3.5.2 Radical nephrectomy (Table 3.7)

Laparoscopic radical nephrectomy is still performed in a few centres worldwide: this surgery is made difficult by the need to remove the intact specimen and the extent of the exeresis. However, in low-stage tumours only (T1-T2), technical results are comparable to open radical nephrectomy with the advantages of minimal invasivity, i.e. low morbidity and great surgical efficiency (107-112). In large, reported series, the advantages of laparoscopic radical nephrectomy have been confirmed (111-113). It can be performed by both trans- and retroperitoneal routes, with or without hand assistance. No clear advantages have been demonstrated for either route, apart from less operative time and hospital stay (107) for the retroperitoneal approach, which can give the possibility of an early ligation of the vascular kidney supply (111). One-port metastasis has been reported (109) in a series where the kidney was morcellated before the removal. However, the follow up is still too short to confirm the validity of laparoscopic radical nephrectomy as an effective treatment for renal cancer (114, 115); nevertheless, the actuarial intermediate-term disease-free survival rate is comparable with open surgery (113) for T1 and T2 tumours.

Table 3.7 Radical nephrectomy: guideline recommendations

Total number of patients	More than 300
Expert opinion	Feasible
Level of evidence	2b
Grade of recommendation	С
Current indications	T1-T2 tumors

3.5.3 Partial nephrectomy (Table 3.8)

This is an established procedure for benign disease, but it is technically difficult. When performed for removing small renal tumours (< 3 cm), the procedure is technically very demanding, and is still experimental and not yet standardized. Only small series have been reported without long-term follow up (111, 112, 116-119). It is not therefore recommended for use in clinical practice and should only be performed in controlled prospective trials.

Table 3.8 Partial nephrectomy: guideline recommendations

Total number of patients	Less than 100
Expert opinion	Established (benign disease), Under evaluation (cancer)
Level of evidence	3 (benign disease) 4 (cancer)
Grade of recommendation	В (benign disease) С (cancer)
Current indications	Hydrocalicectasy, Tumours < 3 cm

3.5.4 Nephro-ureterectomy (Table 3.9)

As with simple nephrectomy, laparoscopic nephro-ureterectomy is an established method for benign disease, i.e. removing a non-functioning kidney and ureter for ureterohydronephrosis.

On the other hand, laparoscopic nephro-ureterectomy for transitional cell cancer (TCC) of the upper urinary tract is technically demanding, though feasible, but with a mandatory technical point - the collecting system should not be opened during the procedure (120). For this purpose, the transperitoneal approach allows the descending removal en bloc of the kidney and the ureter, together with the bladder cuff. Extrafascial nephrectomy with adrenal sparing is advised (121, 122). The laparoscopic approach has some advantages with respect to the open procedure (lower morbidity, shorter hospitalization, better cosmetic results) (123). However it remains controversial from an oncological point of view. TCC has an high frequence of seeding; in addition, port metastases have been reported during nephro-ureterectomy for upper urinary tract TCC (124-135). Because of the low number of cases, results are not conclusive. Good long-term results have been reported only for low-stage tumours and are similar to those obtained with open surgery.

Table 3.9 Nephro-ureterectomy: guideline recommendations

Total number of patients	Less than 100
Expert opinion	Established (benign disease) Under evaluation (cancer)
Level of evidence	2b (benign disease) 3 (cancer)
Grade of recommendation	В (benign disease) С (cancer)
Current indications	Ureterohydronephrotic non-functioning kidneys Low-stage transitional cell carcinomas