those larger than 10 cm or with renal vein involvement. Compared to open renal surgical approaches, several advantages to the minimally invasive approach exist. These include diminished analgesia and narcotic requirements, shorter hospital stay, improved cosmesis, and more rapid recovery.
Both robotic and traditional laparoscopic approaches may be used for simple or radical nephrectomy. Despite a significant cost advantage to laparoscopy, the growth of robotic surgery in modern urologic practice has resulted in greater use of the latter for minimally invasive nephrectomy. As such, this chapter highlights both minimally invasive techniques, focusing on the most commonly used transperitoneal approach. Hand-assisted laparoscopy and retroperitoneal approaches, which are used in practice based on the training and comfort level of the individual urologist, are also discussed.
Simple nephrectomy ( 
)
Indications and contraindications
Minimally invasive simple nephrectomy is the operation of choice for most benign renal conditions, given the diminished morbidity, less perioperative pain, and more rapid recovery than the open surgical approach. Indications and absolute contraindications for laparoscopic or robotic simple nephrectomy are listed in Box 15.1 . Minimally invasive simple nephrectomy can be performed for adult polycystic kidney disease, xanthogranulomatous pyelonephritis (XGP), tuberculosis, and other inflammatory conditions. However, some have advocated for an open approach in such cases, where a minimally invasive approach may be more challenging, require longer operative times, and carry a greater risk of complications and conversion to open surgery. Particularly for inflammatory conditions such as XGP, surgical planes may be distorted and dissection more difficult. Such cases should be attempted only by urologists with experience in minimally invasive surgery. Donor nephrectomy may also be performed through minimally invasive approaches, though the technique is slightly modified to preserve ureteral vascularity and maximize length of hilar vessels. It is not covered in detail in this chapter.
Indications
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Multicystic dysplastic kidneys
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Nonfunction as a result of obstruction, infection, trauma, or stones
- •
Renovascular hypertension
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Xanthogranulomatous pyelonephritis
- •
Renal tuberculosis
- •
Reflux nephropathy
Absolute contraindications
- •
Sepsis
- •
Untreated urinary tract infection
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Hypovolemic shock
- •
Peritonitis
- •
Uncorrected
Absolute contraindications to minimally invasive simple nephrectomy include uncorrected coagulopathy, untreated infection or sepsis, peritonitis, and hypovolemic shock. Though not a strict contraindication, morbid obesity may put patients at greater risk for complications and open conversion. Additional patient factors, such as significant contractures limiting positioning or working space, should also be considered prior to undertaking a minimally invasive approach.
Radical nephrectomy ( 
and 
)
Indications and contraindications
Indications for minimally invasive radical nephrectomy include clinical stage T1–T2 kidney tumors and occasionally patients with clinical T3 disease, including those with renal vein involvement. In carefully selected patients, cytoreductive nephrectomy for metastatic disease can also be performed using a minimally invasive approach. Removal of the adrenal gland is not routinely performed unless there is concern for adrenal involvement on preoperative cross-sectional imaging or intraoperatively. Similarly, routine lymphadenectomy is not performed in the absence of suspicious nodes on preoperative staging studies.
As experience with laparoscopic and robotic radical nephrectomy has grown, the absolute contraindications to minimally invasive radical nephrectomy are diminishing. However, several factors may be considered in deciding between an open or minimally invasive approach. Nephrectomy of very large tumors, such as those greater than 15 cm, may be challenging when performed minimally invasively due to the limited working space within the abdomen. Similarly, patients with tumor thrombus beyond the renal vein may be better candidates for an open surgical approach, which better facilitates tumor thrombus manipulation and control of the great vessels. Patients with advanced tumors invading the Gerota fascia and those with prior ipsilateral renal surgery or extensive abdominal surgery may also have a higher likelihood of requiring conversion to open surgery. Similar to simple nephrectomy, obese patients may be at greater risk of complications with a minimally invasive approach, though this is not a strict contraindication to laparoscopic or robotic radical nephrectomy.
Transperitoneal nephrectomy
Patient preoperative evaluation and preparation
Preoperative evaluation should include a careful history and physical examination, with attention to prior surgical history, abdominal scars, and contractures or skeletal abnormalities that may limit appropriate positioning. Serum laboratory tests should include a complete blood cell count, serum creatinine and electrolytes, clotting parameters, urinalysis and culture, and electrocardiogram or chest radiograph as indicated based on the patient’s age, comorbidities, and indication for surgery (i.e., radical nephrectomy for malignancy). Renal function should be carefully evaluated; those with preexisting chronic kidney disease and proteinuria should be considered for perioperative nephrology referral. For patients undergoing radical nephrectomy, liver function tests should also be obtained. Blood type and screen and the availability of two units of packed red blood cells are recommended in anticipation of any large volume hemorrhage that may be encountered intraoperatively.
Preoperative cross-sectional imaging is critical to allow evaluation of the size, position, vascular anatomy, and extent of disease within the affected kidney. Contrast-enhanced abdominal computed tomography (CT) or magnetic resonance imaging (MRI) may be obtained based on initial work-up indications and the patient’s underlying renal function. Perinephric stranding may indicate significant inflammatory reaction, which may indicate a more challenging dissection and higher likelihood to conversion to open nephrectomy. The hilar vasculature and aberrant vessels should be carefully noted, along with any significant vascular calcifications and the position of the affected kidney relative to the adjacent organs. Additionally, the contralateral kidney should be evaluated for size and relative uptake to ensure adequate function. In equivocal cases, nuclear renal scan may be performed.
For patients undergoing radical nephrectomy, careful evaluation of the adrenal gland and staging of retroperitoneal nodes should also be performed. Particularly in cases where renal vein involvement is suspected, MRI is the preferred imaging study to evaluate the extent of vein involvement. Additional staging studies, including chest X-ray or CT, should be performed prior to radical nephrectomy in order to exclude the presence of distant metastatic disease. For patients planning to undergo cytoreductive nephrectomy, brain MRI should also be obtained to rule out brain metastasis. To optimize survival outcomes for cytoreductive nephrectomy in the era of targeted therapy and immunotherapy, these patients should have good performance status and good or intermediate International Metastatic Renal-Cell Carcinoma Database Consortium/Memorial Sloan Kettering Cancer Center risk classification.
The night before surgery, a clear liquid diet is recommended. All clear liquid intake should be stopped at least 2 hours prior to surgery. Our practice is also to have the patient self-administer magnesium citrate the night prior to minimize colonic distension. A more formal mechanical bowel prep should also be considered for cases where a challenging dissection is anticipated, such as in the case of extensive inflammatory reaction. The informed consent discussion should include a review of the risks of bowel or vascular injury, as well as the possibility of conversion to an open procedure.
Operating room configuration
Laparoscopy
For laparoscopic simple or radical nephrectomy, the operating room should be arranged so that both the surgeon and assistant are positioned on the same side of the operating room table, facing the patient’s abdomen ( Fig. 15.1 ). Ready access to the patient’s airway by the anesthesia team should be ensured. The operating room technician is typically placed at the foot of the bed, where they may help exchange instruments. At least two video monitors should be used to allow visualization of the operation by all operative team members. These should be placed at eye level so that both surgeons can readily visualize these screens in an ergonomic position. The primary monitor should be placed across from the primary surgeon.
Robotic approach
Use of the robotic approach for simple or radical nephrectomy requires sufficient operating room space to accommodate both the standard operating room equipment and the robotic surgery platform. The bedside assistant and operating room technician are positioned on the same side as the patient’s abdomen to facilitate suction, retraction, and stapling, as well as any necessary robotic instrument exchanges or camera cleans during the procedure. The robot is docked from behind the patient, slightly toward the ipsilateral shoulder ( Fig. 15.2 ). Occasionally, the operating room table must be shifted or angled to accommodate maneuvering of the robot. Regardless of final bed position, adequate anesthesia access to the patient’s airway should be maintained. The surgeon console should be placed in a convenient location to facilitate intraoperative discussion and rapid access to the bedside, should this be necessary.
Patient positioning and preparation
After the induction of general anesthesia, a Foley catheter and orogastric tube should be placed. The patient is positioned with the umbilicus at the break of the bed and then rolled into a modified flank position with the laterality of interest up (i.e., left lateral decubitus for right-sided procedures). The patient’s bottom leg is flexed; the top leg is left straight and supported by pillows such that it remains parallel to the table. The ipsilateral arm may be secured to the patient’s side or across the patient’s chest and supported by pillows or an armrest. An axillary roll may also be used to minimize the risk of brachial plexus injury. The operating table is then flexed to increase the working space between the lower aspect of the ribs and the iliac crest ( Fig. 15.3 ). The patient is carefully padded at all pressure points and taped to the bed several times with 3-inch cloth tape. A beanbag may also be used to help maintain patient positioning, depending on surgeon preference. The table should be rotated to both sides with personnel at bedside to ensure adequate patient securement. Additional reverse-Trendelenburg may also be needed to ensure the great vessels remain oriented horizontally. The abdomen should be prepped widely from xyphoid to pubis with sterile solution, and a laparotomy instrument tray should also be available in the room, in the event that conversion to open surgery is necessary.
Abdominal access
Insufflation of the peritoneal cavity may be achieved using a Veress needle or open Hassan technique. The Veress needle is typically placed at the umbilicus, with the patient rotated slightly away from the surgeon. The Veress needle can also be inserted in the midclavicular line just off of the costal margin if initial umbilical access is unsuccessful. Entry into the peritoneal space is confirmed with aspiration through the Veress using normal saline. If no evidence of placement in bowel or a major blood vessel is noted, the drop test is performed. Following rapid drop of the saline into the peritoneal cavity, insufflation with carbon dioxide is begun at low flow. Immediate rise in pressure is indicative of inappropriate placement, typically within the abdominal wall or preperitoneal space. If initial insufflation pressures are appropriately low, the insufflator may be changed to a high flow setting. The abdomen should become tympanitic. Insufflation should continue until pressures of 15 mm Hg are reached. If there is difficulty with placement of the Veress percutaneously, a Hassan technique may be employed, whereby a skin and fascial incision is made, and the first trocar is placed under direct vision through the peritoneum. Insufflation may then be obtained through the trocar.
Once pneumoperitoneum is achieved, a skin incision is made to accommodate the camera trocar. The size of the skin incision must match the size of the trocar. Skin incisions that are too small may result in excessive force when penetrating the abdominal fascia, leading to inadvertent trocar injury to the underlying organs or vessels. Conversely, incisions that are too large may lead to continuous air leakage, crepitus, and loss of pneumoperitoneum during the procedure.
Trocar placement
Laparoscopy
For most cases of laparoscopic simple or radical nephrectomy, a three-trocar configuration is sufficient. A camera port is placed periumbilically, the second port is placed caudally in the midclavicular line, and the third port is placed below the costal margin about a third of the distance between the xyphoid and umbilicus. Fig. 15.4 shows examples of trocar placement for left- (A) and right-sided procedures (B) as well as for obese patients (C). In the latter case, the port configuration is shifted laterally to allow for optimal instrument movement. For right-sided cases, an additional 3- or 5-mm port for liver retraction may be placed just below the xyphoid. In cases where there is a large upper pole tumor, an additional lateral port may also be helpful to facilitate dissection of the hilum and upper pole.
The 10- to 12-mm visual obturator trocar may be used for placement of the first periumbilical trocar, as this allows direct visualization of the fascia, muscle layers, and peritoneum with passage of the trocar. Once the trocar is successfully placed, the laparoscope should be used to inspect the abdomen for signs of injury from initial access, as well as areas of adhesions. The table is then rotated toward the surgeon such that the patient is positioned in a flank position oriented perpendicular to the floor; this allows the bowels to fall medially and facilitates traction of the kidney during the operation. The remaining trocars should be placed under direct visualization, away from any areas of adhesion. Any adhesions may then be taken down with laparoscopic scissors or electrocautery. Tissue dissection may be carried out using hook electrocautery, laparoscopic scissors, harmonic scalpel, curved Maryland dissector, suction-irrigator, right-angle dissector, and/or atraumatic bowel graspers.
Robotic approach
Port configuration for robotic simple or radical nephrectomy will vary depending on surgeon preference and which model robot is being utilized. Generally, port configuration with the da Vinci Si or Xi mirrors that of the laparoscopic approach (see earlier), with care to ensure triangulation of the ports and adequate working distance between ports (8 mm for Si, 6 mm for Xi) to avoid clashing of the robotic arms. When the Xi robot is used, an 8-mm port may be “piggybacked” into the 12-mm camera port for docking; alternatively, initial abdominal entry may be achieved with an optical obturator using a standard 8-mm port and 5-mm laparoscopic camera. Depending on surgeon preference, the fourth robotic arm may be placed caudally to the more inferior trocar, or it may be omitted entirely. A 12-mm assistant port for stapling and an additional 5- or 12-mm assistant port may be triangulated between the camera port and the more cephalad or more caudal port, based on surgeon preference ( Fig. 15.5 ). Alternative port configurations such as a linear port arrangement may also be used, particularly with the Xi robot. Typical instrumentation includes bipolar graspers in the left arm and monopolar scissors in the right arm. Where utilized, an atraumatic grasper may be placed in the fourth arm. The assistant will typically utilize a blunt suction-irrigator, articulated stapler, and Hem-o-Lock clips (Weck Closure Systems, Research Triangle Park, NC).
