Laparoscopic Urology

176 Urology Journal    Vol 6    No 3    Summer 2009

Transperitoneal Laparoscopic Partial Nephrectomy 
Using a New Technique
Akbar Nouralizadeh, Seyed Amirmohsen Ziaee, Abbas Basiri, Nasser Simforoosh, 
Hamidreza Abdi, Nastaran Mahmoudnejad, Amir H Kashi

Introduction: We report our experience with a new technique for 
transperitoneal laparoscopic partial nephrectomy with the kidney turned 
upside down intraoperatively.
Materials and Methods: Laparoscopic partial nephrectomy was performed 
in 10 patients with upper pole lesions through a transperitoneal approach. Once 
complete mobilization of the kidney was achieved, it was rotated 180 degrees 
around the horizontal axis, so that the upper pole was positioned inferiorly. 
After performing partial nephrectomy, the resection bed was sutured by 2-0 
polyglactin sutures and application of Hem-o-Lok clips. Then, the kidney was 
returned into its normal position and fixed to the abdominal wall. 
Results: We performed laparoscopic partial nephrectomy on 9 patients 
with a contrast-enhancing upper pole kidney mass and 1 patient with a 
nonfunctioning upper pole. The median tumor size was 58 mm (range, 41 mm 
to 92 mm). The median operative time was 206 minutes (range, 114 to 262 
minutes) and the mean warm ischemia time was 30 minutes (range, 22 to 35 
minutes). One patient underwent surgical exploration due to bleeding 6 hours 
after the operation. Prolonged urine leakage (more than 7 days) was observed 
in 1 patient, which responded to ureteral stent insertion. Surgical margins 
were negative in all of the patients. Renal cell carcinoma was histologically 
diagnosed in patients with a kidney tumor. 
Conclusion: Laparoscopic upper pole partial nephrectomy had acceptable 
results while the kidney was turned upside down intraoperatively, in terms 
of operative time and complications. This approach facilitates the procedure 
by achieving a better field of vision.

Urol J. 2009;6:176-81. 
www.uj.unrc.ir

Keywords: nephrectomy, 
laparoscopy, renal cell carcinoma, 

urologic surgical procedures

Urology and Nephrology Research 
Center and Shaheed Labbafinejad 
Medical Center, Shaheed Beheshti 

University of Medical Sciences, 
Tehran, Iran 

Corresponding Author: 
Akbar Nouralizadeh, MD 

Urology and Nephrology Research 
Center, No 101, 9th Boustan St,  

Pasdaran  Ave,  Tehran, Iran
Tel: +98 21 2256 7222

Fax: +98 21 2277 0954
E-mail: nouralizadeh@yahoo.com

Received April 2009
Accepted July 2008

INTRODUCTION
Laparoscopic partial nephrectomy 
(LPN) is an acceptable alternative 
option for small kidney tumors,(1-3) 
and similar long-term outcomes in 
terms of oncology have been shown 
with LPN when compared to open 
partial nephrectomy (OPN).(4)  
However, greater intraoperative 
technical complexity of this 
operation and its perioperative 
complications have limited the 

spread of indications for LPN.(5)

Laparoscopic upper pole partial 
nephrectomy (LUPPN) is 
associated with difficulties in tumor 
visualization and resection.(1,3) Some 
authors have proposed modifications 
to facilitate LUPPN.(1) Since the 
inferior and anterior kidney masses 
are accessible for laparoscopic 
surgery with a good field of vision, 
we speculated that rotation of the 



Transperitoneal Laparoscopic Nephrectomy—Nouralizadeh et al

Urology Journal    Vol 6    No 3    Summer 2009 177

kidney for operations on upper pole posterior 
tumors can provide the surgeon with the benefits 
from the advantages of operating laparoscopically 
on the inferior and anterior tumors. We present 
our experience with this new technique of rotating 
the kidney to facilitate tumor visualization and 
resection during LUPPN.

MATERIALS AND METHODS 

Patients
Between September 2003 and October 2007, 9 
patients with a contrast-enhancing upper pole 
mass in the kidney (Figure 1) and 1 patient 
with a nonfunctioning upper pole kidney and 
kidney calculus underwent LUPPN using a 
new technique. We had the experience of 246 
laparoscopic radical nephrectomies and 56 LPNs 
through the study period and before then, and to 
facilitate LUPPN attempted a modified technique 
of rotating the kidney for the operation. The 
patients were evaluated preoperatively by history 
taking, physical examination, chest radiography, 
urinalysis, abdominal computed tomography 
(CT), and serum biochemistry tests including 
creatinine, calcium, phosphorus, aspartate 
aminotransferase, alanine aminotransferase, 
alkaline phosphatase, and the total and direct 
bilirubin. 

Surgical Technique
Our surgical approach was transperitoneal LPN. 
The patients were secured in the flank position. 
Four trocars (5 mm and 10 mm) were placed 

through the umbilicus, pararectal, subcostal, 
and midline areas. After mobilization of the 
colon, the renal artery and vein were exposed. 
The surrounding tissues were dissected from 
the kidney and the kidney was mobilized. The 
perinephric fat was dissected off the kidney except 
for the fat overlying the tumoral tissue. A bulldog 
clamp was applied on the renal artery before 
rotating the kidney. Then, we rotated the kidney 
180 degrees over its pedicular axis, so that the 
upper pole was located inferiorly (Figure 2).  
As a result, the posterior upper pole mass was 
located anteriorly and inferiorly, allowing 
complete visualization of the tumor and easy 
recognition of the dissection plane that facilitated 
dissection by rigid laparoscopic instruments. 
The tumor mass was dissected off the kidney by 
a cold knife, maintaining a safety margin of 5 
mm. The specimen was extracted by an endobag. 
The adrenal gland was removed together with 
upper pole nephrectomy in patients with upper 
pole renal mass. Resection bed was sutured 
by polyglactin 2-0 sutures and application of 
Hem-o-Lok clips. The pyelocaliceal system was 
repaired by freehand suturing with 4-0 polyglactin 
sutures. No bolster or ureteral stent is used in 
the LPN operations performed in this center, as 
indicated before.(6) The clamp on the renal artery 
was removed and after confirming homeostasis, 
the kidney was returned to its original position 
(Figure 3), and it was sutured to the abdominal 
wall with 2-0 polyglactin sutures. 

Figure 1. Computed tomography showed an upper pole left 
kidney mass.

Figure 2. Complete excision of the tumor while the kidney was 
rotated upside down. A indicates the upper pole after excision of 
tumor and B, the lower pole. 



Transperitoneal Laparoscopic Nephrectomy—Nouralizadeh et al

178 Urology Journal    Vol 6    No 3    Summer 2009

Follow-up
Kidney specimens were evaluated and renal 
cell carcinoma (RCC) was graded according to 
the Fuhrman grading system.(7) The patients 
were visited at the urology clinic 2 weeks after 
discharge. In patients with RCC, follow-up 
visits included clinic visits 6 and 12 months after 
the operation, and then every year. Abdominal 
CT was done 12 months after the operation 
and then every year in order to assess local 
recurrence. Chest radiography and biochemical 
laboratory studies including serum calcium, 
phosphorus, aspartate aminotransferase, alanine 
aminotransferase, alkaline phsophatase, and direct 
and total bilirubin were tested in every clinic 
visits. 

RESULTS
The Table outlines characteristics of the patients 
and their perioperative and pathology data. The 
patients were 5 men and 5 women and their 
median age was 45 years (range, 34 to 70 years). 
The side of the operation was right in 5 patients 
and left in 5. Indications for LPN were elective in 
all patients, and no imperative indications were 
recorded. The median of the greatest diameter of 
the tumor on pathology examination was 58 mm 
(range, 41 mm to 92 mm). All of the tumors were 
larger than 40 mm. The median operative time 
was 206 minutes (range, 114 to 262 minutes), and 
the median hospital stay was 6 days (range, 4 to 
16 days). The median warm ischemia time in the 

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Transperitoneal Laparoscopic Nephrectomy—Nouralizadeh et al

Urology Journal    Vol 6    No 3    Summer 2009 179

patients with renal tumor was 30 minutes (range, 
22 to 35 minutes). The median hemoglobin drop 
until the 2nd postoperative day was 2.55 g/dL 
(range, 0.8 g/dL to 4.5 g/dL). Three patients 
required transfusion (two units for each one), 
based on the judgment by the anesthesiologist. 
One patient with grade 2 RCC underwent 
surgical exploration due to bleeding and 
hemoglobin drop on the operation day (6 hours 
after operation). The bleeding source was a tiny 
artery located in the adrenal bed. In this patient, 
urinary leakage lasted more than 1 week and led 
to ureteral stent insertion. 

Pathology diagnoses are shown in the Table. 
Surgical margins were free of tumor in all of 
the patients. One of the tumors was a renal 
leiomyoma and other tumors were RCC. Figure 
4 depicts proper function and anatomy of the 
remaining kidney mass in one patient 8 weeks 
after operation. Follow-up data including CT on 
the 1st postoperative year and later was indicated 
in 8 patients with RCC. No local recurrence 
was observed in the follow-up studies. No 
complications were observed in follow-up studies 
of the two patients with nonfunctioning upper 
pole and leiomyoma.

DISCUSSION
Currently nephron-sparing surgery is considered 
the standard therapy for small kidney masses.(2,8,9)  
Long-term tumor control has been reported 

not different with laparoscopic radical 
nephrectomy,(8,10-12) and LPN has been introduced 
as an alternative option to OPN for small  
tumors.(1,3) Recently, LPN has expanded its 
indications to include larger T1b tumors.(2)  
However, intraoperative difficulties and 
perioperative complications has limited LPN 
acceptance as the standard treatment for nephron-
sparing surgery.(5) Complications rate LPN were 
reported by Gill and coworkers to be higher than 
that in OPN.(13) The tumor location plays an 
important role in the complexity of the operation 
and its postoperative complications. It has been 
reported that LPN for upper pole kidney tumors 
is associated with higher complications relative to 
lower pole and middle pole tumors.(12,14)

Achieving a good field of vision for resection 
of upper pole kidney tumors results in longer 
operative time and more bleeding.(1) Limited field 
of vision and difficulties in kidney positioning 
for suturing of the resection bed are important 
impediments for surgery of these tumors.(3) 
Because of the endoscope angle, these tumors are 
not easily found by rigid laparoscopes and their 
resection and suturing is more complicated.(1) As 
a result of the aforementioned difficulties, some 
urologists prefer to perform laparoscopic radical 
nephrectomy or OPN for tumors amenable to 
management by laparoscopic nephron-sparing 
surgery.(15)

Some authors have proposed methods to tackle 
these challenges. Kim and associates used a gauze 
sling in their report of 2 cases to elevate the 
kidney from its bed, in order to achieve a better 
field of vision for the laparoscopic operation 
of upper pole kidney masses.(1) Large tumors 
are not suitable for percutaneous and ablative 
procedures.(16,17) Retroperitoneal approach may be 
promising for posterior tumors, but not suitable 
for upper pole tumors as they will not be easily 
accessible in this approach. The necessity of a 
direct vision in robotic surgery makes suturing of 
upper pole resection bed difficult. Laparoscopic 
partial nephrectomy for lower pole tumors and 
anterior tumors has been associated with least 
intraoperative complexity and postoperative 
complications.(12,14) Based on this idea, if the 
kidney is rotated 180 degrees over its pedicular 

Figure 4. Intravenous urography of the patient presented in 
Figure 3, eight weeks after the operation. Upper pole removal is 
evident with intact middle and lower pole calyxes. 



Transperitoneal Laparoscopic Nephrectomy—Nouralizadeh et al

180 Urology Journal    Vol 6    No 3    Summer 2009

axis, the upper/posterior pole tumors are located 
inferiorly and anteriorly, and their surgery will be 
accomplished with considerable ease. Therefore, 
after clamping the renal artery and completely 
mobilizing the kidney, we used a180-degree 
rotation of the kidney around its pedicular axis 
to locate the upper pole posterior tumors in 
an inferior and anterior location. One patient 
was explored by open surgery 6 hours after the 
operation, because of continued bleeding from the 
Hemovac drain. This patient was the first who 
was operated on using this technique. Bleeding 
originated form an artery in adrenal resection bed. 

All tumors operated by this technique were larger 
than 40 mm. Patard and coworkers reported 
longer operative time, more bleeding and 
transfusion, and more frequent urinary fistula 
for partial nephrectomy of tumors larger than 40 
mm compared to smaller tumors.(12) Longer warm 
ischemia time and pyelocaliceal system repair 
were reported by Simmons and associates(2) in 
LPN of tumors larger than 40 mm, compared to 
smaller tumors. In their study, however, statistical 
significance was not observed for operative time 
and bleeding volume.

Warm ischemia time and operative time in this 
series is comparable and slightly shorter compared 
with the figures reported by Simmons and 
colleagues(2) for LPN of tumors larger than 40 mm 
(32 minutes versus 38 minutes and 210 minutes 
versus 228 minutes, respectively). However, 
transfusion frequency in this study was more 
than that in many reported series. Nevertheless, 
all patients who received blood transfusion were 
the first 4 patients operated on using the new 
technique. No transfusion was needed in the last 
6 patients. Prolonged leakage (more than 7 days) 
was observed in 1 patient, which responded to 
ureteral stent insertion. Two patients had urine 
leakage from the peritoneal drain for 5 days. 
Other patients had no leakage or leakage duration 
shorter than or equal to 5 days. Follow-up CT 
scans were uneventful in all of the patients.

We learned the following tips in our experience: 
first, the ureter should be dissected free from 
the surrounding tissues up to the ureteropelvic 
junction. This makes kidney rotation easier and 
eliminates the need to release the distal ureter in 

order to compensate for ureter length shortage 
in kidney rotation. Second, dissecting the adrenal 
gland free from the surrounding tissues and 
rotating it with the tumor facilitates kidney 
rotation. 

CONCLUSION
We described a new technique for LPN for upper 
pole kidney tumors by rotating the kidney 180 
degrees over its pedicular axis. We reported 
satisfactory results in 10 patients. We believe 
that this technique will bring considerable ease 
in surgery of upper pole kidney tumors, and 
its intraoperative and postoperative results are 
acceptable. We admit that this technique needs to 
“come to maturity” and should be attempted in 
larger series. 

CONFLICT OF INTEREST
None declared. 

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