title: Anatomic landmarks and time management during retroperitoneoscopic radical nephrectomy.
abstract: OBJECTIVE
  Retroperitoneoscopy has not been widely considered the preferred approach to laparoscopic radical nephrectomy for cancer, in part because the retroperitoneal anatomic landmarks have not been well defined. The aim of this study is to provide prospective, objective data on retroperitoneoscopic radical nephrectomy with regard to anatomic landmarks and time management of the sequential operative steps.
  
  
  METHODS
  A uniform database was devised to record predetermined intraoperative parameters prospectively in 18 consecutive retroperitoneoscopic radical nephrectomies.
  
  
  RESULTS
  A three- or four-port technique was employed to perform 10 left and 8 right retroperitoneoscopic radical nephrectomies. Initial balloon dilation was routinely performed outside of and posterior to Gerota's fascia. The anatomic landmarks visible immediately on initial insertion of the laparoscope were: psoas muscle in 18 cases (100%), Gerota's fascia in 18 (100%), peritoneal reflection in 15 (83%), ureter and/or gonadal vein in 11 (61%), and renal artery pulsations in 10 (56%). Aortic pulsations were seen in 9 of 10 left (90%) and the inferior vena cava in 2 of 8 right (25%) radical nephrectomies. The mean surgical time was 203 +/- 52.9 minutes (range 105-290 minutes). The sequential operative steps and their individual time breakdowns were: port placement 12 +/- 3.9 minutes, hilar dissection 63 +/- 29.1 minutes, adrenal mobilization 49 +/- 12.1 minutes, specimen mobilization 19 +/- 20.8 minutes, and specimen entrapment and exit 23 +/- 18.2 minutes. When the initial balloon dilation resulted in visibility of four or more anatomic landmarks, the hilar dissection time was significantly shorter (P < 0.001).
  
  
  CONCLUSIONS
  Proper development of the retroperitoneal space and identification of adequate anatomic landmarks is important during retroperitoneoscopy. This timed analysis of the sequential operative steps of retroperitoneoscopic radical nephrectomy has served as an important self-assessment tool for us in improving our surgical technique. As a result, our surgical time for retroperitoneoscopic radical nephrectomy has decreased from the earlier 4- to 5-hour range to the current 2- to 3-hour range.
authors.affiliation: Section of Laparoscopic and Minimally Invasive Surgery, Urological Institute, The Cleveland Clinic Foundation, Ohio 44195, USA.
authors.forename: Gyung Tak
authors.initials: GT
authors.lastname: Sung
authors.forename: Inderbir S
authors.initials: IS
authors.lastname: Gill
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002404:Catheterization; D005205:Fascia / Q000033:anatomy & histology; D005260:Female; D006801:Humans; D007668:Kidney / Q000098:blood supply / Q000601:surgery*; D007680:Kidney Neoplasms / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000379:methods*; D011446:Prospective Studies; D016658:Psoas Muscles / Q000033:anatomy & histology; D012077:Renal Artery / Q000033:anatomy & histology; D012082:Renal Veins / Q000033:anatomy & histology; D012187:Retroperitoneal Space / Q000033:anatomy & histology* / Q000601:surgery; D017748:Time Management