• Standard of care for patients with T2 renal tumors (tumor >7 cm, limited to kidney) or smaller tumors not treatable by partial nephrectomy
• Although significant experience has been accumulated with LRN, the maximum tumor size for LRN remains unclear. In general, the principles of oncologic surgery propose the performance of LRN in tumors up to stage T3bN0M0 . Higher stage disease (T4, renal vein involvement), tumors with diameter up to 14cm (without positive surgical margins) have been reported to be successfully managed by LRN. In fact, the indications of the technique are expanding along with the accumulation of laparoscopic experience.

Surgical steps of transperitoneal access

1. Positioning of patient
• Lateral decubitus position, table flexed at level of patient’s umbilicus, appropriate padding and support

2.Planning and placement of trocars
• Establish pneumoperitoneum with Hassan or Veress needle technique at lateral margin of rectus muscle, at the level of the umbilicus
• 12 mm trocar – at the level of the lateral rectus muscle sheath on the anterior axilliary line
• 10 mm trocar – umbilical
• 5mm trocars – at the level of the mid-clavicular line under the costal margin

3.Entry into peritoneal cavity
• Inspection of peritoneal contents, division of adhesions

4. Exposure of retroperitoneal space (White line of Toldt)
5.Identification of ureter and hilar structures (renal vessels and pelvis)
6. Transection of ureter
7. Dissection and ligation of renal vessels (hemolock clips or EndoGIA stapler)
8. Dissection of renal attachments outside Gerota’s fascia
9.Entrapment of surgical sample
10.Retrieval of surgical sample
11.Removal of trocars, exit from peritoneal cavity, suture of incisions