Prone retroperitoneoscopic approach for heminephrectomy: Specific advantages relating to access to vascular pedicle

Abstract

The lateral approach is more widely used in retroperitoneoscopic (RP) heminephroureterectomy (HNU) due to familiar orientation and ease of conversion. The prone approach however gives early and easy access to the vascular pedicle. The main reason for not adopting a prone approach more widely is the perceived difficulty in lower ureteric access. We present a series of 30 HNUs where the prone approach was utilized extremely effectively with no conversions and few complications. Thirty consecutive HNUs performed over a 4-year period (2004-2007) using a prone RP approach were included in the study. Prospectively recorded data and notes were reviewed. Upper HNU was done in 17 and lower HNU in 13 patients. Mean age was 3.2 years (range 0.9-13.3). There were no transfusions or conversions. Follow-up ultrasound showed healthy remnant moieties in all. Residual ureteric stump was seen in six patients but only one was symptomatic requiring a further procedure. With the prone approach the anatomy can be demonstrated quickly and effectively. Dissection can be done easily without the need for kidney retraction as gravity aids demonstration of the renal vascular pedicle. There is a low risk of complications arising from the residual ureteric stump. We recommend that this approach be considered for RP HNU in all patients, irrespective of age.