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 fu- ture 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 la- paroscopic 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 AB Fig. 3 A, B. Illustrating the open approach andthe position of the blunt-tip trocar n Port placement. Three other working ports as indi- cated by the white boxes in the figure above is standard (occasionally an extra port is required for liver or