Laparoscopic partial nephrectomy: comparison of transperitoneal and retroperitoneal approaches

PURPOSE: Laparoscopic partial nephrectomy has become an effective alternative for small renal tumors. Previous reports include transperitoneal and retroperitoneal approaches but to our knowledge the indications for when to apply the techniques have not been defined. We report our experience with comparing the 2 techniques. MATERIALS AND METHODS: A retrospective review of 51 laparoscopic partial nephrectomies was performed. Patients were analyzed based on the surgical approach, operative parameters and postoperative recovery. The 2 approaches used similar operative techniques to control parenchymal bleeding and collecting system entry. RESULTS: There were 32 retroperitoneal and 19 transperitoneal partial nephrectomies. Mean operative time (3.5 vs 5.4 hours, p = 0.000001) and blood loss (192 vs 403 cc, p = 0.002) was significantly less for the retroperitoneal approach. Renal vessel clamping was performed in 81% of retroperitoneal and 63% of transperitoneal operations. Warm ischemia time was not significantly different between the groups. Patients undergoing the retroperitoneal approach had a statistically significant decrease in time to tolerating a regular diet (1.2 vs 1.7 days, p = 0.02), catheter removal (1.4 vs 2.5 days, p = 0.004) and discharge home (2.3 vs 3.6 days, p = 0.0008). CONCLUSIONS: Based on tumor location as the selection criteria the retroperitoneal approach was associated with shorter operative time, less blood loss, more rapid return of bowel function and shorter hospitalization compared with those in patients selected for the transperitoneal technique. Based on our experience we believe that the decision on the approach should be based on the tumor location on the kidney surface. For polar or posterolateral masses the retroperitoneal approach is preferred. The transperitoneal approach is best suited to anterior and medial lesions.