Laparoscopic Surgery for Renal Cell Carcinoma

Abstract

Since Clayman’s initial description of laparoscopic nephrectomy, this procedure has rapidly gained worldwide acceptance. At centers where such expertise is available, laparoscopic radical nephrectomy can comfortably be considered a, if not the, standard of care for the appropriate patient with an organ-confined T1 renal tumor. Either the transperitoneal or the retroperitoneal laparoscopic approach can be employed, depending on the individual patient characteristics and, particularly, the training and expertise of the laparoscopic surgeon. Contraindications for laparoscopic radical nephrectomy today include vena caval thrombus, bulky lymphadenopathy, and locally invasive tumors. Large tumor size is only a relative contraindication, dependent on the comfort level of the laparoscopic surgeon and the individual characteristics of the tumor. Although laparoscopic radical nephrectomy for pT2 tumors has been reported, the possibility of significant-sized peritumoral collateral vessels and desmoplastic reaction must be kept in mind. Contraindications include significant cardiopulmonary comorbidity, uncorrected coagulopathy, and abdominal sepsis. Significant prior surgery in the quadrant of interest and morbid obesity increase the level of technical difficulty, although we have had gratifying success in these two challenging circumstances by employing the retroperitoneal laparoscopic approach.