Yonago Acta medica 2002;45:35–41

Retroperitoneal Laparoscopic Radical Nephrectomy for Renal Cell
Carcinoma: A Report on 2 Initial Cases
Tadahiro Isoyama, Takehiro Sejima, Hiroyuki Kadowaki, Shinji Hirakawa
and Ikuo Miyagawa
Department of Urology, Tottori University Faculty of Medicine, Yonago 683-8504 Japan

We report our experience with retroperitoneal laparoscopic radical nephrectomy in 2
patients with renal cell carcinoma. In this procedure, a working space in the retroperitoneum is created using the blunt balloon dissection technique. Carbon dioxide insufflation is performed, and 4 trocars are inserted into the retroperitoneal cavity through thelateral abdominal wall. The kidney is removed together with the perirenal fat andGerota’s fascia in a muscle-splitting fashion. Using this procedure, a right nephrectomy
was performed in a 65-year-old man with a 2.4-cm tumor and in a 54-year-old woman
with a 3.5-cm tumor. Operative time was 220 min and 195 min, respectively, and estimatedblood loss was 10 mL and 115 mL, respectively. There were no major perioperativecomplications. Although a long-term follow-up is necessary to evaluate the efficacy ofthis procedure, it will probably become a standard treatment modality for localized renal
cell carcinoma.
Key words: laparoscopy; nephrectomy; renal cell carcinoma

underwent shock wave lithotripsy on May 14
and June 4. During shock wave lithotripsy, amass 2.4 cm in diameter was found incidentallyin the right kidney by ultrasonography. CT
revealed a tumor measuring 2.4 cm by 2.1 cm inthe midportion of the right kidney, with no evidence of renal hilar lymphadenopathy or hepatic metastasis (Fig. 1). Chest CT and bone scintigraphy disproved the probability of metastatic
disease. The patient was administered a laxative the day before surgery, and an enema themorning of the surgery. Compression stockings
were applied to both legs and upper thighs.
On August 24, under satisfactory generalanesthesia combined with epidural anesthesia,
a nasogastric tube and an urethral catheter wereinserted. The patient was placed in the flank
position, with the kidney bridge elevated, andthe operating table was bent to widen the space
between the 12th rib and the iliac crest. A 1.5cm incision was made just below the tip of the
12th rib for the 1st trocar port. The flank muscle

Recently, an increasing number of renal tumors
have been detected incidentally in lower stagesof growth due to the widespread use ofultrasonography and computed tomography(CT). Radical nephrectomy had previously
been the standard treatment modality for
localized renal cell carcinoma. In recent years
though, laparoscopic nephrectomy has gained
popularity in treating both benign and malignant renal diseases, and is usually performed
via the transperitoneal or retroperitoneal
approach.
We report on our experience using retroperitoneal laparoscopic radical nephrectomy in
2 patients with renal cell carcinoma.

Patient Reports
Case 1
A 65-year-old man with a left ureteral stone
arrived at our hospital on May 11, 2001. He

Abbreviation: CT, computed tomography

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T. Isoyama et al.

pel (Harmonic Scalpel; Ethicon Inc., Cincinnati,OH) via the 3rd trocar. At first, the lateroconal
fascia was incised along the quadratus lumborum muscle, with exposure of the posterior lamina of Gerota’s fascia. The kidney was retracted anterolaterally by the surgical assistant, whoused a grasping forceps via the 4th trocar. The
leading edge of the psoas muscle was traced
cephalad and renal hilar pulsation could beseen. The renal artery was identified and dissected, secured with five 10.5-mm laparoscopic
clips (Ligaclip ERCA; Ethicon Inc.), and transected with scissors, while 3 clips were left on
the aorta side. The inferior vena cava and therenal vein were then identified and dissected.
Its adrenal and gonadal branches were transected with the Harmonic Scalpel to prevent themfrom being damaged when the renal vein was
dissected. The renal vein was mobilized, stapled and divided with a 35-mm laparoscopic stapler (Endocutter; Ethicon Inc.). The posterior
aspect of the kidney was dissected upwards, andthe anterior aspect of the kidney surrounded by
Gerota’s fascia was dissected free from the peritoneum. An incision was made in Gerota’s fascia at the upper pole of the kidney, and the ipsilateral adrenal gland was spared. The lower

fibers were bluntly separated. The thoracolumbar fascia were gently pierced with a fingertip.
A space for subsequent balloon dilator placement was created by gentle finger dissection of
the retroperitoneum, anterior to the psoas muscle and posterior to Gerota’s fascia. A working
space in the retroperitoneum was created by atrocar-mounted balloon device (PDB; UnitedStates Surgical Inc., Norwalk, CT). The balloon
was inflated with approximately 800 mL of air.
The dilation process was monitored laparoscopically through the transparent balloon. Following the balloon deflation and removal, a second 12-mm trocar was placed 7 cm dorsal to the
1st trocar port under bimanual guidance. A 12mm blunt tip trocar was placed at the 1st trocar
port. Carbon dioxide insufflation was performed at a pressure of 8 mmHg to maintain theworking space in the retroperitoneal cavity, anda 10-mm, 0-degree laparoscope was inserted
via the 1st trocar. The peritoneum was dissected off of the anterior abdominal wall to enable 2
additional trocars to be placed. The 3rd andfourth 5-mm trocars were placed under laparoscopic vision (Fig. 2). Dissection and coagulation during the laparoscopic procedure were performed using the ultrasonically activated scal-

Fig. 1. Early-phase enhanced computed tomogram demonstrating a renal tumor in theright kidney (case 1).

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Laparoscopic radical nephrectomy

Pathological examination of the kidney revealed clear cell-type, grade-2 and stage-pT1a
renal cell carcinoma. Postoperatively, the patient began oral intake on postoperative day 1.
He required analgesia for 3 days. Although a
subcutaneous emphysema occurred at the rightflank abdominal wall, it disappeared on postoperative day 2. Since the patient wanted toreceive adjuvant therapy, he was treated with adaily intramuscular administration of 3 × 106IU/mL interferon-alpha for 2 weeks. He wasdischarged from the hospital on postoperative
day 31.

12th rib

iliac crest

Case 2
Fig. 2. Trocar placement for retroperitoneal laparoscopic radical nephrectomy. , 12-mm trocar; , 5mm trocar. The arrow indicates the line of skin incision to remove the specimen.

A 54-year-old woman visited our hospital with anasymptomatic gross hematuria on June 26, 2001.
Urological examination including ultrasonography and abdominal CT, revealed a tumor
measuring 3.5 cm by 3.5 cm in the lower pole of
the right kidney, and no evidence of renal hilar
lymphadenopathy or hepatic metastasis (Fig.
4). Chest CT and bone scintigraphy showed nosigns of metastatic disease. Preoperative preparation was as described for case 1.
On August 24, retroperitoneal laparoscopic
radical nephrectomy was performed undergeneral and epidural anesthesia. Operative procedure was almost the same as described forcase 1. Two renal veins directly enter the rightpole of the kidney was freed, and the ureter
isolated during the procedure was secured withfour 8.4-mm clips and transected. The specimen was entirely freed upon the completion of
the circumferential mobilization. Insufflation
was lowered to confirm proper hemostasis in
the surgical bed. A 5-mm drainage tube wasthen inserted through the 4th trocar, and left inthe surgical bed. The trocars were removed
under laparoscopic vision.
The specimen was removed
in a muscle-splitting fashion
through an additional skinincision, which was madebetween the 1st and 3rd trocar ports. All wounds wereclosed using a synthetic absorbable suture. Operative
time was 220 min, and estimated blood loss was 10 mL.
The specimen weighed 275
g (Fig. 3).

Fig. 3. Macroscopic appearance of the specimen (case 1).

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T. Isoyama et al.

Fig. 4. Contrast-enhanced computed tomogram showing a renal tumor in the right kidney (case 2).

lateral aspect of the inferior vena cava. A
smaller vein was clipped and transected, and abigger one was divided with the Endocutter.
Operative time was 195 min. Estimatedblood loss was 115 mL. The specimen weighed
200 g (Fig. 5). Pathological examination of thekidney revealed chromophobe cell-type, grade2 and stage-pT1a renal cell carcinoma. There
were no postoperative complications. The patient beganoral intake on postoperative
day 1. She required analgesia
for 2 days. She was discharged from the hospital on postoperative day 17, since she
was anxious about an early
hospital discharge despite ouradvice.

Discussion
Radical nephrectomy is the standard treatment
for localized renal cell carcinoma, and was firstdescribed by Robson (1963). This procedureincludes early ligation of the renal artery andvein before manipulating the renal tumor, en

Fig. 5. Cut surface of the specimen (case 2).

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Laparoscopic radical nephrectomy

bloc removal of the kidney and ipsilateral adrenal gland together with the perinephric fatty tissue and Gerota’s fascia, and dissection of thelymph nodes.
Since the initial report of laparoscopic nephrectomy by Clayman et al. (1991), laparoscopic nephrectomy has become accepted as aminimally invasive procedure for benign, and,more recently, for malignant renal disease.
The benefits for patients undergoing alaparoscopic nephrectomy rather than an open
nephrectomy include a briefer postoperative
course with reduced pain and analgesic requirements, earlier oral intake and mobilization, ashorter hospital stay and convalescence, andbetter cosmetic results (Rassweiler et al., 1998;
Abbou et al., 1999; Hemal et al., 1999; Fornara etal., 2001).
Laparoscopic radical nephrectomy is mostly
done via the transperitoneal approach becauseof a larger working space and well-recognized
anatomic landmarks. Gaur (1992) reported thecreation of an adequate working space in the retroperitoneum using the blunt balloon dissection technique. This led to an increased interestin the retroperitoneal approach for laparoscopic
nephrectomy. Since the kidney is a retroperitoneal organ, the retroperitoneal approach provides several potential advantages. In this approach, the renal hilum is initially exposed,
allowing for early control of the renal vessels.
The risk of intraperitoneal organ injury is very
low compared to the transperitoneal approach.
In laparoscopic radical nephrectomy, specimen removal can be performed 2 different
ways; intact removal performed by extending
the incision at 1 of the port sites, or morcellation
after the specimen has been placed in an entrapment sac. Intact removal of the specimen withor without an entrapment sac requires extensionof the incision (Gill et al., 2000; Cicco et al.,2001). A larger incision, even in a longitudinal
muscle-splitting fashion (Savage and Gill,
2001), may reduce the advantages of laparoscopic surgery. Morcellation can be performed
with a high-speed electrical tissue morcellator(Kavoussi et al., 1993) or mechanical clamp
and forceps (Ono et al., 2001). However, thismaneuver introduces the risk of seeding of thetumor cell at the port sites, and dissemination
into the working space. In addition, precise
evaluation of the surgical margins, which isdependent on pathological examination of theintact specimen, may be difficult because of tissue morcellation.
In our department, simultaneous adrenalectomy during open radical nephrectomy is notroutinely performed, except for large, upperpole tumors (Kadowaki and Miyagawa, 2001).
Paul et al. (2001) reported a total of 866 consecutive patients who underwent nephrectomy
and ipsilateral adrenalectomy with a solitaryadrenal metastasis of only 6 (0.6%). They suggested that if the maximum tumor size measured by CT is less than 8 cm, and when a staging examination does not show organ or lymph
node metastases, adrenalectomy is not necessary.
In this series, we did not perform regional
lymph node dissection. Although regional
lymph node dissection provides for more precise staging of the disease, its therapeutic value
remains controversial. Minervini et al. (2001)
suggested that there is no clinical benefit interms of overall outcome in undertaking regional lymph node dissection in the absence of enlarged nodes detected before or during surgery.
At present, our policy is to restrict retroperitoneal laparoscopic radical nephrectomy to tumors less than 7 cm, and neither regional lymph
node dissection nor ipsilateral adrenalectomy isperformed during the procedure.
There are few reports concerning the longterm disease-free outcome of laparoscopic
radical nephrectomy (Cadeddu et al., 1998; Onoet al., 2001). Ono et al. (2001) evaluated theefficacy of laparoscopic radical nephrectomy.
One-hundred and three patients who had renal
tumors less than 5 cm in diameter underwent
laparoscopic radical nephrectomy. During a
median follow-up period of 29 months (range 3
to 95 months), the seeding of port sites did notoccur in any of the patients. Metastatic diseasedeveloped in 3 patients, and local recurrence in
1 patient. The 5-year disease-free and patient
survival rates were 95.1% and 95.0%, respectively. These rates were comparable to those inpatients who underwent open surgery.
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T. Isoyama et al.

Table 1. Results of retroperitoneal laparoscopic versus open radical nephrectomy
Pa- Age Sex Side Operatient
tive
numbertime(min)

Estimatedblood loss
(mL)

Tumor
size
(cm)

PathologAnalPostHospital
ical
gesia operative
stay
diagnosis(day) oral intake (day)(stage/grade)†(day)

Retroperitoneal laparoscopic radical nephrectomy
1
2
Mean

65 M
54
F
59.5

Rt
Rt

220
195
207.5

10
115
62.5

2.4
3.5
2.95

pT1a/G2
pT1a/G2

3
2
2.5

1
1
1

31
17
24

Open radical nephrectomy
1
63 M
Lt
220
235
3
pT1a/G2
17
4
27
2
59
F
Lt
185
110
4.5
pT1b/G2
4
2
33
3
73
F
Rt
185
260
3
pT1a/G2
7
3
18
4
43 M
Rt
142
90
2
pT1a/G2
9
5
31
5
62 M
Lt
235
530
3.3
pT1a/G2
2
8
24
6
71 M
Lt
180
220
2.9
pT1a/G2
3
4
16
7
59 M
Rt
205
385
3.5
pT1a/G2
3
3
56
*
*
8
47
F
Rt
210
250
3.6
pT1a/G2
2
2
14
9
39 M
Rt
180
190
3
pT1a/G2
3
4
17
10
77
F
Rt
305
145
4.5
pT1b/G2
5
5
11
11
72 M
Rt
200
220
4.4
pT1b/G2
1
2
16
12
63
F
Rt
285
220
4
pT1b/G2
4
3
34
13
51
F
Rt
180
680
6
pT1b/G2
3
3
35
14
66
F
Lt
260
1150
3
pT1a/G2
4
2
32
15
83 M
Lt
160
440
3
pT1a/G1
5
2
16
16
57 M
Lt
235
500
2.3
pT3a/G2
4
3
33
Mean 61.6
210.4
351.6
3.5
4.8
3.4
25.8
F, female; Lt, left; M, male; Rt, right.
* P < 0.05 compared by the Mann-Whitney test.
† According to the general rule for clinical and pathological studies on renal cell carcinoma (Japanese
Urological Association, The Japanese Society of Pathology and Japanese Radiological Society, 1999).

Outcome data were retrospectively compared between groups of patients treated between March 1998 and August 2001 at our department clinic of Tottori University Hospital:
the 2 initial patients undergoing laparoscopic
radical nephrectomy versus 16 patients with localized disease undergoing open radical nephrectomy (Table 1). Mean tumor size was
2.95 cm in the laparoscopic group and 3.50 cm
in the open group (P = 0.52). Outcome analysis
revealed that both groups were comparable inregard to operative time (207.5 min versus
210.4 min). However, the laparoscopic group
showed lower blood loss (P < 0.05) and earlier
postoperative oral intake (P < 0.05).
Although a long-term follow-up is necessary to evaluate the efficacy of this procedure, itwill probably become a standard treatment
modality for localized renal cell carcinoma.

Acknowledgments: Special thanks to Drs. Yoichi
Arai and Koji Yoshimura, Department of Urology,
Kurashiki Central Hospital, for their kind advice on
the surgical technique.

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Received December 19, 2001; accepted January 17, 2002
Corresponding author: Dr. Tadahiro Isoyama

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