Laparoscopic Radical Nephrectomy in the Current Era: Technical Difficulties, Troubleshoots, a Guide to the Apprentice, and the Current Learning Curve

Abstract

Objectives The main aim of this study is to present our experience with laparoscopic radical nephrectomy (LRN) and share practical solutions to various surgical challenges and the learning curve we realized. Materials and Methods We retrospectively analyzed our LRN database for relevant demographic, clinical, imaging, operative, and postoperative data, including operative videos. We described various complications, vascular anomalies, intraoperative difficulties, and our improvisations to improve safety and outcomes. Statistical analysis We evaluated the learning curve, comparing the initial half cases (group 1) against the latter half (group 2), using the chi-squared test for categorical variables and Student's t-test for continuous variables. Results Of the 106 patients included, LRN was successful in 95% (n = 101), and five cases converted to open surgical approach. The mean tumor size was 7.4 cm, 42% incidentally detected. The cumulative complication rate was 15%, including five main renal vein injuries. Intraoperative difficulties included ureter identification (n = 6), venous bleed during hilar dissection (n = 11), double renal arteries (n = 23), and venous anomalies (n = 20). Arterial anatomy had 95% concordance with the imaging findings. We describe various trade tricks to perform hilar dissection, identify and control anomalous vasculature, handle venous bleed, confirm arterial control, and improve decisions using imaging, technology, and guidance of a mentor. No statistically significant difference in the learning curve was observed between the study groups. Conclusions With LRN already established as the current standard of care, our description intends to share the trade tricks and inspire novice urologists, who can assimilate training and reproduce good results under proper guidance. The steep learning curve described in the past may not be apparent in the current era of training and technological advancement.