General anesthesia is used. The usual indications for a laparoscopic nephrectomy or laparoscopic partial nephrectomy are renal cell carcinoma and, rarely, a benign end-stage kidney disease with a nonfunctioning kidney. Partial nephrectomy is almost internationally now the standard treatment for all renal tumors <4 cm in size, and perhaps up to 5 cm, according to European, American, and Australian guidelines, and laparoscopic nephrectomy is considered standard treatment for all other tumors except complicated ones (T4). Open nephrectomy for tumors >10 cm in size is the usual standard approach; otherwise laparoscopic nephrectomy is widely used. The robotic approach is now becoming more popular where available and appropriate.

The aim of the procedure is to remove the affected kidney or the tumor-bearing part of the kidney. The approach used depends on the pathology, lesion size, extent, required access, and surgeon preference. A transperitoneal or a retroperitoneoscopic approach may be used. Port placement depends on pathology, lesion size, extent, required access, and surgeon preference and requires 3–4 ports. Hand-assisted techniques are used in some centers. Laparoscopic nephrectomy has become the preferred technique for nephrectomy for benign indications in noninfected kidneys. Laparoscopic partial nephrectomy for small renal cell carcinoma (T1a, <4 cm in diameter) is preferred in some centers and has been shown to carry favorable oncological outcomes. In general, surgery is determined by the extent of disease with the laparoscopic approach confined to smaller tumors generally under 7 cm diameter, but larger tumors can be removed depending on the surgeons’ experience and skill. Resection of the kidney, adrenal glands, and proximal ureter is usual, with surrounding lymph nodes, and involved organs, if appropriate. Removal of a surrounding bladder cuff around the vesicoureteric junction may be required. Hilar clamping and warm renal ischemia time remain a controversial issue in laparoscopic partial nephrectomy in view of the preservation of renal function (which is the underlying issue in partial nephrectomy). The port sites are usually closed deeply using absorbable muscle sutures and the skin closed with suture, staples, or tapes.

The kidneys develop as three successive sets of organs between the 4th and 8th week of gestation and migrate to about the L1 level by birth. Both kidneys may be joined anteriorly, forming a single horseshoe kidney, or each kidney may be segmented with separate ureteric drainage and/or vascular supply. Duplex ureteric systems are not uncommon. Ectopic kidneys or unilateral renal agenesis can occur. Congenital anomalies of the renal system may underlie vesicoureteric reflux or renal failure. The anatomical extent of the tumor determines the surgery required, and this may be planned preoperatively using ultrasound and CT or MRI.