What are the indications for extraperitoneal nephrectomy?

Updated: Sep 24, 2019
  • Author: Michael Grasso, III, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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In general, the indications for an extraperitoneal laparoscopic nephrectomy are similar to those for the intraperitoneal approach. Using a retroperitoneal approach has certain advantages over a traditional laparoscopic nephrectomy, which include prompt access to the great vessels and renal vasculature without requiring medial mobilization of solid viscus or bowel.

This is particularly beneficial in the morbidly obese patient, in those who have undergone previous abdominal surgery or radiation where intra-abdominal adhesions are expected, and when renal vascular anomalies and/or neovascularity associated with a tumor mass are expected based on preoperative radiographic imaging, for which early vascular control is essential.

Furthermore, owing to the lack of bowel manipulation and irritating effects of carbon dioxide on the gastrointestinal tract, the incidence of postoperative ileus and time to refeeding is far less.

Additionally, the prompt access to the great vessels and renal hilum is particularly helpful when the retroperitoneum is distorted by such factors as lymphadenopathy and tumor neovascularity.

Retroperitoneal laparoscopic nephrectomy is regularly performed for both benign and malignant lesions. The decision to perform simultaneous adrenalectomy and regional lymphadenectomy is individualized but is routinely performed using this approach. [8] Extraperitoneal laparoscopy has become the primary mode of access for adrenal lesions, including adrenal cortical carcinoma and pheochromocytoma. Renal tumor size, location, and radiographic or intraoperative evidence of lymphadenopathy do not prohibit using this procedure and are commonly facilitated by using a retroperitoneal procedure.

For the largest renal tumors, extraperitoneal extraction may be challenging. In those cases, initial retroperitoneal renal vasculature control with subsequent conversion to a transperitoneal dissection for tumor mobilization and specimen extraction is advantageous.

Retroperitoneal laparoscopic nephrectomy is also routinely performed for benign renal lesions. The term "simple nephrectomy" is a misnomer; removal of nonfunctioning hydronephrotic kidneys and kidneys associated with chronic pyelonephritis can reflect particularly challenging renal dissections. [9, 10] As with radical nephrectomy, early access to the major retroperitoneal structures is facilitated with retroperitoneal laparoscopic nephrectomy in this setting as well. In cases where renal infection and pyonephrosis are present, maintaining a retroperitoneal surgical field has the added advantage of localizing the infectious process to a contained space.

Lastly, laparoscopic donor nephrectomy can also be performed using a completely extraperitoneal approach, in which adequate length of the renal vessel for transplantation is facilitated by direct access to the aorta and vena cava. [11]

Once the technique is adequately mastered, the retroperitoneal approach is used for various surgical procedures, including nephroureterectomy, [12] partial nephrectomy, [13] pyeloplasty, [14] and adrenalectomy. [15]

Relative disadvantages of the retroperitoneal approach include a smaller working space that makes large specimen entrapment and removal challenging, as well as marginally higher tissue absorption of the insufflation agent as compared with standard laparoscopy with associated hypercarbia. This, however, is usually clinically insignificant and the theory itself is being challenged by current studies (see Results). [16]

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