Laparoscopic radical nephrectomy.

Although open nephrectomy is the standard of care for localized renal-cell carcinoma, the significant postoperative pain and lengthy convalescence have encouraged the use of laparoscopy, which can yield similar 2- to 5-year survival rates. Either a transperitoneal or a retroperitoneal approach may be used, and sometimes, they are combined. Generally, the technique is limited to tumors <10 cm, but larger tumors can be removed. Nitrous oxide is avoided as an anesthetic agent. The dissection follows accepted oncologic principles: in situ renal dissection within Gerota's fascia, early ligation of the renal vessels, and careful removal of the specimen to prevent tumor spillage. Dissection of the hilum is facilitated by a PEER retractor and an Endoholder. On average, patients having laparoscopic radical nephrectomy return to normal activities approximately 4.5 weeks sooner than those having open surgery, a fact not taken into account in cost analyses. Laparoscopic nephrectomy may offer a special benefit in patients with known metastatic disease, as interleukin-2 administration can be started a month earlier than after open surgery. There may also be immunologic benefits of minimally invasive v open surgery. The technique and instruments continue to evolve, and cost-effectiveness should continue to improve.