2.1 Transperitoneal Radical Nephrectomy

2.1Transperitoneal Radical Nephrectomy

Alwin F. Tan, Adrian D. Joyce

Contents Introduction Introduction 19 Robson in 1963 established the technique and princi- Indications and Contraindications 20 Indications 20 ples ofopen radical nephrectomy [1], and today the Contraindications 20 technique ofradical nephrectomy is still regarded as Preoperative Preparation 20 the standard treatment for localized renal cell carcino- Imaging 20 ma. Consent 20 It took another 27 years before Clayman et al. at Positioning Patients 21 Washington University in 1990 undertook the first la- Operative Technique 21 paroscopic transperitoneal radical nephrectomy. The Peritoneal Access 21 Colon Mobilization and Retroperitoneal Incision 22 patient was an 85-year-old woman and the operation Right Radical Nephrectomy 22 took 6.8 h and was a success [2]. The first transperito- Left Radical Nephrectomy neal simple nephrectomy to be performed in Europe (Beware of the Spleen!) 22 was by Coptcoat et al. [3] 1 year later, in 1991, and Dissection Continues up the Groove by Elevating the rest is history. the Ureter and Mobilizing the Lower Pole Over the last 10 years, the combined worldwide ex- of the Kidney 23 perience has established laparoscopic transperitoneal Hilar Dissection and Vascular Control 23 Upper Pole Detachment 24 simple nephrectomy as a safe procedure, with the Specimen Entrapment and Extraction 24 added advantages ofdecreased analgesia requirements, Final Check for Haemostasis and Closure improved cosmesis, shorter hospital stay and early re- of Port Sites 24 turn to premorbid activity. It is therefore not surpris- Results 24 ing that laparoscopic nephrectomy for benign disease Complications 24 has gained acceptance both by the urological commu- Operative Time (Efficiency) 25 nity and patients as a standard ofcare. It is natural to Morbidity 25 Oncological Control 25 assume that the next challenge would be to apply the Immediate Adequacy 25 acquired skills to radical nephrectomy for malignancy Seeding Risk (Peritoneum or Port) 25 and currently, the transperitoneal route remains the Metastasis and Survival 26 most popular approach. Cost Benefits 26 This chapter aims to explore the current status of Controversies 26 the practice oftransperitoneal laparoscopic radical ne- Morcellation 26 phrectomy. The discussion will cover the indications Tumours 4cm or Less ± Laparoscopic Radical vs Open Partial Nephrectomy 27 and contraindications for the technique, the preopera- Transperitoneal vs Retroperitoneal Approach 27 tive preparation, positioning, surgical technique, po- Future Horizons 27 tential complications, morbidity, functional impact, ef- References 27 ficiency and oncological effectiveness. The related cost benefits, controversies and current limitations of the technique will be assessed together with possible future horizons. Where possible, we will compare the technique to the current traditional standard ofcare 20 A.F. Tan, A.D. Joyce ofopen radical nephrectomy. However, as yet there ofthe surgeons' experience with the technique and are no randomized controlled data available compar- their ability to perform a radical nephrectomy without ing the laparoscopic with the open technique, but a comprising the oncological safety of the procedure. number ofcomparative studies have been published, and the key issues are whether the laparoscopic approach is surgically equivalent or better compared Preoperative Preparation to the open technique and whether there is equiva- lence in oncological outcome with the new technique. Imaging Diagnostic staging is mandatory prior to embarking Indications and Contraindications on the procedure involving a contrast computer tomo- graphy (CT) urogram, where the tumour is identified Indications as showing contrast enhancement. CT angiography, or MRA may be used as an adjunct, especially ifthere is The indications continue to expand as the surgeon's concern over vascular invasion from the tumour and expertise grows, and we feel that all patients who are it should be noted that aberrant vessels can occur in a candidate for an open radical nephrectomy should as many as 30%±40% ofcases. Some institutions have be potentially considered for their suitability to a la- the luxury of3D reconstruction imaging facilities paroscopic approach. There is growing evidence that readily available, even in the operating theatre, which suggests that for T1 and T2 tumours, laparoscopic may assist in operative planning, particularly in ne- radical nephrectomy is emerging as a strong alterna- phron-sparing procedures (Fig. 1). tive to the open procedure [4, 5]. The upper limit of T2 in terms ofsize is very much coloured by the indi- Consent vidual surgeon's experience, and laparoscopic removal ofT3a and even T3b tumours have been reported. Laparoscopic surgery demands special skills and it is In 1999, Walther et al. pushed the ceiling even important to discuss with your patient that there are further by performing laparoscopic nephrectomy in specific risks that they must be aware of before con- patients as a cytoreductive procedure prior to immu- senting to this approach: notherapy. Interestingly, they noted that the recovery n Possible risk ofaccess injury due to the inadvertent ofthese patients was significantly better than their puncture ofan organ ifa Veress needle is used to open-surgery counterparts, such that they were able to create the pneumoperitoneum initiate their immunotherapy treatment by up to 1 month earlier [6].

Contraindications Patient selection is important and current relative contraindications include T3 and T4 tumours together with bulky nodal disease and caval involvement. Other relative contraindications rather than absolute factors include: n Severe COAD n Difficult body habitus n Previous upper abdominal scar or adhesions n Patient's choice after full informed consent

The published literature supports the caveat that laparoscopic radical nephrectomy is indicated for stages T1±T3a where the tumour is confined to the kidney with no radiological evidence ofvenous or nodal in- Fig. 1. CT showing typical features of renal malignancy in volvement. The upper limit ofsize is again a reflection the (L) kidney a 2.1 Transperitoneal Radical Nephrectomy 21 n Possible risk ofinadvertent injury to another organ Operative Technique during the dissection ofthe kidney (<1%) n Possible risk ofbleeding from the artery and vein Since its inception in 1990, the technique has con- n The potential need to convert to the traditional stantly evolved with significant advancements. New open operation if difficulties arise (<10%) technology and instrumentation have also emerged in the meantime. Therefore, it is not surprising that Optimal preoperative medical and anaesthetic assess- there is variation in the technique between centres. ments should include: However, the authors consider the following key steps n Basic investigations ± full blood count, electrolytes, important in contributing to a successful outcome: liver function tests, blood gas estimations, X-match n Bowel preparation ± not routine in the author's Peritoneal Access approach, although some advocate an enema for a left-sided tumour We have long advocated the open technique (Hasson n Instrument check list, with both open and laparo- cannula technique), currently using the Tyco 10-mm scopic set up available blunt tip trocar (BTT) (see Fig. 3) for our initial port. This trocar arrangement provides a good occlusive seal with minimal gas leak and is especially helpful in Positioning Patients obese patients. Alternatively, one may choose the closed technique utilizing the Veress needle, but we Our preferred placement is the flank position ± lateral are concerned that one ofthe major risks oflaparo- decubitus ± with the affected side up with break at the scopy is associated with access. Four per cent ofla- level ofumbilicus and a degree ofposterior rotation, paroscopic complications are related to access injury but the break is only to open up the area beneath the involving the Veress needle; therefore it is an easy 12th rib and is not the typical renal position (see complication to avoid with the open technique and Fig. 2). Meticulous padding ofthe softtissues and only adds a few minutes to the procedure. bony sites is extremely important to avoid possible n CO2 insufflation is initially delivered at low flow. A neuropraxia due to a lengthy procedure, with particu- low abdominal pressure confirms that the tip of the lar support given especially to the downside shoulder, trocar is in the peritoneum. Ifthere is any concern, hip, knee and ankle. This is crucial, particularly at the then elevation ofthe anterior abdominal wall with start ofthe surgeon's experience where the procedure a subsequent pressure drop confirms a satisfactory times tend to be longer. position. We also advocate the use ofa body warmer to n An overview inspection is necessary to ensure no minimize patient cooling and calfstimulators to re- inadvertent injury to underlying bowel caused by duce the potential risk ofdeep vein thrombosis peritoneal access, particularly in patients where the (DVT). Veress needle technique is utilized, and to look for alternative pathology.

Fig. 2. Illustrating the position of the patient on the table 22 A.F. Tan, A.D. Joyce

Fig. 3 A, B. Illustrating the open approach andthe position of the blunt-tip trocar

n Port placement. Three other working ports as indicated by the white boxes in the figure above is standard (occasionally an extra port is required for liver or spleen retraction).

Colon Mobilization and Retroperitoneal Incision On the right side the kidney, the splenic flexure often lies above the hepatic flexure, whereas on the left side the it usually has to be mobilized (Fig. 4). n Line ofToldt ± incise and reflect colon medially. n Identify the ªcracklyº bloodless plane between the bowel mesentery and the anterior surface of Gerota to allow peeling as in the open approach.

Right Radical Nephrectomy n Incise along posterior hepatic ligament to free the Fig. 4. Colon mobilization inferior posterior liver edge from the specimen (the length ofthe line depends on whether the adrenal is to be spared). Left Radical Nephrectomy n Incise the peritoneum parallel to ascending colon (Beware of the Spleen!) and above the hepatic flexure medially until the inferior vena cava (IVC) is exposed. n Incise along the line ofToldt parallel to the des- n The duodenum, which is medial to the IVC, must cending colon to free the lienophrenic ligament be identified and dissected free from Gerota and first. rotated medially (Kocher manoeuvre) to further ex- n Peel the left colon away from Gerota by dividing pose the anterior surface of IVC. the splenocolic ligament at the splenic flexure. a 2.1 Transperitoneal Radical Nephrectomy 23

Fig. 5. Identification of ureter, gonadal vein and psoas (key Fig. 6. Lower renal pole mobilisation landmark) n Great respect and time must be taken to mobilize the spleen from the upper pole of Gerota by dividing the splenorenal peritoneal attachments. n Delicate care must be exercised when handling the tail ofthe pancreas, which can be nestled across the renal hilum (Fig. 5). n The fourth port is placed using a grasper for the ureter to provide lateral traction and elevation (we prefer not to divide the ureter at this point).

Dissection Continues up the Groove by Elevating the Ureter and Mobilizing the Lower Pole of the Kidney n Mobilization is achieved by a combination ofdis- section with the harmonic scalpel and blunt dissection using the sucker tip or Endo-dab along the IVC (on right) and the aorta (on left) (Fig. 6). Fig. 7. Illustrating dissection and Hem-o-Lok ligation of the renal artery n Blunt dissection ofGerota frees the lower pole ± to facilitate the anterior rotation of lower pole ± to bring out the renal artery, which is usually located nadal vein to facilitate posterior dissection of the posteriorly. renal vein for any posterior lumbar veins. n Renal artery: mobilized circumferentially using a Hilar Dissection and Vascular Control right-angle dissector (see Fig. 7) ± then ligated using the Hem-o-Lok device with a minimum of n Right side: often the gonadal vein needs formal li- three on the major vessel side. Ifthere is concern gation (clip and divide), to minimize the risk of over access, then a single clip can be applied and traction avulsion and awkward bleeding. The renal further ligation after division of the renal vein. vein is usually just superior. n Renal vein: careful dissection right down to the n Left side: also identify the gonadal vein, which will vessel wall to display the branches, especially the lead to the trifurcation of the renal, adrenal and adrenal vein (left nephrectomy) and beware of any gonadal veins. Divide the last two and use the go- lumbar veins posteriorly. 24 A.F. Tan, A.D. Joyce

± Renal vein: generally secured with an endo-GIA Specimen Entrapment and Extraction stapler via the size 12 port (care must be taken not to fire across any adjacent clips which can n Various entrapment sacs can be utilized, e.g. Endo- result in misfiring and profuse bleeding!) catch/Endopouch/Bert series ofbags made ofpara- n Be cautious ofany aberrant vessels. chute superdurable material. Currently the 15 mm Endocatch bag (Tyco) is preferred. Adrenalectomy is indicated in upper pole tumours, n Extraction is done via small muscle splitting with but is not routinely advocated for lower pole lesions: an extension ofthe size 12 port preferred. n Right side: continue superior dissection along vena n Morcellation is not advocated. cava medial to adrenal, which is short and often posteromedial to the cava and may need further Final Check for Haemostasis and Closure Hem-o-Lok ligation. Beware ofthe adrenal vein. of Port Sites n Left side: the adrenal vein is usually quite evident n Haemostatic check with carbon dioxide flow low- once the renal vein is displayed at the trifurcation. ered n Closure and tube drain Upper Pole Detachment n The authors prefer to utilize a grasper via the fourth Results port to retract a peritoneal leafstill attached to the liver or spleen. Apply medial traction within the The latest published data for transperitoneal laparo- pseudo-triangle made up ofthe psoas, liver/spleen scopic radical nephrectomy are shown in Table 1. and diaphragm. This pseudo-cave facilitates detachment ofthe upper pole, especially ifthere is more Complications than the usual adhesions to the Gerota fascia (Fig. 8). As most centres started with laparoscopic simple nephrectomy, it is not surprising that progression to radical nephrectomy resulted in few complications relating to the laparoscopy learning curve. Thus the operative complication rates are generally low in the laparoscopic radical nephrectomy series, with major complication rates under 10%. However, the reporting ofcomplications is highly variable and subjective, with some authors including conversion as a complication and others not. Analysis ofearly experience demonstrates minor complication rates as high as 34%. However, a follow- up analysis in 2000 by Gill et al. [7] ofa worldwide aggregate ofexperience with 266 patients demonstrates figures of 23% for minor complication rates and 7% for major complication rates. The overall con- Fig. 8. Illustrating division of any additional adrenal veins version rate was 4%. However, there were four re-

Table 1. Published data for transperitoneal radical nephrectomy

Series No. of Operating Blood loss Hospital Complication Complication Conversion patients time (hours) (ml) stay minor major rate Janetschek et al. (2002) [9] 121 2.4 154 6.1 5% 4% 0 patients Dunn et al. (2000) [8] 60 5.5 172 3.4 34.4% 3.3% 1 patient Ono et al. (1999) [13] 60 5.2 255 ± 3% 8% 2 patients Barrett et al. (1998) [12] 72 2.9 ± 4.4 3% 5% 6 patients a 2.1 Transperitoneal Radical Nephrectomy 25

Table 2. Classification laparoscopic complications a 29% reduction in the time spent in hospital, has 10% fewer complications and has 73% less convales- Access relatedOrgan or abdominalwall injury cence time. Patients also lose less blood and thus have Intraoperative Vascular, bowel, splenic injury or a lower transfusion rate. Hospital stays ranged from 3 failedentrapment Postoperative E.g. respiratory, gastrointestinal to 7 days in the large reported series [4, 8, 9, 12, 13]; bleeding however, the length ofstay can be a reflection oflocal healthcare issues. Siqueira et al. [21] Biochemically, there is evidence to suggest a re- duced stress response in the laparoscopic cohort of patients. Miyake et al. retrospectively compared hu- ported deaths: three were from myocardial infarction moral stress mediators released 48 h preoperatively to and one was unknown. 96 h in the postoperative period between laparoscopic Shalhav's group in Indiana reported a series of61 and open urological surgery. Their cases included rad- laparoscopy radical nephrectomies with most ofthem ical nephrectomy, nephroureterectomy, prostatectomy approached transperitoneally. Their major complica- and cystectomy. They focused on levels of interleukin- tion rate was 5%, predominately due bleeding. More 6 (an early mediator oftissue damage), granulocytic significantly, they have proposed a classification table elastase (a serine protease released by granulocytes in for laparoscopic complications, as shown in Table 2, response to necrosis) and interleukin-10 (a marker of which will require universal acceptance. tissue damage severity). The maximum levels ofall three mediators were significantly higher in the open Operative Time (Efficiency) surgery group [14]. Operative time is definitely a function of experience. It has also been suggested that there is less immu- At Washington University where the technique was nosuppression in studies from laparoscopic cholecys- first reported, with experience they were able to drop tectomy patients [15]. the operative time from 7 h to 5.5 h [8]. A recent pub- lication from Janetschek in 2002 reported a mean op- Oncological Control erative time as low as 2.4 h [9]. Our standard operative time for an uncomplicated laparoscopic radical Immediate Adequacy nephrectomy is 2.3 h. Various suggestions have been made with regard to Laparoscopic transperitoneal radical nephrectomy pro- reducing operative time utilizing alternative tech- vides an equivalent specimen to the open procedure. It niques for dissection such as the harmonic scalpel, adheres to the principle ofopen surgery in providing the system for bipolar dissection in the nondominant an en bloc excised kidney, adrenal, perirenal fat, hilar hand, aquajet dissection, the CO2 insufflation heating nodes and the Gerota fascia [4]. In comparing speci- device and projecting the image [9±11]; however, the men weight, it is important to remember that morcel- most significant factor is the team approach so that lation can account for a specimen weight reduction of instruments are ready and available with minimal de- 21% [8]. lay between instrument change, leading to a smooth uninterrupted sequence ofsteps. Seeding Risk (Peritoneum or Port) Despite earlier fears, so far there is no recorded case Morbidity ofintraperitoneal seeding. However, there is one local recurrence in a multinational study at the 5-year mark Universally, there has been a clear advantage in com- reported by Portis et al. in 2002, as well as a case of parative studies ofnephrectomy for similar tumour local recurrence in the comparative open group [4]. sizes in patients in favour of the laparoscopic As far as port site seeding is concerned, there has approach. been one case reported to date [16]. It involved a 76- Studies undertaken at Washington University dem- year-old man, and the tumour recurrence was de- onstrate a clear advantage [10] with the laparoscopic tected after 25 months of follow-up at the nonmorcel- approach. This approach requires 67% less analgesia, lated site. The original operation was for an 862-g 26 A.F. Tan, A.D. Joyce specimen with T3NoMo tumour, and the histology re- 1 year follow-up, while the open group involved a pa- vealed a renal cell carcinoma with sarcomatous ele- tient with a 15-cm lesion detected at 8.2 years offol- ments. low-up. The comparable actuarial disease-free rate and can- Metastasis and Survival cer survival appears to reiterate the results ofearlier series with shorter follow-up by Ono [5] and Cadeddu The question ofequivalence with open surgery at 5-year [17]. survival was addressed by a landmark paper by Portis et al. in 2002. It was a retrospective international multicentre study involving three centres in Nagoya, Japan, Sas- Cost Benefits katoon, Canada and St. Louis, Missouri [4]. It reported on all patients who had undergone radical nephrectomy ªAlthough one cannot avoid the issue ofcost, it is im- before November 1996. In total, there were 64 laparo- portant that we do not forget that our foremost duty scopic vs 69 open radical nephrectomies. Most ofthe la- to our patients is to do no harm.º paroscopic cases (52/64) were performed transperitone- Cost-benefit analysis very much reflects local health ally. Forty-three ofthe 64 specimens included the adre- care provision and has been an important factor in nal en bloc; 39 tumours out of64 were removed intact. the overall analysis in the United States. For example, However, the average tumour size was smaller in the la- an analysis in a US health provider setting at Wash- paroscopic group (4.3 vs 6.2 cm). Table 3 illustrates ington University showed that laparoscopic nephrec- their results [4]. tomy is only cost-effective if the surgeon can reduce Thus, the intermediate data at the 5-year mark indi- the operating time below 3.5 h [10]. cates that laparoscopic transperitoneal radical nephrec- Further analysis by The Cleveland Clinic showed tomy appears to be every bit as effective as the open that despite a 5-day reduction in hospital stay, laparo- procedure. There is no significant difference in terms scopic radical nephrectomy was still 29% more expen- ofoverall survival, cancer-specificsurvival and when sive than the open procedure [2]. analysed with the new TMN classification in terms of The same institution also pointed out in an earlier T1 and T2, as demonstrated in Table 3 above. study that costs do come down with time, especially There was one recurrence in each group. In the la- with reduction in operating times. They priced laparoscopic group it was for a 9-cm lesion detected at paroscopic nephrectomy initially as 33% more expensive but with experience the laparoscopic procedure can be 12% cheaper than open nephrectomy, as the Table 3. Laparoscopic versus open radical nephrectomy most expensive factor seems to be the operating the- Mass size (cm) Laparoscopic Open P value atre cost in terms oftime and disposables. Mean follow-up (years) However, taking the bigger picture into considera- All 4.49 5.77 0.000 tion, one needs to remember the reduction in commu- Less than 7 cm 4.65 5.89 0.002 nity cost made possible by the reduction ofthe conva- 7 cm or greater 3.82 5.69 0.017 lescence period ofup to 4±6 weeks in the laparoscopic Overall survival group [8]. Another factor that is often ignored is the All 81% 89% 0.260 cost to primary health care ofmanaging the patient in Less than 7 cm 82% 92% 0.272 the community as a consequence ofproblems related 7 cm or greater 89% 86% 0.883 to the incision in the open group. Recurrence-free survival All 92% 91% 0.583 Less than 7 cm 92% 95% 0.951 Controversies 7 cm or greater 87% 83% 0.804 Cancer-specific survival All 98% 92% 0.124 Morcellation Less than 7 cm 97% 95% 0.303 Although the issue oftumour spillage has been pla- 7 cm or greater 100% 87% 0.383 gued with much concern, there is only one reported Portis et al. [4] case ofport-site recurrence [16]. Even so, care must a 2.1 Transperitoneal Radical Nephrectomy 27 be taken to drape the field and isolate the port prior need to be varied to suit the individual patient differ- to morcellation. There are now entrapment bags avail- ences; for example, evidence of previous abdominal able that are impermeable and disruption-resistant, as surgery may favour an extraperitoneal approach. demonstrated by Urban et al. [18]. Supporters ofmorcellation claim that with a smaller incision, there is less morbidity. This was certainly Future Horizons not supported by Gettman et al. 2002 [19]. In a prospective trial oflaparoscopic radical nephrectomy, sev- After more than a decade since laparoscopic radical en specimens were fragmented and extracted via the nephrectomy was introduced, one can say with confi- umbilical port incision (average, 1.2 cm) while five dence that the evidence supports the contention that other specimens were removed intact via an incision this is a reasonable alternative to open radical ne- averaging 7.6 cm in diameter. There was no significant phrectomy for T1 and T2 disease. Patients can expect difference in intraoperative parameters, postoperative less morbidity in terms ofa shorter hospital stay, less pain or time to resumption ofnormal activity. pain, less blood loss, lower complication rates and an Furthermore, in a retrospective case controlled co- earlier return to premorbid activities and life style, hort study, Savage and Gill [20] found no significant without compromising the oncological outcome. With difference with regard to opiate analgesia require- regard to long-term cancer control, the analysis at the ments, hospital stay, recovery or convalescence be- 5-year mark shows promise. Only time will determine tween muscle cutting and muscle splitting incisions the ultimate role oflaparoscopic radical nephrectomy relating to extraction. as the standard ofcare in the new millennium. Ifthat is the case, then one should consider the im- plication ofthe sacrificeofexact pathology where the specimen is morcellated in the name ofcosmesis. References

1. Robson CJ (1963) Radical nephrectomy for renal cell Tumours 4 cm or Less ± Laparoscopic carcinoma. J Urol 89:37 Radical vs Open Partial Nephrectomy 2. Clayman RV, Kavoussi LR, Soper NJ et al (1991) Laparo- scopic nephrectomy: initial case report. J Urol 146:278 The difficult issue that has plagued open surgery of a 3. Coptcoat MJ, Rassweiler J, Wickham JEA, Joyce AD radical vs partial nephrectomy for a small tumour in (1991) Laparoscopic nephrectomy for renal cell carcino- the presence ofa normal functioning contralateral ma. 3rd international congress ofminimally invasive kidney is certainly a challenging one to address and is therapy (abstract 66). Boston the subject ofongoing discussion and prospective 4. Portis AJ, Yan Y, Landman J, Chen C, Barrett PH, Fentie DD, Ono Y, McDougall EM, Clayman RV (2002) Long- trials. term follow-up after laparoscopic radical nephrectomy. J Urol 167:1257±1262 Transperitoneal vs Retroperitoneal 5. Ono Y, Kinukawa T, Hattori R, Gotoh M, Kamihira O, Approach Ohshima S (2001) The long-term outcome oflaparoscopic radical nephrectomy for small renal cell carcino- Currently there is no randomized prospective trial ma. J Urol 165:1867±1870 comparing the two procedures even though the opera- 6. Walther MM, Lyne JC, Libutti SK, Linehan WM (1999) Laparoscopic cytoreductive nephrectomy as preparation tive time seems to favour the retroperitoneal approach for administration of systemic interleukin 2 in the treat- [7]. ment ofmetastatic renal cell carcinoma: a pilot study. The obvious advantages for the transperitoneal Urology 53:496±501 approach include familiarization of anatomical land- 7. Gill I (2000) Laparoscopic radical nephrectomy for can- marks and greater freedom for mobilization and or- cer. Urol Clin North Am 27:707±719 gan entrapment. Disadvantages must include bowel 8. Dunn MD, Portis AJ, Shalhav AL, Elbahnasy AM, Hei- handling, which can lead to prolonged ileus, and also dorn C, McDougall EM, Clayman RV (2000) Laparo- scopic versus open radical nephrectomy: a 9-year ex- the extra time taken for dissection. perience. J Urol 164:1153±1159 The general consensus is that one should perform 9. Janetschek G, al-Zachrani H, Vrabec G, Leeb K (2002) the operation that has the best outcome in the hands Laparoscopic tumor nephrectomy (in German). Urologe ofthe individual surgeon. However, techniques may A 41:101±106 28 A.F. Tan, A.D. Joyce: 2.1 Transperitoneal Radical Nephrectomy

10. Portis AJ, Elnady M, Clayman RV (2001) Laparoscopic 19. Gettman MT, Napper C, Corwin TS, Cadeddu JA (2002) radical/total nephrectomy: a decade ofprogress. J En- Laparoscopic radical nephrectomy: prospective assess- dourol 15:345±354 ment ofimpact ofintact versus fragmented specimen 11. Gill IS, Savage SJ, Hobart MG, Schweizer DK, Sung GT, removal on postoperative quality oflife.J Endourol Klein EA, Novick AC (2000) Laparoscopic radical ne- 16:23±26 phrectomy for large (>5 cm) renal tumours. J Urol 163 20. Savage SJ, Gill IS (2001) Intact specimen extraction dur- [Suppl]:19 ing renal laparoscopy: muscle-splitting versus muscle- 12. Barrett PH, Fentie DD, Taranger LA (1998) Laparoscopic cutting incision. J Endourol 15:165±169 radical nephrectomy with morcellation for renal cell 21. Siqueira TM Jr, Kuo RL, Gardner TA, Paterson RF, Ste- carcinoma: Saskatoon experience. Urology 52:23±28 vens LH, Lingeman JE, Koch MO, Shalhav AL (2002) 13. Ono Y, Kinukawa T, Hattori R (1999) Laparoscopic radi- Major complications in 213 laparoscopic nephrectomy cal nephrectomy for renal cell carcinoma: a 5 yr experi- cases: the Indianapolis experience. J Urol 168:1361±1365 ence. Urology 53:280±286 22. Ono Y, Kinukawa T, Hattori R (1999) Laparoscopic radi- 14. Miyake H, Kawabata G, Gotoh A, Fujisawa M, Okada H, cal nephrectomy for large renal cell carcinoma. J En- Arakawa S, Kamidono S, Hara I (2002) Comparison of dourol 13:A62 surgical stress between laparoscopy and open surgery 23. Dunn MD, Portis A, Shalhav A (1999) Laparoscopic vs in the field of urology by measurement of humoral open radical nephrectomy for renal tumour. Washington mediators. Int J Urol 9:329±333 University experience. J Urol 161:166 15. Kloosterman T, von Blomberg BME, Borgstein P, Cuesta 24. Kavoussi LR, Chan DY, Fabrizio MD et al (1999) Cancer MA, Scheper RJ, Meijer S (1994) Unimpaired immune control oflaparoscopic nephrectomy for renal cell carci- functions after laparoscopic cholecystectomy. Surgery noma: J Urol 161:167 115:424±428 25. Janetschek G, Jeschke K, Peschel R, Strohmeyer D, Hen- 16. Fentie DD, Barrett PH, Taranger LA (2000) Metastatic ning K, Bartsch G (2000) Laparoscopic surgery for stage renal cell cancer after laparoscopic radical nephrectomy: T1 renal cell carcinoma: radical nephrectomy and wedge long-term follow-up. J Endourol 14:407±401 resection. Eur Urol 38:131±138 17. Cadeddu JA, Ono Y, Clayman RV (1998) Laparoscopic 26. Chan DY, Cadeddu JA, Jarrett TW, Marshall FF, Kavous- radical nephrectomy: evaluation of efficacy and safety: si LR (2001) Laparoscopic radical nephrectomy: cancer multicentre experience. Urology 52:773±777 control for renal cell carcinoma. J Urol 166:2095±2099 18. Urban DA, Kerbl K, McDougall E (1993) Organ entrap- 27. Hobart MG, Schweizer DK, Gill IS (199) Financial cost ment and renal morcellation: permeability studies. J analysis oflaparoscopic vs open radical nephrectomy. J Urol 150:1792±1794 Endourol 13:A63