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Transperitoneal Laparoscopic Radical Nephrectomy Treatment & Management

  • Author: William J Harmon, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
 
Updated: Dec 28, 2015
 

Preoperative Details

A full staging workup is indicated for all renal malignancies, regardless of the chosen surgical approach. This includes laboratory evaluation, chest radiography, and a CT scanning of the abdomen and pelvis. A bone scan, gadolinium-enhanced MRI of the abdomen and pelvis, 3-dimensional reconstruction CT scan of the abdomen and pelvis, chest CT scan, or renal arteriography may be helpful in select patients.

Patient preoperative counseling includes the usual discussion of the risks of nephrectomy, but it includes several points unique to laparoscopy. Because this approach is transperitoneal, the risks of bowel injury and trocar placement and those related to carbon dioxide pneumoperitoneum are discussed (see Complications). The patient is counseled that conversion to an open nephrectomy is necessary in up to 5% of cases. Inflammatory processes and prior renal or abdominal surgery are associated with a higher rate of conversion.

The authors do not routinely use a preoperative bowel preparation, and perioperative antibiotics are administered.

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Intraoperative Details

Procedure

Laparoscopic radical nephrectomy (LRN) at the authors' institution is mostly performed transperitoneally. The procedure can be divided into the following 8 steps critical to success:

  1. Patient positioning and equipment check
  2. Veress needle and trocar placement
  3. Mobilization of the colon
  4. Identification of the ureter and gonadal vein
  5. Renal hilar dissection
  6. Remaining renal attachments
  7. Specimen removal
  8. Closure

Patient positioning and equipment check

An important aspect of laparoscopy that is often overlooked is the preoperative equipment check. In few areas of surgery does the surgeon depend more on technology for the procedure. The carbon dioxide tanks must be full, and the insufflator, light source, camera, and cautery need to be in good working order. Having ready access to both the argon beam coagulator and the harmonic scalpel or the LigaSure system[12] is useful if intraoperative hemorrhage is encountered. Finally, the desired instruments (eg, trocars, Endoshears, staplers, clips) must be available, with the surgical technician having knowledge of each device. Generally, a laparoscopic procedure should not be started unless all instrumentation is functional.

After general anesthesia is administered, a urinary catheter and orogastric tube are placed. The patient is placed in a 45° modified flank position with the top of the iliac crest at the top of the kidney rest and the table flexed. The arms are typically taped over a folded pillow, although an armrest is satisfactory. The patient is then securely taped to the operative table to allow banking of the table during surgery. All appropriate areas are padded to include the axilla, knees, elbows, and ankles. A wide sterile preparation and drape is performed in the event that open conversion is necessary. Pneumatic compression devices to the lower extremities help prevent thromboembolic phenomena.

Veress needle and trocar placement

Initial pneumoperitoneum can be achieved with the Veress needle to 15 mm Hg. This can be performed at either the umbilicus or lateral to the umbilicus at the midclavicular line. Often, the patient's prior abdominal scars dictate which area is optimal because, as a rule, staying as far away as possible from these scars is better to avoid inadvertent bowel injury from adhesions. Alternatively, a Hassan technique may be used with S-retractors to cut down to the peritoneum under direct vision (this is currently the authors' preferred method). An Optiview or Visiport may also be used with a 0° camera to enter the abdomen in a controlled fashion after just a skin incision.

The initial 10-mm trocar is placed under vision at or near the umbilicus for both left-sided and right-sided procedures. Subsequent trocars are placed under vision with the 10-mm laparoscope in the umbilical trocar. For left-sided tumors, a 5- to 12-mm trocar is placed lateral to the umbilical port at the edge of the left rectus abdominus muscle. Finally, a third 5-mm trocar is placed midway between the xiphoid and the umbilicus. For right-sided tumors, the 5- to 12-mm trocar is placed midway between the xiphoid and the umbilicus, and the 5-mm trocar is placed lateral to the umbilical port at the edge of the rectus. If necessary, an additional 5-mm trocar is placed laterally at the anterior axillary line, below the ribcage for liver retraction. The first image below depicts trocar placement for the left-sided procedure; the second image shows placement for the right-sided procedure.

Trocar placement for a left laparoscopic radical n Trocar placement for a left laparoscopic radical nephrectomy (LRN).
Trocar placement for a right laparoscopic radical Trocar placement for a right laparoscopic radical nephrectomy (LRN).

Several scenarios call for different port placements. The first is in the presence of prior abdominal surgery when the initial ports need to be adjusted to allow for lysis of adhesions. This varies with each patient and challenges even the most experienced laparoscopist. The next scenario involves patients who are obese and in whom port placement as described would complicate lateral and superior dissection. Therefore, in these patients, all ports are moved laterally as needed to allow better purchase of instruments for dissection. Finally, in patients who are very tall, move ports superiorly for similar reasons.

The 10-mm, 30° laparoscope is used via the umbilical port for performance of the LRN.

Mobilization of the colon

The following description of LRN is for a right-sided procedure; variations for a left-sided approach are provided.

The lateral line of Toldt is identified and incised with either the harmonic scalpel or a hook electrode approximately 1 cm from the colon. At this point, care is taken not to allow dissection to stray too deep. Only the thin layer of peritoneum over the anterior surface of the kidney is mobilized from the iliac vessels to the hepatic flexure of the colon (see image below). If the dissection is too deep, the Gerota fascia is entered and the bowel mesentery is more difficult to roll medially.

Colon mobilization for a right laparoscopic radica Colon mobilization for a right laparoscopic radical nephrectomy (LRN).

This plane is bluntly dissected by dividing the colorenal ligaments until the colon has rolled medially. The 5-mm suction irrigator is particularly useful in this dissection. Small vessels that are encountered are either cauterized or clipped with a 5-mm clip applier. An alternative is to use either the harmonic scalpel or the LigaSure system to control these vessels. Remaining in the correct plane between the colonic mesentery and Gerota fascia is important. Care should be taken to avoid entering the bowel mesentery, as hemorrhage would ensue. Once the colon has rolled medially, the duodenum is rolled medially. This allows identification of the inferior vena cava. To fully visualize the upper pole of the right kidney under the liver, dividing the right triangular ligament and part of the anterior coronary ligament is usually necessary.

For a left-sided LRN, the procedure begins in similar fashion at the line of Toldt. The phrenicocolic, splenocolic, and splenorenal ligaments at the splenic flexure of the colon are divided to allow the upper pole to drop into view.

Identification of the ureter and gonadal vein

The correct identification of the ureter and gonadal vessels is one of the crucial steps for a successful LRN. Understanding the relationship of these structures at various levels aids in this dissection. At the level of the lower pole of the kidney and proximal ureter, the gonadal vessels are medial to the ureter. As they proceed inferiorly, they cross the ureter and course laterally as they exit the internal inguinal ring. Understanding this relationship is important for correct identification of the ureter and ease of subsequent identification of the renal hilum.

Additional methods to help identify the ureter include pinching with atraumatic grasping forceps to observe peristalsis and noting the color differences between structures. Generally, the gonadal vein appears blue, while the ureter appears white. If neither structure is identified, it is occasionally necessary to begin the dissection medially along either great vessel and to extend laterally on top of the psoas until the ureter or gonadal vessels are identified.

Once the ureter and gonadal vein are identified, the next step for a right-sided LRN is following these structures superiorly to identify both the lower pole of the kidney and the renal hilum. This is accomplished by lateral retraction of these structures with the left hand using the grasping forceps or the 5-mm suction/irrigator and dissecting with the right hand using the harmonic scalpel or LigaSure (see image below).

Right ureteral dissection using a suction aspirato Right ureteral dissection using a suction aspirator.

The branching of the right gonadal vein from the inferior vena cava is controlled with two 5-mm clips on either side and divided. The distalmost aspect of the right gonadal vein can be divided, if necessary; however, leaving the ureter intact to provide inferior retraction during the remainder of the nephrectomy is important. For a left-sided LRN, the gonadal vein and the ureter are again used to identify the renal hilum by dissecting superiorly. Following the gonadal vein leads the surgeon directly into the left renal vein. The branching of the left gonadal vein is double clipped and transected, if necessary, for retraction or hilar dissection.

At this point in the procedure, the lower pole dissection is easily performed. The surgeon uses the left hand to retract the kidney anterolaterally, and attachments between the lower pole and the psoas muscle or the posterior body wall are taken down. During this portion of the procedure for a right-sided LRN, the placement of a fourth 5-mm trocar for liver retraction is usually unnecessary. However, once the surgeon proceeds to the right renal hilar dissection, this additional trocar placement may be necessary. This can be placed at the anterior axillary line subcostally or in the midline superior to the upper 5-mm trocar. A 5-mm laparoscopic snake retractor is introduced into this trocar, and the liver is retracted superiorly.

Renal hilar dissection

Once the ureter and gonadal vein are secure and the inferior pole of the kidney is dissected free posteriorly, proceed with the renal hilar dissection. The left hand, once again, is used to hold 5-mm grasping forceps to provide lateral and superior retraction of the kidney. The right hand is used to divide the tissue planes gently until the renal vein is identified. Small lymphatic channels can be controlled with either clips or cautery.

If lateral retraction proves difficult, introducing a large silk suture on a Keith needle through the patient's flank is useful. This is then hooked around the ureter, and the needle is passed outside the body. The suture is secured with forceps to tent the ureter against the interior body wall; this provides excellent lateral retraction and frees a hand to aid in the hilar dissection. On the right side, the renal hilar dissection is slightly easier because the renal vein has no branches. This is dissected circumferentially until enough of its length is free to allow division with the laparoscopic EndoGIA stapler with a vascular load. The renal artery posterior to the renal vein is identified and dissected in a similar fashion. Dividing the artery first is customary.

For a left-sided LRN, dissection proceeds in the same manner until the renal vein is encountered. The gonadal vein has already been transected, but the adrenal and lumbar veins must be identified. Once these 3 branches are visualized and controlled, the remainder of the vein is dissected circumferentially, and the artery is identified just posterior to the vein.

The authors' approach is to use a stapler to divide the renal artery and then the vein (see image below), although most surgeons clip and divide the artery first. This stapler applies 3 rows of titanium staples on either side of a divided vessel and is very effective in controlling the hilar vessels. One caveat is to keep the vessel clamped in the stapler for at least 10-15 seconds prior to deploying the staples. This allows for the tissue to release third-space fluid and to become thinner, resulting in a better seating of the staples. The renal artery and vein may be stapled en bloc, when necessary.[13] Although this is not advocated for routine use, the authors feel it is reasonable in lieu of open conversion if a complex or bleeding hilum can be controlled in this manner.

Transection of right renal artery with the endovas Transection of right renal artery with the endovascular stapler.

No arteriovenous fistulas have been reported in humans when the stapling device is used. Historical reports of arteriovenous fistula seem to have occurred mainly in the setting of an inflammatory process involving sutures. The 3 rows of titanium staples likely confer an advantage to sutures, although the authors would still exercise caution in the setting of an inflammatory renal condition. After the hilum is taken, leaving the closed stapler in its trocar and using this instrument to bluntly dissect the medial portion of the upper pole can be useful. This large instrument provides excellent purchase and bluntly dissects tissue effectively.

On the right side, if an adrenalectomy is being performed, the medial dissection continues along the inferior vena cava superiorly until the adrenal vein is encountered, which is usually controlled with clips. The dissection then proceeds superiorly around the adrenal gland. Small adrenal arterial branches may be effectively divided with the harmonic scalpel or LigaSure. For a left-sided adrenalectomy, the adrenal vein already has been transected, and dissection continues superiorly around the gland.

If an adrenalectomy is not indicated, the surgeon bluntly dissects along the plane between the adrenal gland and the superior pole of the kidney. If small vessels are encountered in this fatty plane, they are divided easily with various cautery devices.

Remaining renal attachments

All that should be left holding the kidney in situ is the lateral attachments to the body wall, the superior attachments lateral to the adrenal gland, and the ureter. These attachments are dissected free with a combination of sharp and blunt dissection using the cautery device of choice, with the grasping forceps for counter traction. The ureter may be divided before or after the lateral attachments are completely freed. The authors typically place two 5-mm clips on the ureter and transect it. The specimen is now completely dissected and placed on either the liver or the spleen in anticipation of its removal.

Specimen removal

Two options exist for removing the kidney—morcellation or intact removal. A Pfannenstiel or expanded port site (eg, vertical periumbilical) incision may be used for intact removal. A recent study suggests decreased pain, incisional hernia rate, and hospital stay among patients who underwent a Pfannenstiel incision compared with the expanded port site.[14]

The 15-mm EndoCatch is used for intact kidney removal. Under vision, it is placed through a small opening in the peritoneum at the incision site. (A seal may then be created around the instrument shaft to allow for pneumoperitoneum by placing the adjacent abdominal wall tissue in an Allis clamp or towel clip.) The bag is advanced until it springs open. Grasping forceps are used to place the kidney into the bag under direct vision. Visualizing completely around the ring of the EndoCatch opening to ensure that no bowel is being included with the specimen is important. The string is detached and pulled so that the bag closes, and the ring that held the bag open is retracted under direct visualization.

The opening of the bag is now brought out through the incision site. The incision is extended to approximately 5 cm, and the fascial incision is extended to approximately 7 cm. This usually allows easy removal of most kidneys. If necessary, the incision can be extended. Once the kidney is removed, the fascia is closed with a running No. 1 PDS suture. Pneumoperitoneum is reestablished, and the renal fossa and inferior and superior extent of the resection are examined for hemorrhage.

An alternative method to remove the specimen is by tissue morcellation. The LapSac (Cook Urological, Spencer, Ind) is introduced through the umbilical site. Prior to placement, the scrub technician prepares it by placing a nitinol wire doubly rapped through its cuff to allow for better spontaneous opening of the bag once inside. The tails of the wire are maintained outside the incision after the port is replaced. It is then held open at the inferior edge of the liver or spleen with two 5-mm grasping forceps. The kidney is dropped into the sack, which is closed. The neck is then brought out through the umbilical site. The skin and fascial incision are extended a few millimeters. A second sterile drape is place over the site with a small hole through which to allow the neck of the LapSac to pass. The sack is then opened and a ring forceps and large Kelly clamp or scissors are used to morcellate manually and to remove pieces of kidney and tumor (see image below).

Kidney is entrapped in a sack and is then morcella Kidney is entrapped in a sack and is then morcellated with ring forceps.

Although more tedious than an electric morcellator, this technique results in bigger pieces that allow for better pathologic diagnosis and staging. The LapSac is the preferred bag for tissue morcellation because it has been shown in animal studies to be impermeable to cells and its nylon reinforced plastic is more durable and resistant to perforation. Morcellation provides the advantage of improved cosmesis and decreased incision-related morbidity (eg, hernia, adhesions) and is safe when performed with the proper technique and bag. To date, no cases of port-site seeding clearly related to the morcellation process have been reported with the use of the LapSac.[15]

Closure

Once the specimen is removed, the umbilical fascia closed, and pneumoperitoneum achieved, the renal fossa and inferior and superior extent of the dissection are examined for hemorrhage. Pneumoperitoneum, once again, is decreased to 5 mm Hg for a few minutes and hemostasis is confirmed. The 5-mm trocars are removed under laparoscopic vision. Finally, the last 10-mm trocar is directed into the corresponding upper quadrant, and as much carbon dioxide as possible is vented. The trocar is then removed with the laparoscope inside to prevent bowel entrapment. Finally, all skin edges are approximated with Monocryl suture, skin staples, or Dermabond adhesive.

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Postoperative Details

The patient is returned to the supine position and extubated. A blood gas may be sent to the laboratory if hypercarbia is a concern. The orogastric tube is removed, and the urinary catheter is left in.

The night of the surgery, the patient is given a morphine patient-controlled analgesia pump.

On the first postoperative day, the patient begins a liquid diet, the urinary catheter is removed, and oral pain medications are provided.

Patients typically return home on the first or second postoperative day once they can tolerate a regular diet and the pain is controlled.

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Complications

Overall, complication rates (9-13%) associated with laparoscopic radical nephrectomy (LRN) are comparable with those of open radical nephrectomy series.[16] Differentiating complications that occur intraoperatively and those that occur postoperatively is important because the former may be managed laparoscopically or may contribute to open conversion.

Several intraoperative complications of LRN are worth noting. Bowel injuries can occur either during trocar placement or during electrocautery. A small perforation can be managed with laparoscopic suturing; however, if the adequacy of closure is questionable, convert the procedure to an open repair.

Cautery injuries to the bowel are somewhat more elusive. If not noticed intraoperatively, they may present in the early postoperative period with a characteristic appearance. Rather than widespread peritoneal signs, they usually cause distinct pain or redness at one of the trocar sites. In addition, patients can have a low white blood cell count contrary to what is expected, and they often have only a low-grade fever. A surgeon must have a low threshold for suspicion because these injuries often progress quickly to sepsis and even death.

Another common injury during LRN is either splenic or liver laceration. General principles implemented to avoid this injury include using only blunt retraction and remaining at least 1 cm away when reflecting the various ligaments required for renal mobilization. If an injury does occur, the argon beam coagulator can be effective for hemostasis, especially when combined with an absorbable substrate such as oxidized cellulose gauze. Both BioGlue[17] and fibrin glue have also been used with success.[17] Finally, in the case of splenic injury, splenectomy may be necessary. Persistent liver hemorrhage not amenable to the above measures usually requires open conversion and formal repair.

Vascular injuries can normally be managed with either clips or the laparoscopic stapler. If suturing is required for an extensive injury, direct pressure can be applied with an inflated Foley catheter balloon over a mandarin while the patient is being opened for repair.

The overall conversion rate to open in a recent meta-analysis for LRN was 2.5%.[16]

The authors keep a genitourinary major set of instruments in the operating room unopened during LRN in case of emergent open conversion.

Postoperative complications are similar to those that occur with open radical nephrectomy (eg, pulmonary embolus, myocardial infarction, deep venous thrombosis of the legs, wound infections) and have a similar incidence. Incisional hernias are less common and blood loss and transfusion rates are lower than in open surgery series.

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Outcome and Prognosis

The operative results for laparoscopic radical nephrectomy (LRN) are presented as a series of commonly asked questions.

Are the survival and recurrence rates of laparoscopic radical nephrectomy similar to those of open radical nephrectomy?

The actuarial disease-free rate among 157 patients undergoing LRN in a large multi-institutional review was 91%. This series reported one local recurrence at the ureteral stump, which was subsequently resected. Unfortunately, the patient developed another recurrence at the bladder neck. The remaining recurrences were distant metastases.[18]

Four large single-institution reviews also report favorable recurrence and survival rates. Some of these patients are included in the above multi-institutional review. Dunn et al reported on 35 patients who underwent LRN for localized renal cell carcinoma (RCC), for which a minimum of 6 months and a mean of 25 months of follow-up were available.[19] Three recurrences occurred in this group; 2 were metastatic and one was local (the above-mentioned ureteral stump recurrence). Gill et al reported 2 metastatic recurrences among 42 patients[20] (mean follow-up of 13 mo), Ono et al reported metastases in 2 of 60 patients[21] (mean follow-up of 24 mo), and Barrett et al reported no recurrences among 57 patients[22] (mean follow-up of 21 mo). In the Barrett et al series, only physical examination, serum tests, and chest radiography were used for follow-up.

Portis et al reviewed experience with laparoscopic nephrectomy and open nephrectomy at 3 centers; the median follow-up period was 54 months. Sixty-four laparoscopic cases (mean tumor size was 4.5 cm) were compared with 69 open cases (mean tumor size was 6.2 cm). The Furman nuclear grade between the two groups did not significantly differ. The 5-year recurrence-free survival rate was 98% versus 92% (not statistically significant).[23]

Does the cancer recur at the port site used for intact tumor removal or morcellation?

To date, 9 port-site recurrences have been reported, 4 in conjunction with morcellation. In two of these cases, the entrapment bag was permeable and therefore inappropriate. In another, the tumor was stage T3N0, grade 4, with sarcomatoid features. In another case, a stage T1N0 grade 2 tumor was associated with ascites, which was thought to be a contributing factor.

The incidence of this may be underreported.[15] Successful principles used to avoid this complication include the use of a bag for intact specimen removal, use of an impermeable sack for morcellation, and separate draping prior to morcellation with changing of gloves before surgery is resumed. (Clayman and Kavoussi both have >10 y of experience with morcellation, with no reported recurrences.)

What is the learning curve for laparoscopic radical nephrectomy?

Good evidence indicates that approximately 20 cases are required before a laparoscopic surgeon becomes facile with LRN. In the multi-institutional review of laparoscopic nephrectomies, Gill et al showed that 9 of the 14 technical complications occurred in the first 20 patients.[20] Furthermore, of the 10 patients in whom open conversion was necessary, 8 were among the initial 20 patients. Overall, 71% of complications occurred in the first 20 patients from each institution, while 33% occurred in the remainder.

Can an adequate margin be obtained with laparoscopic radical nephrectomy?

If the laparoscopic surgeon follows the successful guidelines of established open radical nephrectomy, the margins are equivalent.

How do the costs of laparoscopic radical nephrectomy compare with those of open radical nephrectomy?

In the recent past, LRN had cost 29% more than open radical nephrectomy at the Cleveland Clinic; similarly, LRN had cost roughly $2000 more at Washington University in St. Louis. The higher cost was due mainly to longer operative times and more intraoperative disposables.

Operative times have decreased significantly since these studies were performed. Contemporary studies now suggest that LRN costs less than open radical nephrectomy.[24, 25] With the decreased operative times, the length of stay seems to have become the main determinant in cost.[26] Typically, the length of stay following LRN is half or less than half than following open radical nephrectomy.

The cost to the patient’s quality of life is what should be considered when making these comparisons. In virtually every review of laparoscopic renal surgery, patients who undergo LRN experience less pain and return to normal activities (including work) in half the time compared with those who undergo open surgery; these are much more important costs to consider.

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Future and Controversies

Laparoscopic radical nephrectomy (LRN) has become the standard of care for kidney cancer surgery. An open approach is necessary for only about 5% of patients. Shorter hospital stays with less postoperative pain are possible for patients who undergo LRN, and they return to activities in half the time required for patients who undergo open surgery. Survival and recurrence rates associated with LRN are excellent and compare favorably with those associated with open surgery series.

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Contributor Information and Disclosures
Author

William J Harmon, MD Medical Director, Urology San Antonio, PAAssociate Clinical Professor, Division of Urology, UTHSC, San Antonio, TX

William J Harmon, MD is a member of the following medical societies: American Urological Association, Phi Beta Kappa

Disclosure: Received honoraria from Pacira Pharmacal for speaking and teaching.

Coauthor(s)

Jay T Bishoff, MD Chairman, Department of Urology, Intermountain Health Care; Director, Intermountain Urological Institute; Vice Chairman, Department of Surgery, Intermountain Medical Center; Associate Clinical Professor of Surgery, University of Utah College of Medicine

Jay T Bishoff, MD is a member of the following medical societies: American College of Surgeons, American Urological Association, Endourological Society

Disclosure: Received honoraria from Pfizer for speaking and teaching; Received none from PerSys for consulting.

Robert P Caruso, MD Director of Robotic and Laparoscopic Urologic Surgery, Essex-Hudson Urology PC, Bloomfield, NJ

Robert P Caruso, MD is a member of the following medical societies: Alpha Omega Alpha, American Urological Association, Phi Beta Kappa

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Bradley Fields Schwartz, DO, FACS Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, Society of Laparoendoscopic Surgeons, Society of University Urologists, Association of Military Osteopathic Physicians and Surgeons, American Urological Association, Endourological Society

Disclosure: Nothing to disclose.

Acknowledgements

Dan Theodorescu, MD, PhD Paul A Bunn Professor of Cancer Research, Professor of Surgery and Pharmacology, Director, University of Colorado Comprehensive Cancer Center

Dan Theodorescu, MD, PhD is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Urological Association, Medical Society of Virginia, Society for Basic Urologic Research, and Society of Urologic Oncology

Disclosure: Key Genomics Ownership interest Co-Founder-50% Stock Ownership; KromaTiD, Inc Stock Options Board membership

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Trocar placement for a left laparoscopic radical nephrectomy (LRN).
Trocar placement for a right laparoscopic radical nephrectomy (LRN).
Colon mobilization for a right laparoscopic radical nephrectomy (LRN).
Right ureteral dissection using a suction aspirator.
Transection of right renal artery with the endovascular stapler.
Kidney is entrapped in a sack and is then morcellated with ring forceps.
 
 
 
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