After obtaining local institutional ethics approval, between September 2015 and December 2017, 40 consecutive patients undergoing laparoscopic nephrectomy (LN) for various renal diseases (malignant and non-malignant) were assessed in a prospective fashion. Inclusion criteria were benign renal diseases, non-functioning kidney—either atrophic or hydronephrotic documented by nuclear isotope scanning—and malignant renal diseases diagnosed by radiologic studies. Exclusion criteria were patients with multiple comorbidities such as congestive heart failure, respiratory insufficiency, patient with uncorrectable coagulopathy, morbid obesity (BMI ˃ 35), abdominal wall infection, aortic aneurysms, acute diffuse peritonitis and presence of distended bowel. Patients were divided into two groups: The first 20 cases were included in group A and the next 20 cases were included in group B. All procedures were performed by single trainee urologist under supervision of expert, fellowship-trained, endourologist. The urology trainee was enrolled in a training program with mandatory laparoscopic simulation skills training, using both dry laboratory (laparoscopic training box) once weekly and wet laboratory simulation training (using a live pig training model) biannually. Surgical
technique used for training was based on the validated basic laparoscopic urologic surgery (BLUS) technique which is proposed by the AUA [9]. Learning curve was assessed in terms of operative time and the incidence of complications.
2.1 Technique of the procedure
Trans-peritoneal LN is typically performed using either a three- or four-port technique.
The technique of LN has been previously described [3]. In brief, the intraperitoneal space was accessed through closed technique using a Veress needle in all cases. After pneumoperitoneum is achieved, the remaining ports are placed under direct vision. The colon is reflected along Toldt’s line to expose the kidney. The renal hilum is identified at the level of the aorta after the lower pole of the kidney is lifted away from the psoas muscle. The upper pole of the kidney is dissected away from the liver on the right side, or the spleen and the tail of the pancreas on the left. The renal artery is occluded and transected with clips—either titanium or Hem-o-lok (Weck Closure Systems, Research Triangle Park, NC). The renal vein is then occluded and transected with hem-o-lok clips or ligated with a silk suture (Fig. 1).
If indicated, the adrenal gland is resected by securing the adrenal vein with titanium clips, and the remainder of the kidney can be mobilized bluntly.
The renal specimen is then retrieved through a small incision and sent for histopathological examination.
2.2 Outcome measures
Operative efficacy measures include laparoscopic time (time started from introduction of the laparoscopy into the abdomen until extraction of kidney tissue).
Operative safety measures include intraoperative blood loss and bleeding necessitating blood transfusion or conversion to open surgery. Moreover, perioperative hemoglobin and hematocrit levels were noted. Length of hospital stay and perioperative complications was also noted.
Postoperative follow-up patients were scheduled for 6 months after surgery for any specific complications related to the procedure.
2.3 Statistical analysis
Data were collected and tabulated using SPSS software version 21 (SPSS Inc., Chicago, IL, USA). Descriptive statistics were presented in terms of percentages, frequencies and means. Differences between both groups were compared with the Fisher’s exact test for categorical variables and Student’s t-test or Mann–Whitney U test to compare normally and abnormally distributed continuous variables, respectively. Two-tailed p value of less than 0.05 was considered significant.