Laparoscopic Renal Surgery for Benign Disease Joseph C. Liao, MD, Alberto Breda, MD, and Peter G. Schulam, MD, PhD Corresponding author fibrosis could pose immense challenges toward surgical dis- Joseph C. Liao, MD section. Patients with xanthogranulomatous pyelonephritis Department of Urology, Stanford University School of Medicine and VA Palo Alto Health Care System, 3801 Miranda Avenue, (XGP), tuberculous nephritis, and prior renal surgery should MC112, Palo Alto, CA 94304, USA. be reserved for the most experienced laparoscopic surgeons. E-mail: [email protected] These patients should be counseled regarding the increased Current Urology Reports 2007, 8:12–18 likelihood of complications and possible open conversion. Current Medicine Group LLC ISSN 1527-2737 With improvement in instrumentation and dissemina- Copyright © 2007 by Current Medicine Group LLC tion of skills, laparoscopic renal surgery is now routinely practiced in many centers around the world. Since the last review [10], there has been continued improvement in Fifteen years after the first report, laparoscopic nephrec- instrumentation including smaller scopes (5 mm), visual tomy has demonstrated proven efficacy and safety obturator trocars, and a new generation of digital cameras comparable with an open approach, with a significant [11,12]. The use of a morcellator for specimen removal advantage of a faster recovery. Wide dissemination of does not lead to reduction in operating or recovery time these surgical techniques and continued improvement and remains as the surgeon’s preference [13]. in instrumentation has made laparoscopy the preferred In this review, the current state of laparoscopic renal approach for treating benign pathologic conditions of surgery for benign disease, with particular emphasis the kidney. In this review, the expanding indications of on simple nephrectomy, is discussed. We cover patient laparoscopic simple nephrectomy and the outcomes selection, technical aspects of transperitoneal and retro- of the larger clinical series are examined. We discuss peritoneal nephrectomy, and review the outcomes of the the technical aspects of both transperitoneal and larger clinical series to date. Other applications including retroperitoneal approaches. Finally, laparoscopic cyst laparoscopic cyst decortication and some of the newer decortication and some of the novel applications of procedures are highlighted. Reconstructive procedures laparoscopic renal surgery are highlighted. such as pyeloplasty are not covered in this review. Introduction Patient Selection Since the first report of transperitoneal laparoscopic Laparoscopic simple nephrectomy should be considered nephrectomy by Clayman et al. [1] in 1991 and the report for any benign pathologic conditions of the kidney indi- of retroperitoneal approach using a dissecting balloon by cated for removal (Table 1). Indications for nephrectomy Gaur et al. [2] in 1993, laparoscopy has emerged as the include refractory pain, bleeding, chronic infection, or standard of care for benign renal disease requiring surgical hypertension. Absolute contraindications are similar to intervention. More than 1200 cases have been reported those for open nephrectomy, which include uncorrected in the literature. The advantages of reduced postoperative coagulopathy, active peritonitis, and severe cardiopulmo- pain, a shorter hospital stay, earlier return to normal nary disease. Renal anatomic anomalies, such as horseshoe activities, and improved cosmesis compared with the open [14–16] or ectopic kidney [17], do not preclude the laparo- approach are well-documented [3,4,5•,6–9]. scopic approach, provided adequate preoperative imaging The most common indication for laparoscopic renal is obtained. Relative contraindications are directly related surgery for benign disease is simple nephrectomy. Although to the surgeon’s experience and comfort level. With expe- laparoscopic removals of small atrophic kidneys are ideally rience, obese patients and patients with enlarged kidneys suited for the less experienced surgeon, simple nephrectomy such as autosomal dominant polycystic kidney disease remains as one of the great misnomers in urologic surgery. (ADPKD), which are more challenging to mobilize, may be Simple by no means equates to uncomplicated nephrectomy, attempted. In obese patients, initial access may be challeng- particularly in situations in which dense inflammation and ing due to the thickened abdominal wall. In experienced Laparoscopic Renal Surgery for Benign Disease Liao et al. 13 Table 1. Indications for laparoscopic with only one open conversion. Similar favorable results have simple nephrectomy also been observed by others [5•,27]. The authors argue that Renovascular disease laparoscopic nephrectomy should be the first-line treatment for renal TB. Ureteropelvic junction/ureteral obstruction As part of the preoperative work-up, all patients need Reflux nephropathy a complete history and physical examination. Standard Stone disease laboratory studies including complete blood count, serum Renal dysplasia chemistries, coagulation studies, and urine culture are obtained. Chest radiograph, electrocardiogram, and addi- Renal tuberculosis tional cardiac work-up (if warranted) are also obtained. Xanthogranulomatous pyelonephritis All patients are required to have an abdominal imaging Polycystic kidney disease study to visualize the renal pathology. Our imaging study Native nephrectomy before renal transplant of choice is CT of the abdomen with and without intrave- nous contrast with delay phase, which provides excellent visualization of the renovascular and collecting system hands, laparoscopic renal surgery in obese patients results anatomy. The CT scan is also helpful to delineate the in similar operative times and complication rates but is relationship among the kidney and the surrounding organs associated with less blood loss and faster recovery when and presence of perinephric stranding as a sign of inflam- compared with the open approach [18]. Others have found mation. If there are concerns regarding the residual renal longer operative times and increased estimated blood loss function, a MAG-3 nuclear scan with differential function but similar complication and conversion rates and recovery is useful. We generally place the patients on a clear liquid period compared with the nonobese cohort [19•,20]. diet 2 days before the surgery. The day before the surgery, The most difficult cases are related to the presence patients are instructed to take two bottles of magnesium of severe scarring and fibrosis, which may completely citrate and are placed on nothing by mouth after midnight. obliterate normal anatomic planes for capsular and hilar dissection. Examples include XGP, renal tuberculosis (TB), and prior open abdominal/renal surgeries. These Surgical Technique situations are typically associated with higher complica- Laparoscopic nephrectomy may be performed either by tion and conversion rates [21,22] and should be reserved transperitoneal (“pure” or hand-assisted) or retroperitoneal for the most experienced laparoscopic surgeons. XGP is approaches. The hand-assisted approach is useful to bridge a severe, chronic bacterial infection of the renal paren- the steep learning curve needed to transition from open to chyma that results in significant inflammatory changes pure laparoscopic surgery. Some have advocated its use if within the kidney and the surrounding tissues. XGP has severe fibrosis is anticipated [28]. The technical aspect of been called the “great imitator” because it may mimic the hand-assisted approach is well-described elsewhere [29] other inflammatory or neoplastic conditions of the kid- and is not further commented on here. The transperitoneal ney. Nephrectomy is the treatment of choice. Given its approach offers the advantage of more intuitive anatomic challenging nature, XGP has been considered as a rela- landmarks and greater working space. The retroperitoneal tive contraindication for laparoscopic removal. There approach offers faster access to the renal hilum without have been few laparoscopic case series in the literature the need to mobilize intra-abdominal structures and may [23,24]. Khaira et al. [24] compared a small series of be advantageous in patients with prior abdominal surgery. patients who underwent laparoscopic (n = 3) versus We describe the technical aspects of both approaches, with open (n = 8) nephrectomy for XGP. Major complications particular emphasis on the transperitoneal approach, our rates were 33% for the laparoscopic group (vascular preferred choice. injury requiring open conversion) and 25% for the open group (unrecognized bowel injury, pneumothorax). The Transperitoneal nephrectomy authors concluded that a laparoscopic approach, albeit We have developed a generalized transperitoneal approach challenging, does not necessarily pose a greater risk in for renal surgery in which near-identical trocar configura- selected XGP patients by an experienced surgeon. tions (Fig. 1) are used for both extirpative and reconstructive Similarly to XGP, renal TB results in dense perinephric procedures. Using this standard approach, we have success- fibrosis, which makes laparoscopic dissection very challeng- fully performed more than 600 laparoscopic renal surgery ing, with prolongation of the operative time and increased cases, including simple nephrectomy, donor nephrectomy, risks of open conversion. An early series reported up to an radical nephrectomy, partial nephrectomy, adrenalectomy,