title: Transperitoneal versus retroperitoneal laparoscopic partial nephrectomy: patient selection and perioperative outcomes.
abstract: OBJECTIVE
  We compared the results of transperitoneal (T) and retroperitoneal (R) approaches to laparoscopic partial nephrectomy (LPN) in regard to perioperative outcomes and technical considerations, thereby, identifying patient selection guidelines for each approach.
  
  
  METHODS
  The choice of approach was dictated primarily by tumor location, that is TLPN for anterior or lateral lesions and RLPN for posterior or posterolateral lesions. The approaches differed primarily by the hilar control technique. During TLPN en bloc hilar control was achieved with a Satinsky clamp, while during RLPN individual vessel control was obtained with bulldog clamps.
  
  
  RESULTS
  In a 3-year period 100 TLPNs and 63 RLPNs were performed for renal tumor. Of posterior tumors 77% were managed by RLPN, whereas 97% of anterior tumors were managed by TLPN. TLPN was associated with significantly larger tumors (3.2 vs 2.5 cm, p <0.001), more caliceal suture repairs (79% vs 57%, p = 0.004), longer ischemia time (31 vs 28 minutes, p = 0.04), longer operative time (3.5 vs 2.9 hours, p <0.001) and longer hospital stay (2.9 vs 2.2 days, p <0.01) than RLPN. Blood loss, perioperative complications, postoperative serum creatinine, analgesic requirements and histological outcomes were comparable between the groups.
  
  
  CONCLUSIONS
  We perform TLPN for all anterior or lateral tumors as well as for large or deeply infiltrating posterior tumors that require substantive resection (heminephrectomy). The limited retroperitoneal space makes RLPN technically more challenging but provides superior access to posterior and particularly posteromedial lesions. When feasible, we prefer to perform laparoscopic partial nephrectomy by the transperitoneal approach because of its larger working area and superior instrument angles for intracorporeal renal reconstruction.
authors.affiliation: Section of Laparoscopic and Robotic Surgery, Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
authors.forename: Christopher S
authors.initials: CS
authors.lastname: Ng
authors.forename: Inderbir S
authors.initials: IS
authors.lastname: Gill
authors.forename: Anup P
authors.initials: AP
authors.lastname: Ramani
authors.forename: Andrew P
authors.initials: AP
authors.lastname: Steinberg
authors.forename: Massimiliano
authors.initials: M
authors.lastname: Spaliviero
authors.forename: Sidney C
authors.initials: SC
authors.lastname: Abreu
authors.forename: Jihad H
authors.initials: JH
authors.lastname: Kaouk
authors.forename: Mihir M
authors.initials: MM
authors.lastname: Desai
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D007677:Kidney Function Tests; D007680:Kidney Neoplasms / Q000601:surgery*; D010535:Laparoscopy / Q000379:methods*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D017351:N-Acetylglucosaminyltransferases; D009392:Nephrectomy / Q000379:methods*; D010043:Outcome and Process Assessment, Health Care; D018579:Patient Selection; D010537:Peritoneum / Q000601:surgery; D011183:Postoperative Complications / Q000209:etiology*; D012187:Retroperitoneal Space / Q000601:surgery; D012189:Retrospective Studies
chemical_list: D017351:N-Acetylglucosaminyltransferases; C047834:N-acetylglucosaminyldiphosphodolichol N-acetylglucosaminyltransferase