Evaluation of efficacy of four laparoscopic needle drivers.

INTRODUCTION: To evaluate the impact of needle driver design on laparoscopic suturing skills by experts and novices. METHODS: Three experienced laparoscopic surgeons and 3 novice junior residents were asked to perform a fixed set of suturing tasks in a laparoscopic pelvic-trainer. The laparoscopic needle drivers compared were (1) the Ethicon driver (E 705R), (2) Karl Storz (KS) pistol grip (26173 KC), (3) KS finger grip (26167 SK), and (4) KS palm grip (26173 ML). Times were recorded for each operator to grasp and position a needle for suturing in a particular angle, as well as to throw a horizontal and a vertical stitch and tie a single square knot using 2-0 Vicryl suture with a taper CT-1 needle. Subsequently, participants were asked to complete a subjective questionnaire rating the drivers. RESULTS: The average suturing time provided the most discriminatory power in comparing the needle drivers. For experienced operators, the KS pistol grip allowed faster suturing times than did the KS finger grip and the KS palm grip but not the Ethicon driver. For novice users, the Ethicon driver allowed faster suturing times than did the KS finger grip but not the KS pistol grip or the KS palm grip. In the subjective questionnaire, the KS pistol grip received the highest scores, and the KS finger grip received the lowest scores. CONCLUSION: Novice laparoscopists performed best with the KS pistol grip as well as the Ethicon laparoscopic needle drivers while experienced laparoscopists performed best with the pistol grip KS needle driver.

Intravesical Weck clip migration after laparoscopic radical prostatectomy.

Multiple modalities are used for hemostasis during laparoscopic radical prostatectomy. We report an instance of migration of a hemostatic clip into the bladder leading to stone formation. As such, these devices should be used with caution in the region of the vesicourethral anastomosis.

Case report: renal infarct mimicking renal mass: further rationale for minimally invasive management.

A 55-year-old man presented with an exophytic asymptomatic right renal lower-pole mass simulating a renal-cell carcinoma. He underwent retroperitoneoscopic partial nephrectomy, and histopathologic examination revealed a chronic renal infarct with calcifications. We report this case to stimulate the inclusion of focal chronic renal infarct in the differential diagnosis of asymptomatic renal masses, as well as to advocate a minimally invasive approach to appropriate renal lesions.

In vitro evaluation of ureteral perforation forces.

OBJECTIVES: Ureteroscopy has become a very effective treatment option for ureteral and upper tract abnormalities. The reported complication rates have ranged from 1.5% to 13% for perforations and have been less than 1% for avulsions. We present a study that quantified the ureteral avulsion force in porcine ureters and ureteral perforation forces in human and porcine ureters. METHODS: The avulsion force was measured in six porcine kidneys. A 2.4F stainless steel flat-wire basket was advanced through an incision made in the renal pelvis, and a 10-mm stone was placed in the extraction basket. The external end of the basket (handle) was attached to a miniature, low-force load cell and slowly pulled with increasing force until the ureter avulsed. The ureteral perforation forces were measured in 10 fresh porcine and 9 human ureters. Perpendicular perforation with either the blunt end of a CT-1 needle (0.038 in.) or the back end of a stiff guidewire (0.035 in.) was measured using the miniature, low-force load cell. RESULTS: The average maximal force to avulse the pig ureter was 2.21 +/- 0.43 pound-mass (lb(m)). The force required to perforate the porcine ureter was significantly greater than that required to perforate the human ureter, irrespective of whether a needle (1.70 +/- 0.26 lb(m) versus 1.05 +/- 0.29 lb(m), P = 0.019) or guidewire (1.30 +/- 0.25 lb(m) versus 0.79 +/- 0.25 lb(m), P = 0.013) was used. Greater force was required to perforate with the needle than with the guidewire in both the porcine (P = 0.037) and the human (P = 0.26) ureter. CONCLUSIONS: Quantifying the ureteral perforation forces will facilitate the design of endourologic devices, open the door for "smart devices" that sense forces and provide feedback, provide information critical to the design of endourologic and suturing simulators, and, finally, establish competency parameters for professionals in training.

Novel technique of knotless hemostatic renal parenchymal suture repair during laparoscopic partial nephrectomy.

Free-hand parenchymal suturing during warm-ischemia, laparoscopic partial nephrectomy is a complex and time-sensitive task. We describe a relatively simpler technique of achieving renal parenchymal hemostasis during laparoscopic partial nephrectomy using a polymer self-locking (Hem-o-Lok) clip.

A pilot study on the early use of the vacuum erection device after radical retropubic prostatectomy.

OBJECTIVE: To evaluate the effect of the early use of the vacuum erection device (VED) on erectile dysfunction (ED) and penile shortening after radical retropubic prostatectomy (RP), as these are important concerns for men choosing among treatment alternatives for localized prostate cancer. PATIENTS AND METHODS: Twenty-eight men undergoing RP were randomized to early intervention (1 month after RP, group 1) or a control group (6 months after RP, group 2) using a traditional VED protocol. An International Index of Erectile Function (IIEF) score of >11 (no, mild or mild to moderate ED) was required as a baseline criterion for inclusion in the study. Only patients in whom unilateral or bilateral nerves were spared were subsequently randomized. Patients in group 1 followed a daily rehabilitation protocol consisting of 10 min/day using the VED with no constriction ring, for 5 months. Patients were evaluated with the IIEF-5 questionnaire and measurements of penile flaccid length, stretched length, prepubic fat pad, and midshaft circumference before and at 1, 3, 6, 9 and 12 months after RP; the mean (range) last follow-up visit was 9.5 (6-12) months after RP. RESULTS: The mean (sd) baseline IIEF scores were similar in groups 1 and 2, at 21.1 (4.6) and 22.3 (3.3), respectively (P = 0.54). The IIEF scores were significantly higher in group 1 than group 2 at 3 months, at 11.5 (9.4) vs 1.8 (1.4) (P = 0.008) and at 6 months, at 12.4 (8.7) vs 3.0 (1.9) (P = 0.012) after RP. There were no significant changes in penile flaccid length, prepubic fat pad, or mid-shaft circumference in either group. Stretched penile length was significantly decreased at both 3 and 6 months, by approximately 2 cm (P = 0.013) in group 2. By contrast, stretched penile length was preserved in group 1 at all sample times. At the last follow-up, the proportion of men with a mean loss of penile length of >/= 2 cm was significantly lower in group 1 than group 2 (two/17, 12%, vs five/11, P = 0.044). CONCLUSIONS: Initiating the use of a VED protocol at 1 month after RP improves early sexual function and helps to preserve penile length.

Novel technique for removal of misdirected laparoscopic Weck clips.

The Weck clip has emerged as an attractive option for laparoscopic vascular control. It is secure and easy to use. However, once fired, the clip can be difficult to remove. We describe a novel technique for the safe removal of misdirected Weck clips using the Harmonic scalpel.

A new spin on the entrapped ureteral calculus.

We describe ureteroscopic lithotripsy using a revolving 1.5F tipless basket. After passing a laser fiber alongside the basket and performing lithotripsy, one uses a rotary wheel at the base of the basket handle to spin the stone to a different area for further fragmentation. This allows complete stone fragmentation, in contrast to traditional laser baskets, which bore a hole through the center of the stone. Irrigation flow testing demonstrated significant advantages with the 1.5F basket with or without a laser fiber alongside the basket compared with traditional baskets.

Novel device to assist urethrovesical anastomosis during laparoscopic radical prostatectomy.

We evaluated a novel urethral sound (Benique sound-Karl Storz) to assist suturing during laparoscopic radical prostatectomy. This sound provides for a more secure grip compared with the traditional sound, thereby affording controlled traction of the gland during the procedure and smooth coordinated movements of the sound during the anastomosis.

Laparoscopic ureterectomy for the management of painful calculi in a ureteral stump.

We present a rare case of a laparoscopic ureterectomy for the treatment of unusual chronic pain from a large retained stone in a ureteral stump. The history of long-term co morbidities from retained ureteral stumps is reviewed, as well as a discussion on the possible etiology of the pain for this particular patient. An argument for the change of the standard of care for the management of ureters in relation to nephrectomies is also made in regard to adult patients with a history of stone disease.

Transperitoneal versus retroperitoneal laparoscopic partial nephrectomy: patient selection and perioperative outcomes.

PURPOSE: 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. MATERIALS AND 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.

Radial dilation of ureteral balloons: comparative in vitro analysis.

BACKGROUND AND PURPOSE: The dynamics of ureteral balloon expansion may differ with increasing extrinsic compressive forces and inflation pressures. This study compared the ability of ureteral balloons to expand under different conditions. MATERIALS AND METHODS: The balloons tested were the Cook Accent, Ascend, Ascend AQ, and Pursuit; the Bard 195503 and UroForce; and the Boston Scientific Microvasive UroMax Ultra. When available, multiple balloon diameters and lengths were tested. With a guidewire in place, the balloon tip was secured by elevated vise grips on either side of the balloon. A string was wrapped around the balloon center once, and incremental increases in load were added (2 g, 42 g, 82 g, 122 g) to represent increasing extrinsic compression. The balloon was inflated with contrast medium, and circumference changes were measured at increments of 2 atm up to burst pressure. Balloons were tested in triplicate for each weight. RESULTS: The majority of the balloons were unable to reach 90% of their expected diameter with larger constrictive loads (122 g) at low inflation pressure (4 atm). The only balloons that achieved a diameter at 4 atm that was at least 90% of the expected diameter with a coefficient of variance (CV) of <10% at all radial loads were the Pursuit 6 mm x 4 cm (98.2 +/- 2.2%; CV 7.88%), UroMax Ultra 7 mm x 4 cm (97.5 +/- 1.4%; CV 5.94%), and the UroMax Ultra 7 mm x 6 cm (101 x 1.2%; CV 7.67%). At inflation burst pressure, the balloons able to maintain a diameter at or above 100% of expected with a CV of <5% at burst pressure were the Ascend AQ 4 mm x 4 cm (116 +/- 1.0%; CV 3.34%) and the Pursuit 6 mm x 4 cm (108 +/- 2.0%; CV 4.53%). CONCLUSION: Reaching maximum inflation diameter at low pressures in the face of increasing extrinsic compression may help minimize the risk of ureteral injury. Reliable expansion to maximum diameter even with higher extrinsic compressive forces is another important characteristic of ureteral balloons. Balloon material, configuration, and dimensions may contribute to differences in dilation properties.

Impact of intraoperative heparin on laparoscopic donor nephrectomy.

PURPOSE: At many centers systemic heparinization is performed during laparoscopic donor nephrectomy because of concerns regarding graft thrombosis. However, no consensus exists in this regard. We evaluated the impact of intraoperative heparin on donor and recipient outcomes. MATERIALS AND METHODS: Between September 2000 and February 2003, 79 consecutive patients underwent laparoscopic live donor left nephrectomy at our institution. They were sequentially divided into 2 groups, that is group 1-the initial 40 patients who intraoperatively received 5,000 IU heparin intravenously and group 2-subsequent patients who did not receive heparin. The 2 groups were well matched demographically. Data were compared using the paired 2-tailed t test. RESULTS: The 2 donor groups were comparable in regard to mean blood loss (139 vs 179 cc, p = 0.59), intraoperative urine output (1.6 vs 1.6 l, p = 0.74), warm ischemia time (4 vs 4.2 minutes, p = 0.52), operative time (3.5 vs 3.5 hours, p = 0.97), and cold ischemia time (75 vs 82 minutes, p = 0.38). Complications occurred in 1 patient in group 1 (rhabdomyolysis induced acute renal failure) and in 2 in group 2 (chylous ascites and lumbar vein injury, respectively). No graft was lost due to vascular thrombosis in either group. Recipient immediate, early and delayed (6-month) graft function was comparable between the 2 groups. Acute rejection occurred in 5 recipients in group 1 and 1 in group 2. There was 1 recipient death per group at delayed followup. CONCLUSIONS: Routine use of heparin during laparoscopic donor nephrectomy is not necessary. Because of its potential for causing intraoperative or early postoperative hemorrhage, we no longer routinely administer intraoperative heparin during laparoscopic donor nephrectomy at our institution.

Dismembered percutaneous endopyeloplasty: a new procedure.

PURPOSE: We recently described a novel technique of percutaneous non-dismembered endopyeloplasty (Fenger type). Herein, we extend this transrenal technique further and report percutaneous dismembered endopyeloplasty (Anderson-Hynes type). MATERIALS AND METHODS: In five pigs with unilateral ureteropelvic junction (UPJ) obstruction created 3 to 6 weeks earlier, percutaneous dismembered endopyeloplasty was performed. Percutaneous transrenal access to the UPJ was obtained, and the UPJ was completely dismembered from within the renal pelvis through the solitary percutaneous tract. The dismembered proximal ureter was circumferentially mobilized, and in two animals, the UPJ segment was completely excised and removed. A spatulated end-to-end endopyeloplasty anastomosis (Anderson-Hynes) was created transrenally with 5 to 10 interrupted sutures using a novel nephroscopic suturing device (Sew-Right SR-5; LSI Solutions, Rochester, NY). In two animals, the entire percutaneous procedure was performed with CO2 insufflation instead of fluid irrigation. RESULTS: The technique was developed in three pigs. Subsequently, two pigs were treated and sacrificed at 2 and 5 weeks. All UPJs were dismembered successfully, and a precisely sutured mucosa-to-mucosa anastomosis was created. Intraoperative bleeding was negligible, and the operative time ranged from 3 to 5 hours, with the majority of the time dedicated to transrenal retroperitoneal dissection of the scarred, fibrotic UPJ. Carbon dioxide insufflation was efficacious because it minimized fluid extravasation and tissue edema and additionally enhanced visibility. Postoperative pyelograms revealed an adequately funneled UPJ, with good flow into the distal ureter. The two survival animals had minimal apparent morbidity from the procedure, and retrograde pyelograms at euthanasia revealed a patent anastomosis without extravasation. A 6F catheter easily crossed the reconstructed UPJ at autopsy in all animals. CONCLUSIONS: Dismembered percutaneous Anderson-Hynes endopyeloplasty is technically feasible and is promising. Further technical experience and additional functional outcome analysis in the survival model are necessary. With the technique described herein, we introduce the concept of percutaneous intrarenal reconstructive surgery (PIRS), wherein advanced intrarenal and retroperitoneal dissection with reconstruction can be performed endourologically, further broadening the horizons of conventional percutaneous techniques.

Improved hemostasis during laparoscopic partial nephrectomy using gelatin matrix thrombin sealant.

OBJECTIVES: To evaluate whether using a biologic hemostatic sealant facilitates hemostasis during laparoscopic partial nephrectomy. Secure and durable parenchymal hemostasis is a critical requirement during laparoscopic partial nephrectomy. METHODS: Since September 1999, laparoscopic partial nephrectomy has been performed in more than 300 patients by a single surgeon, duplicating open surgical principles. Recently, from patient 225 onward, we modified our technique by incorporating topical application of a gelatin matrix thrombin sealant (FloSeal) to cover the partial nephrectomy bed before sutured renorrhaphy over a Surgicel bolster. The impact of FloSeal on reducing hemorrhagic complications was evaluated by comparing two sequential groups of patients: group 1 consisted of 68 patients in whom FloSeal was not used (patients 156 to 224) and group 2 consisted of 63 patients in whom it was used (patients 225 to 288). RESULTS: Groups 1 (no FloSeal) and 2 (FloSeal) were comparable in tumor size, number of central tumors, and performance of pelvicaliceal suture repair (84% versus 92%; P = 0.16). Intraoperative variables were also comparable in terms of mean warm ischemia time (36.1 versus 37.2 minutes; P = 0.55), blood loss (150 versus 106 mL; P = 0.36), operative time, and hospital stay. However, the FloSeal group had significantly fewer overall complications (37% versus 16%; P = 0.008) and tended toward a lower rate of hemorrhagic complications (12% versus 3%), although this did not achieve statistical significance (P = 0.08). CONCLUSIONS: The results of this study have shown that adjunctive use of gelatin matrix thrombin sealant substantially enhances parenchymal hemostasis and has decreased our procedural and hemorrhagic complications to levels comparable with contemporary open partial nephrectomy series. This gelatin matrix-thrombin tissue sealant is now a routine part of laparoscopic partial nephrectomy at our institution.

The impact of warm ischaemia on renal function after laparoscopic partial nephrectomy.

UNLABELLED: Authors from Cleveland assessed the impact of warm ischaemia on renal function, using their large database of laparoscopic partial nephrectomies for tumour. While agreeing that renal hilar clamping is essential for precise excision of the tumour, and other elements of the operation, the authors indicate that warm ischaemia may potentially damage the kidney. However, they found that there were virtually no clinical sequelae from warm ischaemic of up to 30 min. They also found that advancing age and pre-existing renal damage increased the risk of postoperative renal damage. OBJECTIVE: To assess the effect of warm ischaemia on renal function after laparoscopic partial nephrectomy (LPN) for tumour, and to evaluate the influence of various risk factors on renal function. PATIENTS AND METHODS: Data were analysed from 179 patients undergoing LPN for renal tumour under warm ischaemic conditions, with clamping of the renal artery and vein. Renal function was primarily evaluated in two groups of patients: 15 with tumour in a solitary kidney, who were evaluated by serial serum creatinine measurements; and 12 with two functioning kidneys undergoing unilateral LPN, and evaluated by renal scintigraphy before and 1 month after LPN to quantify differential renal function. Also, in all 179 patients, mean serum creatinine data at baseline, 1 day after LPN, at hospital discharge, and at the last follow-up were provided as supportive evidence. Logistic regression analyses were used to assess the effect of various risk factors on renal function after LPN, i.e. patient age, baseline serum creatinine, tumour size, solitary kidney status, duration of warm ischaemia, pelvicalyceal suture repair, urine output and intravenous fluids during LPN. RESULTS: In the group of patients with a solitary kidney the mean warm ischaemia time was 29 min, kidney parenchyma excised 29%, and serum creatinine at baseline, discharge, the peak after LPN and at the last follow-up (mean 4.8 months) 1.3, 2.3, 2.8, and 1.8 mg/dL, respectively. One patient (6.6%) required temporary dialysis. In the second group, assessed by renal scintigraphy, the function of the operated kidney was reduced by a mean of 29%, commensurate with the amount of parenchyma excised. For all 179 patients, a combination of age > or = 70 years and a serum creatinine level after LPN of > or = 1.5 mg/dL correlated with a higher serum creatinine after LPN. On logistic regression, baseline serum creatinine and solitary kidney status were the only variables significant for serum creatinine status after LPN. CONCLUSIONS: The bloodless field provided by renal hilar clamping is important for precise tumour excision, pelvicalyceal suture repair and securing parenchymal haemostasis during LPN. However, renal hilar clamping causes warm ischaemia. These data indicate that the clinical sequelae of warm ischaemic renal injury of approximately 30 min are minimal. Advancing age and pre-existing azotaemia increase the risk of renal dysfunction after LPN, especially when the warm ischaemia exceeds 30 min.

Complications of laparoscopic partial nephrectomy in 200 cases.

PURPOSE: We analyzed complications of the initial 200 cases treated with laparoscopic partial nephrectomy for a suspected renal tumor. MATERIALS AND METHODS: Since August 1999, 200 consecutive patients have undergone laparoscopic partial nephrectomy. Mean patient age was 61.6 years, mean body mass index was 29.9 and mean tumor size was 2.9 cm (range 1 to 10). There were 51 central tumors (25%) and 15 solitary kidneys (7.5%). A central tumor was defined as any tumor infiltrating up to the collecting system or renal sinus, during the excision of which entry into and repair of the collecting system was necessary. Mean estimated blood loss was 247 cc and mean operative time was 3.3 hours. Data on complications were obtained from a prospectively maintained computerized database and via telephone calls to patients and/or local referring physicians. RESULTS: A total of 66 patients (33%) had 1 or more complications, which were intraoperative in 11 (5.5%), postoperative in 24 (12%) and delayed in 31 (15.5%). Overall 30 patients (15%) had a non-urological complication and 36 (18%) had a urological complication, including hemorrhage in 19 (9.5%) and urine leakage in 9 (4.5%). Hemorrhage occurred intraoperatively in 7 cases (3.5%) and postoperatively in 4 (2%), while it was delayed in 8 (4%). Of patients with urine leakage none required reoperation, 6 (3%) required a Double-J stent (Medical Engineering Corp., New York, New York) only, 2 (1%) required a Double-J stent with computerized tomography guided drainage and 1 required no treatment. Open conversion was necessary in 2 patients (1%), reoperation was done in 4 (2%) and elective laparoscopic radical nephrectomy was performed in 1 (0.5%). CONCLUSIONS: Laparoscopic partial nephrectomy is an advanced procedure with potential for complications. It requires considerable experience with reconstructive laparoscopy.

A novel dual-diameter ureteroscope working channel: impact on irrigant flow.

OBJECTIVES: To compare irrigant flow characteristics through standard working channels (3.6F to 4.5F) and a dual-diameter working channel. Irrigant flow is critical for adequate visualization during endoscopic procedures. METHODS: Working channels were created out of 80 cm of light wall polytetrafluoroethylene (PTFE) tubing (inner diameter 3.6F, 4.0F, and 4.5F) with a male Luer connector attached to one end by epoxy resin. The dual-diameter working channel was created with a 70-cm segment of PTFE (4.5F inner diameter, 0.059 in.) and a 10-cm segment of PTFE (3.6F inner diameter, 0.047 in.) with a male Luer connector attached to the free end of the 4.5F tubing. Stone basket shafts (100 cm in length, outer diameter 1.9F, 2.4F, and 3.0F) were created out of unmodified polyimide tubing with a 0.018-in.-diameter nitinol mandrel epoxy core for stability. Irrigant flow was measured at 100 mm Hg pressure for 1 minute with an empty channel and with stone basket shafts in the channel. RESULTS: The flow rates were significantly greater with the dual-diameter working channel than with the standard flexible ureteroscope (3.6F) working channel using an empty channel (79.2 versus 44.1 mL/min, P = 0.0001), 1.9F basket (35.9 versus 10.0 mL/min, P = 0.003), 2.4F basket (20.7 versus 4.3 mL/min, P = 0.002), and 3.0F basket (6.0 versus 0.7 mL/min, P = 0.0002) sheath. CONCLUSIONS: A dual-diameter working channel may optimize irrigant flow characteristics for flexible ureteroscopes while maintaining a small distal tip diameter.

Laparoscopic radical nephrectomy for large (greater than 7 cm, T2) renal tumors.

PURPOSE: Laparoscopic radical nephrectomy has emerged as a standard of care in appropriate candidates with clinical stage T1 renal tumors (7 cm or less). Herein we present our experience with laparoscopic radical nephrectomy for clinical stage T2 tumors (greater than 7 cm). MATERIALS AND METHODS: Patients undergoing laparoscopic radical nephrectomy between September 1997 and July 2003 were retrospectively subdivided into group LAPT1-166 with tumor size 7 cm and group LAPT2-65 with tumor size greater than 7 cm. Also, group LAPT2 was compared with a group of 34 contemporary, comparable patients undergoing open radical nephrectomy for tumor greater than 7 cm (group OPENT2). RESULTS: Compared with group LAPT1, group LAPT2 had younger patients, larger tumors and greater blood loss (100 vs 200 ml) (each p <0.001). Importantly operative time, analgesic requirements, hospital stay, and convalescence and complication rates were comparable. Group LAPT2 and group OPENT2 patients had similar sized tumors (9.2 and 9.9 cm, respectively) but shorter operative time (p = 0.03), lesser blood loss (p <0.001), shorter hospital stay (p <0.001) and more rapid convalescence (p = 0.02) occurred in LAPT2. CONCLUSIONS: Laparoscopic radical nephrectomy for stage T2 renal masses (greater than 7 cm) is feasible and efficacious. Laparoscopic nephrectomy offers the advantages of decreased blood loss, shorter hospital stay and more rapid recovery over open radical nephrectomy for comparable tumors greater than 7 cm. Although surgical outcomes are comparable with laparoscopic radical nephrectomy for smaller tumors (7 cm or less), adequate laparoscopic experience is necessary before performing radical nephrectomy for large T2 tumors.