[Laparoscopic renal surgery]

Spurred by the development of laparoscopic lymphadenectomy and nephrectomy, laparoscopic surgery has gained acceptance in Urology, although not as rapidly as endourology. Laparoscopic access to the kidney is easier by the transperitoneal than by the retroperitoneal approach. Insertion of a trocar through the umbilicus for the optic and utilizing three to five accessory trocars is the standard practice. In some simple procedures two accessory trocars will suffice, four trocars and periumbilical trocar are required for nephrectomy, and an additional trocar is inserted in the hypogastrium for distal ureter release in nephroureterectomy. The procedure is performed using intravenous general anesthesia with endotracheal intubation and the patient is placed in the supine decubitus position with a 45 degrees lateral tilt or in the total lateral decubitus position (nephrectomy) with a slight anti-Trendelenburg. Exposure of the kidney is achieved by opening the posterior peritoneum along the line of Toldt and, in some cases, releasing the hepatic angle or the splenic colon. The kidney can be released partially or completely depending on the type of surgery. It is easier to perform an extended nephrectomy since dissection is performed better between the capsule of Gerota and the pararenal tissue. The renal vessels can be controlled with clips or an automatic stapling/cutting device. Laparoscopic access to the mid and upper ureter is very simple and the only difficulty encountered is in its correct identification. The current and future applications of laparoscopic renal surgery are discussed, including some original procedures that have been performed by the authors, such as in situ excision of a renal tumor and two pyelolithotomy procedures in solitary kidney.