Laparoscopic retroperitoneal nephrectomy for giant hydronephrosis: when simple nephrectomy isn't simple

BACKGROUND AND PURPOSE: Retroperitoneoscopic nephrectomy (RN) for giant hydronephrosis (GH) is regarded as a more challenging procedure than RN for small nonfunctioning kidneys (SNFK). We describe specific technical modifications to facilitate surgery in the GH group and compare outcomes in the two groups. PATIENTS AND METHODS: Data were collected in a prospective fashion on all patients undergoing upper urinary-tract laparoscopy at a single institution. Eleven patients (eight women, three men; mean age 41 years) underwent RN for GH. The etiologies were congenital ureteropelvic junction obstruction in 10 and obstruction secondary to endometriosis in 1. Technical modifications to facilitate surgery included initial fingerplasty, balloon dissection in two directions, initial intact dissection, subsequent pelvic puncture and aspiration, and extracorporeal retraction if required. The results were compared with those of a matched group of 19 patients who had RN for SNFK. RESULTS: All procedures were completed without open conversion. In the GH group, the mean operating time was 126 minutes (range 65-240 minutes) and the estimated blood loss 101 mL (range 5-450 mL). No patient required transfusion, and the mean length of the hospital stay was 2.9 days (range 1.5-6 days). In the group undergoing RN for SNFK, the mean operating time was 116 minutes (range 55-270 minutes), the estimated blood loss 46 mL (range 5-400 mL), and the mean length of stay 2.8 days (range 1-5 days). In the GH group, the estimated blood loss was significantly greater (P = 0.042), and the operative time was longer, although this difference did not reach statistical significance. CONCLUSION: An RN for GH is not as simple as laparoscopic simple nephrectomy for other benign lesions. Operative duration and blood loss are greater. Technical modifications have been vital to our success with this procedure.