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Year : 2005  |  Volume : 21  |  Issue : 2  |  Page : 102-105

Laparoscopic retroperitoneal nephrectomy: overcoming the learning curves

Department of Urology and Transplantation, Institute of Kidney Diseases and Research Centre and Institute of Transplantation Sciences, Civil Hospital Campus, Ahmedabad, India

Correspondence Address:
P R Modi
A-161, Sarvodaya Nagar-1, Sola Road, Ghatlodia,Ahmedabad - 380061,Gujarat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-1591.19630

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Objective: To assess the results of retroperitoneal laparoscopic nephrectomy at a single centre. Materials and methods: A retrospective study of 40 patients (group A: initial 20, group B: late 20 cases) who underwent retroperitoneal laparoscopic nephrectomy was done. Analysis of the complication rate, conversion rate to open surgery, operative time and the blood loss and analgesia requirement were studied. Results: Laparoscopic retroperitoneal nephrectomy was carried out successfully in 60% cases of group A and in 95% cases of group B cases. There was a statistically significant reduction in the blood loss and duration of surgery in group B. Analgesia requirement was not different in either group. Conclusions: Retroperitoneal laparoscopic nephrectomy has a steep learning curve. Results of the procedure improved and complications reduced significantly after the initial 20 cases.

Keywords: Laparoscopy; Learning curve; Nephrectomy; Retroperitoneum

How to cite this article:
Modi P R, Kadam G V, Dodia S, Jain R, Patel R, Devra A. Laparoscopic retroperitoneal nephrectomy: overcoming the learning curves. Indian J Urol 2005;21:102-5

How to cite this URL:
Modi P R, Kadam G V, Dodia S, Jain R, Patel R, Devra A. Laparoscopic retroperitoneal nephrectomy: overcoming the learning curves. Indian J Urol [serial online] 2005 [cited 2023 Feb 3];21:102-5. Available from:

Wittsomer was the first to access the retroperitoneum laparoscopically for lumbar sympathectomy in 1973. Wickham was the first to undertake any urological procedure laparoscopically by performing ureterolithotomy.[1] Dealing in the retroperitoneum has its inherent disadvantages for laparoscopy such as a limited space for working, identifying the landmarks and limited creation of pneumoretroperitoneum. Gaur [2] revolutionised the laparoscopic approach to the retroperitoneum by innovating a glove balloon on a simple rubber catheter for blunt dissection and creation of space in retroperitoneum. We present our experience of overcoming the learning curve of laparoscopic retroperitoneal nephrectomy at our institute in a single unit.

   Materials and methods Top

A retrospective analysis was done for 40 patients who underwent laparoscopic retroperitoneal nephrectomy from December 2001 to December 2003. The initial 20 cases are denoted as Group A and the subsequent 20 cases are denoted as Group B. [Table - 1] summarizes these 40 cases. All surgeries were performed by a single surgeon (PRM).

The patients in groups A and B were age matched. Male patients were more than female patients in both groups. The indications for nephrectomy are shown in [Table - 1]. In group B, six (30%) prerenal transplant nephrectomy were performed; four for reflux nephropathy and two for calculous disease. One (2.5%) patient underwent nephroureterectomy of native kidney after renal transplantation for persistent urinary tract infection with low-grade reflux.

The standard operative procedure as described by Gill [3] was carried out in all patients. In brief, under general anaesthesia with endotracheal intubation and EtCO2 monitoring the patient was kept in flank position with flexion of the operating table. Three ports kept; one primary 10 mm at posterior axillary line at the tip of the 12th rib and two secondary ports one of 5 mm size at anterior axillary line and another 10 mm at paraspinal region at the renal angle. We inflated Gaur balloon outside the Gerota's fascia and secondary port placement was done under laparoscope guidance. Opening of Gerota's fascia pushes the kidney and the peritoneum more anteriorly thereby decreasing the chances of peritoneal injury and direct approach to the renal hilum. Renal vessels were dissected and titanium clip applied in all cases, three proximally and two distally. In three cases, large calibre of the renal vein prompted us to ligate it intracorporeally before applying the titanium clips. Extra 5 mm port placement was required in two of these cases. The kidney was mobilisd from all the aspects. In the initial cases, the sites of ports A and C were joined but subsequently only the site of primary port incision was extended depending on the size of the kidney and the specimen was removed intact. Drain was kept from anterior 5 mm secondary port. Muscles were sutured by polyglactin No.1 and skin by nylon no.3-0.

The duration of surgery and blood loss was noted. Analgesics were administered in the form of either diclofenac sodium or tramadol hydrochloride. Oral feeding was started in all the patients the next morning. Patients were discharged the day after the drain was removed. Statistical analysis was done by Student's t -test.

   Results Top

During access, no injury occurred to any of the structure in the retroperitoneum. During dissection of the kidney, peritoneum was inadvertently opened in four (10%) patients but this did not hamper the progress of laparoscopy. Just before completing the procedure, a verress needle was inserted in the peritoneal cavity and the gas was aspirated. As shown in [Table - 3], the cases have been analysed and the level of significance was considered at P < 0.05.

The overall success rate in the study was 77.5%. The success rate of the procedure in group A was 60%, which subsequently improved to 95% in group B. The overall success rate in patients with pre-operatively placed nephrostomy tubes was 81.81%. All the patients of prerenal transplantation nephrectomy were successfully dealt with laparoscopically. All three patients with previous history of renal surgery required conversion to open surgery; two of them had non-progression caused by fibrosis and in one case renal artery injury occurred. The duration of surgery and blood loss significantly reduced in group B than that in group A. The scar length also reduced significantly in group B. There was no statistical difference in the duration of drain removal and discharge from the hospital in both the groups. There was also no statistical difference in the analgesia requirement in both the groups.

[Table - 2] shows the reasons for conversion to open surgery and the postoperative complications. Elective open conversion was defined as non-urgent conversion due to failure to progress by laparoscopy because of extensive inflammation or fibrosis precluding safe dissection. Elective conversion was not classified as a complication. Urgent or emergency open conversions due to causes such as bleeding were classified as complication.

Two (5%) patients had subcutaneous emphysema due to leak at primary port site, which resolved by conservative means after 2 days. Three (7.5%) major complications occurred in our study. In one patient, the titanium clip applied to the renal artery dislodged inadvertently after transecting the artery leading to hemorrhage. This was due to malfunctioning clip applicator, which was not diagnosed intraoperatively. Another patient had dense adhesions around the hilum and during dissection the renal artery was injured. The third patient had dense adhesions around the hilum; the inferior vena cava was injured during dissection. All required immediate exploration to control the bleeding and intraoperative and postoperative blood transfusion. The histopathology of a case of vena cava injury was calculous xanthogranulomatous pyelonephritis. Other than the above three cases of conversion to open surgery, in group A six (30%) cases were converted to open surgery due to failure to progress. The overall conversion rate to open surgery and reintervention rate in the study was 22.5 and 2.5%. The patient in whom reintervention was required was due to bleeding from the adrenal gland. The patient required blood transfusion. The conversion rate in groups A and B was 40 and 5%, respectively.Minor wound infection occurred in three (7.5%) patients in the study; one of them had preoperative nephrostomy tube. Fever developed in three (7.5%) patients in the postoperative period which was controlled by antibiotics and antipyretics. Three (7.5%) of the patients had persistent pain in the opposite flank for 6-7 days, which may be attributed to the hyperflexion of the operating table; it was relieved by rest and analgesics. Paralytic ileus occurred in two (5%) patients who were managed conservatively and recovered in 3 days. Metabolic acidosis occurred in one (2.5%) patient of end stage renal disease. There were no complications like pulmonary embolism or pneumothorax.

   Discussion Top

Patience is required during laparoscopic surgery in the phase of learning curve since it is a technically difficult procedure.[4] This is especially true in case of retroperitoneoscopy since the retroperitoneum is a potential space which limits the area to work. Since Gaur pioneered the technique of retroperitoneal balloon dilatation, retroperitoneoscopy has become safe and reproducible.

Surgical learning curve in laparoscopy is usually assessed by the complication rate, reintervention rate and the operative time.[1],[5],[6],[7] In our series, initial failure (six patients in group A) was due to gas leak from side of ports, difficulty in orientation of landmarks in retroperitoneum and hence we failed to progress. Instead of taking port fixation stitch with the skin we started taking with the external oblique muscle sheath. The stitch is taken prior to placement of trocar and tied after placing the trocar under vision. With this technique we did not find either major gas leak from the primary port site or subcutaneous emphysema.

In patients of group A, we opened the Gerota's fascia before balloon dilatation by blunt finger dissection. This causes balloon to inflate in an unpredictable place and often the fat in retroperitoneum gets loose which comes in the field of vision while performing the surgery. Further, precise cutting of Gerota's fascia was not possible and dissectin of ureter and renal pedicle was difficult. Later on, in patients of group B we started inflating the balloon between Gerota's fascia and psoas sheath. After balloon inflation and port placement under vision we started cutting Gerota's fascia, which gives a precise cutting of fascia and encountering renal hilum earlier. As we keep on cutting the Gerota's fascia from caudal to cephalad direction more and more space is available for further dissection.

In a review by Rassweiller et al., it was observed that majority of the complications, conversion rates and reintervention rates occurred in the first 20 cases of each surgeon during the phase of initial learning curve.[8] In another review Rassweiller et al., it was observed that there was a significant learning curve during the first 50 cases. In the initial 50 cases the complication rate, conversion rate and open reintervention rate decreased from 14, 10 and 6% to 2, 4 and 2%, respectively, in the last 50 cases.[1] In a study by Gill et al., it was observed that 71% of the complications occurred during the first 20 patients.[9] In our study, with experience our conversion rate decreased which reiterates the fact that a surgeon is liable to more failures in the early part of the learning curve. In the initial 20 cases, six (30%) of the patients were converted to open surgery because of failure to progress. We could attribute the majority of conversions due to technical failure like inflammation in the peri-renal region and inexperience of the surgeon. The higher conversion rate also depends on the renal pathology for which the patient undergoes nephrectomy. In various studies, the conversion rate was higher in patients having tuberculosis or xanthogranulomatous pyelonephritis.[1],[10],[11] We had a patient of calculous xanthogranulomatous pyelonephritis in whom the inferior vena cava was injured during dissection. For retroperitoneal procedures previous open surgery and history of peritonitis are not necessarily regarded as contra-indications.[2],[12] But all our patients who had previous history of surgery had to undergo open conversion.

In a study by Gill et al., the major complications were splenic laceration in one, pneumothorax in one, paralytic ileus in three and congestive heart failure in one patient.[9] In a review by Rassweiller et al., bleeding was the major complication in 4.6%, visceral injury in 0.6%, hypercarbia in 0.4% and pulmonary embolism in 0.2% of the patients.[8] Three (7.5%) of our patients had vascular injury during the surgery, which required immediate exploration and control of haemorrhage. No visceral injury occurred in our study since the secondary ports were inserted under vision away from the peritoneal fold. We encountered two (5%) patients of subcutaneous emphysema due to leak from primary port site initially. Subsequently, muscle splitting was done at the primary port site instead of incising and a suture was passed through the muscle before trocar insertion. With this modification, no surgical emphysema was noted subsequently. To minimise complications, Keeley et al.[13] proposed suggestions like inserting trocar under vision, direct hilar approach, adequate exposure, selection of patient and regular team of surgeons and nurses to avoid unnecessary delay and frustration.

In a study by Keeley et al., the operative time in the first 20 cases was 204 min, which reduced to 108 min in the last 20 cases.[13] In another review by Eraky et al., the mean operative time for the initial 53 cases and the subsequent 53 cases were 217 ± 84 min and 154 ± 48 min, respectively.[14] With experience, identification of anatomical landmarks and techniques of dissection became refined which subsequently led to a significant decrease in the operative time and the amount of blood loss during the surgery which was also found in our study.

In a study by Hernandez et al., it was concluded that there was no significant difference in surgical time, pain or hospital stay in patients in whom the specimen was retrieved by morcellator and those by intact specimen extraction except the incision length.[15] We removed the specimen by intact extraction method. The average incision length was 3.5 cm.

   Conclusion Top

Retroperitoneal laparoscopic nephrectomy for benign renal diseases has emerged as a good alternative to open surgery. The surgeon in the initial phase of his learning curve has a higher failure rate, longer operative time and more blood loss. Patience and perseverance should be constant companions during the learning curve of laparoscopic surgery to achieve success. History of previous retroperitoneal open surgery is likely to have more conversion or complication rate than in patients without such history. However, minimal invasion like placement of nephrostomy tube does not decrease the success rate of retroperitoneal laparoscopic surgery.

   References Top

1.Rassweiler JJ, Seemann O, Frede T, Henkel TO, Alken P. Retroperitoneoscopy: experience with 200 cases. J Urol 1998;160:1265-9.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Gaur DD: Laparoscopic operative reteroperitoneoscopy: use of a new device. J Urol 1992;148:1137.  Back to cited text no. 2    
3.Gill IS. Retroperitoneal Laparoscopic Nephrectomy : Urol Clin N Amer 1998;25:343-60.  Back to cited text no. 3  [PUBMED]  
4.Bishoff JT, Kavoussi LR. Editorial: Urological Laparoscopy- Why bother? J Urol 1998;160:28.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Cadeddu JA, Wolfe Jr. JS, Nakada S, Chen R, Shalhav A, Bishoff JT et al. Complications of laparoscopic procedures after concentrated training in Urological Laparoscopy. J Urol 2001;166:2109-11.  Back to cited text no. 5    
6.Fahlenkamp D, Rassweiler JJ, Fornara P, Frede T, Loening SA. Complications of laparoscopic procedures in urology: experience with 2,407 procedures at 4 German centers. J Urol 1999;162:765.  Back to cited text no. 6    
7.Dunn MD, Portis AJ, Shalhav AL, Elbahnasy AM, Heidorn C, McDougall EM et al. Laparoscopic versus open radical nephrectomy: a 9-year experience. J Urol 164:1153.  Back to cited text no. 7    
8.Rassweiler JJ, Fornara P, Weber M. Laparoscopic nephrectomy: the experience of the laparoscopy working group of the German Urological Association. J Urol 1998;160:18-21.   Back to cited text no. 8    
9.Gill I, Kavoussi L, Clayman R, Clayman RV, Ehrlich R, Evans R et al. Complications of laparoscopic nephrectomy in 185 patients: a multi-institutional review. J Urol 1995;154:479-83.  Back to cited text no. 9    
10.Hemal AK, Gupta NP, Kumar R. Comparison of Retroperitoneoscopic nephrectomy with open surgery for Tuberculous nonfunctioning kidneys. J Urol 2000;164:32-5.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]
11.Shekarriz B, Meng MV, Lu H, Yamada H, Duh QY, Stoller ML. Laparoscopic nephrectomy for inflammatory renal conditions. J Urol 2001;166:2091-94.  Back to cited text no. 11    
12.Rassweiler JJ, Henkel TO, Stock C, Frede T, Alken P. Retroperitoneoscopic surgery-technique, indications and first experience. Min Inv Ther 1994;3:179.   Back to cited text no. 12    
13.Keeley FX, Tolley DA. A review of our first 100 cases of laparoscopic nephrectomy: defining risk factors for complications. Br J Urol 1998;82:615-8.  Back to cited text no. 13  [PUBMED]  
14.Eraky, El-Kappany, Ghonem MA. Laparoscopic Nephrectomy: Mansoura experience with 106 cases. Br J Urol 1995;75:271-5.   Back to cited text no. 14    
15.Hernandez F, Rha KH, Pinto PA. Laparoscopic Neprectomy : Assessment of morcellation versus intact specimen extraction on postoperative status. J Urol 2003;170:412-5.  Back to cited text no. 15    


  [Table - 1], [Table - 2], [Table - 3]

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