Laparoscopy has become diffused in the treatment of many urological diseases; the most effective use of laparoscopy has been experienced in radical nephrectomy for tumors confined to the kidney and is the preferred operative approach for most urologists[1–5, 11]. Dunn and colleagues reported that laparoscopic surgery could efficiently lower the intraoperative blood loss, postoperative analgesic requirement and hospital stay. Although these techniques are widely used and have been the subject of many variations, there is still a wide margin for further development. Many surgeons are now focusing on modification of the laparoscopic surgical technique.
In our study, Group 1 involved the previous technique. After entirely mobilization of the kidney (dorsal and abdominal side, upper and lower pole), renal vessels were dissected, ligated and divided. However, in our modified technique, after mobilizing the dorsal side and lateral side of the kidney adequately, we could recognize the location of the renal pedicle definitely according to several anatomic landmarks. The renal vessels were then manipulated as explained above. According to our experience, the critical points of fast access to the renal pedicle can be summarized as follows: extensively mobilize the lateral and dorsal side of kidney to the inner side of the psoas major muscle; after full mobilization of the kidney’s lateral and dorsal side, the eminence of the renal pedicle is usually located near the inner side of the medial arcuate ligament; the position of the renal pedicle could not be moved due to the pulling of renal vessels; and the eminence was actually the fat and fibrous vagina vasorum of renal artery. In brief, the important anatomic landmarks during this process included the psoas major muscle, the medial arcuate ligament and the eminence of the renal pedicle.
To reproduce the principles of open radical nephrectomy and to achieve early ligature for the treatment of renal cell carcinoma with transperitoneal approach, Porpiglia and colleagues[15–17] described their experience with direct access to the renal artery while performing transperitoneal radical nephrectomy procedures. However, due to the transperitoneal approach, there are some unavoidable risks with these procedures. For example, the risk of ligation of the superior mesenteric artery would be a fatal mistake for the patient. Retroperitoneoscopy also seems to permit faster access to the renal artery than the transperitoneal approach. In the present study, we attempted fast access and early ligation of the renal vessels. The advantages of fast access and early ligature of renal pedicle can be summarized as follows: reduce the manipulation of renal tumor; reduce the potential risk of malignant cell spread due to reducing manipulation of the kidney before ligating renal vessels; lower the blood loss in further steps of dissection; facilitate the dissection of the kidney in further steps due to less bleeding and loosen the kidney from renal pedicle; and relieve the mental stress of surgeon in the further operation steps.
Owing to the advantages above, our modified technique resulted in less operation time and intraoperative blood loss compared with the previous one. However, there is no doubt that patients in Group 2 were operated on after a certain amount of upper urinary tract laparoscopic urologic experience gained in Group 1 – which we think might have an impact on the results, particularly the operation time. Surgeons’ experience might be suboptimal during operating on patients in Group 1 when compared with Group 2. In addition, a disadvantage of this technique might be difficulty in the presence of hilar and para-aortic metastatic lymph nodes or a large renal mass, which could result in displacement of the renal pedicle’s position.
All procedures were completed and no procedure required conversion to open surgery. Renal vein injury occurred in two patients of Group 1 and in one patient of Group 2 during renal pedicle dissection. Bleeding due to renal vein injury was controlled laparoscopically in all three patients. These observations suggest that the modified technique is safe and feasible for retroperitoneal laparoscopic radical nephrectomy.