Objective To summarize the complications of retroperitoneal laparoscopic nephrectomy.Methods From November 2002 to May 2006,122 patients with renal carcinoma underwent retroperitoneal laparoscopic nephrectomy.Complications occurred in 7 patients,and the morbidity was 5.7%.One case of injury to vena spermatica converted to open surgery,the blood loss was 1000 ml with blood transfusion 800 ml.One postoperation hemorrhage of accessory renal artery which was cut off only by harmonic scalpel,leading to blood pressure decrease to 90/60 mm Hg,and a reoperation was performed and the blood loss was 600 ml with blood transfusion 400 ml.Injury of inferior vena cava by linear cutter stapler in one case,and there was no blood loss.Hemorrhage of renal artery stump after linear cutter stapler in one case and it was controlled by titanium clip.Injury of renal vein occurred in two cases and all were controlled by Hem-o-lok or titanium clip.Injury of tail of pancreas in one case and a drainage tube was placed.Results A patient with vena cava injury was followed for 30 months and no abnormality was noted.A patient with pancreas injury was followed for 1 year and nothing remarkable was noted.The other 5 cases was followed for 20-40 months,and they remained in good health.Conclusion The major complication for retroperitoneal laparoscopic surgery is injury to large blood vessels,the principle of treatment is to elevate the pressure of pneumoperitoneum up to 18-20 mm Hg and clip the blutpunkte or convert to open surgery promptly.A good drainage is necessary for the treatment of injury of pancreas.

Objective To evaluate the feasibility of minimally invasive therapy for peripelvic renal cysts by retroperitoneal laparoscopy.Methods Clinical data of 10 cases of peripelvic renal cysts treated by retroperitoneal laparoscopic fenestration in this hospital from October 2003 to March 2005 were retrospectively reviewed.Results All the 10 cases of operation were successfully completed.The operation time ranged 40~60 min(mean,55 min).Follow-up observations in the 10 cases for 3~24 months(mean,12.8 months) showed no recurrence.Conclusions Retroperitoneal laparoscopy is a safe and feasible alternative for the management of peripelvic renal cysts.

Objective To evaluate the outcomes of laparoscopic live donor nephrectomy via retroperitoneal approach. Methods From December 2003 to June 2004,6 patients underwent laparoscopic live donor nephrectomy (younger brother to elder sister in 1 case,elder brother to younger brother in 1, younger sister to elder brother in 1,elder sister to younger brother in 1,father to son in 1,mother to son in 1).For tissue matching,1 case was mismatched of 0 locus,2,of 2 loci and 3,of 3 loci.The results of PRA and lymphocytotoxicity test were negative.The patient was placed in the lateral decubitus.With 3 trocars, the left kidney was dissected via retroperitoneal approach.The arteries and veins were cut off by endoscopic articulating linear cutter. The donor's left kidney was taken out through a 6-7 cm long incision between 2 trocars.Staplers on renal arteries and veins were cut off,and the donor kidney was perfused with liquid,and then was implanted at the right iliac fossa of the recipients.Triple immunosuppressant therapy was used to prevent rejection. Results Laparoscopic donor nephrectomy was successfully performed on all the 6 cases by retroperitoneal approach.The kidney transplantations using the donor live kidneys were also successful.Postoperatively,the mean urine volume was 5036 ml(range,3500-6500 ml) on the first day;the mean serum creatinine level was 598 ?mol/L on the first day and 129 ?mol/L at 1 month.Follow-up of 3-9 months showed that the renal function was normal and no rejection occurred. Conclusions Laparoscopic donor nephrectomy via retroperitoneal approach is safe,feasible,and less invasive to the donor; however,this technique needs skilled surgeons of laparoscopy and renal transplantation.

Objective To evaluate the safety and efficacy of retroperitoneoscopic radical nephrectomy. Methods A total of 46 patients (24 males and 22 females;age range,23-86 years;mean age,58 years) underwent retroperitoneoscopic radical nephrectomy from November 2002 to July 2004.Of the 46 cases,43 were detected by B-ultrasound during physical examination and the rest 3,when visiting doctors due to painless hematuria.The masses by B-ultrasound was on average 4.5 cm (range,1.5-8.0 cm) in diameter, with 17 masses at the upper pole of the kidney,13 at the middle and 16 at the inferior pole.CT scan was performed on all the 46 cases and MRI,on 41.The tumor size detected by CT and MRI was consistent with that by B-ultrasound.Preoperatively,3 cases had the tumors of clinical stage T 1N 0M 0,38 of T 2N 0M 0 and 5 of T 3aN 0M 0. Results The operative time was 60-255 min (mean,145 min),and blood loss was 20-1000 ml (mean,133 ml).Adrenalectomy was performed on 32 patients (70%).Complications occurred in 3 cases,of whom only 1 required conversion to open surgery due to injury of genital gland vein,with blood loss of 1000 ml.Pathology showed that 41 cases were of renal clear cell carcinoma,2 of cystic renal cell carcinoma,1 of chromophobe carcinoma,1 of hamartoma and 1 of oxyphil cell tumor.During the follow-up of 1-20 months (mean,9 months),45 patients survived;only 1 died of liver metastasis. Conclusions Retroperitoneoscopy radical nephrectomy is safe and effective.

Objective To evaluate the technique and effect of laparoscopic live donor nephrectomy via retroperitoneal approach. Methods Thirty-two donors (15 males and 17 females) underwent laparoscopic donor nephrectomy at our institution. Twenty-nine left and 3 right procedures were performed. Under general anesthesia, all donors were placed in lateral decubitus. Three transretroperitoneal trocars were used through different ports. The first 12 mm port was placed 2 cm inferior to the edge of rib and 1 cm lateral to the edge of sarcospinous muscle. The second 10 mm port was about 8 to 10 cm anterior to the first, or on the anterior axillary line and 2 cm inferior to the edge of rib. The third 5 mm port was also on the anterior axillary line but 2 cm superior to the iliac crest. The surgeon created the retroperitoneal working space with a constructed catheter balloon device, and made the donor kidney and ureter dissociated. Renal arteries and veins were cut with endoscopic articulating linear stapler for the first 6 patients and then with Hemo-Lok, a plastic clip with a lock, for the others. Finally, the dissected donor kidney and ureter were taken out through an incision extended from the first trocar port. Results All the 32 donor grafts were dissected successfully. The duration of procedure was ranged from 60 to 180 min, and the volume of blood loss was from 20 to 200 ml. The range of warm ischemia time was 3 to 8 min, and 25 to 50 min of cold ischemia time. Short renal veins were found in 3 cases, 1 cm, 1.5 cm and 2 cm respectively. And one case of renal endoarterial injury occurred. On the day after transplantation, the urine volume of recipients was from 2800 to 10 100 ml. There was no delayed graft function found in recipients. Conclusion Laparoscopic donor nephrectomy via retroperitoneal approach is available and safe to renal transplantation with minimal invasion to donors. It can help to obtain donor grafts with higher quality, though skillful laparoscopic technique is demanded.

1cm.

Objective To explore the techniques and efficacy of retroperitoneal laparoscopic operations in the treatment of renal cyst. Methods A total of 35 patients were operated on under general anesthesia. A water-filled balloon was used to dilate the retroperitoneal cavity. The renal cyst was exposed by identifying the psoas major muscle, peritoneal reflection, pillar of diaphragm and so on. All cyst walls were unroofed with ultrasonic scalpel 3～5 mm from the edge of renal parenchyma. Results With renal cysts removed, the operations were successfully accomplished in all the 35 patients. The operation time was 15～60 min (mean, 32 min). The intraoperative blood loss was 5～60 ml (mean, 35 ml). The postoperative hospital stay was 3～6 days. Pathological examinations reported benign lesions in 34 patients and suspected cystadenocarcinoma in 1 patient. All the 35 patients were followed for 1～22 months. No recurrence was found with exception of 1 case of remaining renal cyst 1.5 cm in diameter under B-ultrasonography at the first postoperative month. The patient with suspected adenocarcinoma had been followed for 1 year and no evidences of neoplasm or metastasis were detected on the chest roentgenogram and B-ultrasonography of the liver and the kidneys. Conclusions Retroperitoneal laparoscopic unroofing is a safe and effective procedure for renal cyst.

Objective To evaluate the feasibility and curative effects of retroperitoneal laparoscopic surgery for adrenal pheochromocytoma. Methods Clinical records of 9 cases of retroperitoneal laparoscopic adrenalectomy of pheochromocytoma from October 2002 to November 2004 were reviewed. Results The operations were successfully completed in all 9 cases without severe complications. A sudden rise of blood pressure with an amplitude over 30 mmHg appeared in 3 cases during the operation, which took a favorable turn after adjusting the surgical performance and blocking the central vein. The operation time was 90~210 min (mean, 150 min). The intraoperative blood loss was 30~150 ml (mean, 50 ml). Blood transfusion was required in no cases. The postoperative length of hospitalization was 4~9 days (mean, 5 days). Pathological examination revealed benign adrenal pheochromocytoma in all cases. Follow-up for 3~24 months (mean,11 months)in the 9 cases found symptom free and no recurrence by B-ultrasonography or CT scans. Conclusions Retroperitoneal laparoscopic surgery for adrenal pheochromocytoma is a feasible procedure which offers advantages of minimal invasion, short operation time, less blood loss, quick postoperative recovery, fewer complications and good curative effects, having a promising future.

Objective To discuss anatomic landmarks during retroperitoneoscopic radical nephrectomy. Methods A total of 46 patients underwent retroperitoneoscopic radical nephrectomies from November 2002 to July 2004.The first trocar was introduced at the union of the site 2 cm below the 12 th costal margin with the lateral side of the musculus sacrospinalis.The second trocar was placed at the midpoint of the upper border of the iliac crest,or at the location above and medial to the anterior superior iliac spine.And the third one was inserted at the union of the anterior axillary line with the costal margin.In the first place,the greater psoas muscle was identified as the dorsal marker.Then the diaphragmatic muscle was identified as the posterior marker of the upper pole of the kidney,and the adrenal gland as the medial marker of the upper pole of the kidney,and the peritoneum as the ventral marker.The renal vein lay below and anterior to the renal artery.The right renal vein was routinely sperated right up to the joining site with the inferior vena cava.A linear cutter was used to resect the renal vein and artery respectively. Results The mean operation time was 145 min (range, 60~ 255 min) and the mean intraoperative blood loss was 133 ml (range, 20~1 000 ml). Adrenalectomy was performed in 32 patients (69 6%). A conversion to open surgery was required in 1 patient because anatomic landmarks could not be well seen. The inferior vena cava was wrongly closed off by 1/2 cross-section when using a linear cutter to sever the right renal vein in 1 patient. Peritoneal injuries happened in 4 patients.Follow-up was carried out for 1~20 months (mean,9 months) in all the 46 patients.One patient died of liver metastasis 1 year after the surgery, while the remaining 45 patients survived without recurrence. Conclusions Proper identification of anatomic landmarks is crucial to a successful retroperitoneoscopic nephrectomy.

Objective To introduce the experience for managing the renal artery and vein during retroperitoneal laparoscopic nephrectomy. Methods A series of 52 consecutive patients underwent retroperitoneal laparoscopic nephrectomy. The operation was performed under a general anesthesia. Patients were maintained in the lateral decubitus position. Two 10 mm trocars and one 5 mm trocar were introduced into the lumbar part. A self-made water-filled balloon was used to dilate the retroperitoneal cavity. In the performance of dissection of the renal artery, the renal hilum should be kept away from as much as possible. When the artery had been separated for 1~2 cm in length, a linear cutter was utilized to sever it. The management of the renal vein was identical with that for the artery. During the management of the renal artery and vein, utmost care should be exercised to dissect the vessels longitudinally; else they were liable to be ruptured. Results All procedures were completed smoothly. A double artery supply was found in 6 patients and a triple artery supply in 1. Five patients had a double venous return-flow. A conversion to open surgery was required in 1 patient for spermatic vein injuries. No postoperative vascular complications were observed. Conclusions Use of a linear cutter to sever the renal artery and vein under retroperitoneal laparoscope is safe and reliable.