What is the best laparoscopic approach for laparoscopic radical nephrectomy?

Laparoscopic radical nephrectomy is rapidly becoming the gold standard as the surgical procedure of choice in patients with localized renal cell carcinoma.

Many laparoscopic approaches exist, including hand assisted (HAL), transperitoneal (TPL), and retroperitoneal (RPL) techniques, each with its own benefits and drawbacks.  Nadler and colleagues, out of Northwestern, compared each of these techniques in patients with T1 tumors in a prospective randomized trial.

Thirty three consecutive patients with T1 renal tumors were included in the trial and randomized to HAL, TPL, or RPL laparoscopic radical nephrectomy.  Of note, all of the TPL patients had specimen morcellation for tumor removal, whereas the other two approaches had intact extraction.  Mean patient age was 60.3 years, and the ASA score and BMI was similar between the three groups.  Twenty-one patients in the study had had previous abdominal surgery.  No difference was noted in blood loss or use of narcotics post-operatively.  Patients who underwent HAL had a significantly decrease OR time (139 minutes HAL, 196 minutes TPL, 185 minutes RPL, p=0.01).  Incision size, length of stay, and time to normal activity all were significantly less in the TPL group.  One patient in the TPL group was converted to HAL because of intra-operative difficulties.  Four patients (36%) in the HAL had post-operative incisional hernias.  Two patients had flank bulges and 5 patients had pain or paresthesias in the RPL group.  With a median follow-up of 20 months, there were no recurrences or disease progression.

In the end, the "best" approach to laparoscopic nephrectomy remains the one that the surgeon is most comfortable with, as each clearly has its own benefits and drawbacks.  In this study, TPL with specimen morcellation appeared to have the best outcome, but opponents of morcellation would point to the real risk of tumor seeding during the morcellation process and lack of adequate pathologic material as drawbacks to this approach.  One finding in this study that deserves further consideration is the high incidence of post-operative incisional hernia associated with the HAL approach seen in this study.  Placing the hand and arm through a port device in the fascia, while trying to maintain an occlusive seal to establish pneumoperitoneum, may have more detrimental effects to wound healing than is appreciated at first glance.


 J Urol 175: 1230-1234, 2006


Nadler RB, Loeb S, Clemens JQ, Batler RA, Gonzalez CM, Vardi IY

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