Laparoscopic radical nephrectomy

Operative visualisation

UrOops3D · UroRef · © Nity G

Operative steps

1. Imaging + positioning Before access, the case is mapped rather than discovered: confirm side, measure the 6-7 cm lower-pole tumour, count the renal arteries, trace the renal vein and its adrenal, gonadal and lumbar tributaries, and exclude venous thrombus. The patient is secured in 45-60 degrees of lateral decubitus with the table broken to open the space between costal margin and iliac crest. Pressure points are protected, the dependent leg is flexed and the kidney rest is used only where the team can verify that it is not creating pressure injury. The displayed port map and viewing cone then show how the 30 degree laparoscope will approach the hilum.
   Spatial target: Map the synthetic 6-7 cm lower-pole tumour, count one main artery or two in the accessory variant, and rehearse 45-60 degrees of lateral positioning. Trace: Scenario-authored feature IDs F13, F17 and F21. Status: Scene targets; no claim that EAU or BAUS validates these numeric animation details.
2. Ports + colon reflection Access starts with a safe initial entry and the remaining ports are placed under direct vision in positions that let the whole kidney be worked from upper pole to pelvis. The colon is reflected medially along the white line of Toldt, sweeping the mesentery off Gerota’s fascia with blunt dissection and the diathermy kept on the mesenteric side. The check that the plane is right is the ureter on psoas and, on the left, the gonadal vein running cranially towards the renal vein; on the right, orientation instead returns to the short renal vein beside the cava. The whole reflection stays outside Gerota’s fascia, because entering it early shreds the plane into perinephric fat and every later step is harder for it.
   Spatial target: Establish a displayed 12-15 mmHg pneumoperitoneum and keep all four ports under vision and triangulated on the hilum. Trace: Scenario-authored feature IDs F22 and F29. Status: Technique rehearsal; the pressure and port pattern are not attributed to EAU or BAUS.
3. Ureter to the hilum The ureter is identified where the colon reflection exposed it on psoas and followed upward toward the lower pole. It is slung, two clips are placed on the patient side, and it is divided immediately on the specimen side of them: two visible clips in total. The specimen-side end is raised with adjacent tissue as a controlled handle so lower-pole lift presents the hilum without pulling directly on a vein. On the left, the gonadal vein leads cranially into the renal vein; on the right, the short renal vein and exposed cava replace that tributary map and require a separate approach. Dissecting blindly into fat to find the hilum without controlled traction is the error, because the instruments then go where the vein lives.
   Spatial target: Use two visible ureteric clips in total, both on the patient-side stump, then divide immediately specimen-side to them. Trace: Scenario-authored feature IDs F6 and F23. Status: Control geometry; the explicit total matches the two visible clip meshes.
   where it bites: blind traction to "find" the hilum is the mechanism of the vein tear.
4. Artery first The artery is found posterior and slightly superior to the vein, reached by lifting the lower pole and working behind the vein rather than over it. The synthetic pulse animation is an orientation cue, not a diagnostic threshold. In this technique rehearsal, a visible working length is developed before three patient-side and two specimen-side clips are placed and the vessel is divided between fixed control points. Both controlled stumps remain in view. Arterial control first visibly pales the synthetic kidney and decompresses the venous side. Only after main-artery control is complete does the sequence perform the accessory-artery sweep, because a missed branch leaves a live stump bleeding behind a field that looks finished.
   Spatial target: Develop a displayed 1.5-2 cm artery window and reconcile five clips: three patient-side and two specimen-side, before division. Trace: Scenario-authored feature ID F24. Status: Technique target; not presented as an EAU or BAUS clip-count standard.
   where it bites: a missed accessory artery leaves a bleeding retroperitoneal stump.
5. Renal vein divided With the artery secure and the accessory-artery sweep complete, the vein is freed around its full circumference back to the great vessel so a 45 mm vascular stapler can be applied without touching anything behind. The translucent jaw path dwells first on the adrenal tributary above and then the lumbar tributary behind; both must sit outside the bite, while the gonadal vein remains on the patient-side stump. The vein is divided between paired staple rows under direct vision, with no traction while the blade crosses. A short vein, level 0 thrombus or an early adrenal take-off shortens the safe working length and must already be known from imaging.
   Spatial target: Use the displayed 45 mm vascular load only after arterial control, with both jaws and every named tributary clear. Trace: Scenario-authored feature ID F25. Status: Device choreography; not presented as an EAU or BAUS stapler prescription.
6. Upper pole + adrenal plane After hilar division, the kidney remains supported by its upper-pole, lateral and posterior attachments and can be drawn away from the splenic hood under direct control. For this lower-pole tumour, an amber dotted adrenal-sparing plane is rehearsed and the adrenal settles back onto its retained fat pad. EAU RCC 2026 supports adrenal preservation when there is no clinical evidence of adrenal invasion. The assistant holds the splenic hood while the splenorenal and remaining lateral attachments are divided. On the right, liver retraction and duodenal mobilisation replace the splenic and pancreatic relationships. The error is a loaded retractor or grasper swept high and lateral in one careless move.
   Spatial target: Rehearse an adrenal-sparing plane with two or three synthetic crossing vessels when imaging shows no clinical adrenal invasion. Trace: Scenario-authored feature ID F26 for the vessel count and plane; EAU RCC 2026 disease-management guidance for the broad adrenal-preservation indication. Status: EAU supports the broad preservation decision, not the synthetic vessel count or illustrated dissection minutiae.
   where it bites: the spleen and pancreatic tail are one careless sweep away at the upper pole.
7. Bag + extraction The rolled bag enters through the 12 mm port, unfurls, receives the kidney inside Gerota’s fascia and cinches above the intact specimen. Pneumoperitoneum then falls from 12 to 8 mmHg for a seven-point bed check: artery stump, vein staple line, spleen or liver, pancreas or duodenum, colon, ureteric stump and large-port sites. Those sites are inspected under vision while the ports remain in place, before extraction and port withdrawal. The bagged specimen leaves through a protected Pfannenstiel incision without morcellation. The extraction fascia and indicated 10-12 mm port fascia are then closed, the abdominal dome deflates and the final clip and gauze counts reconcile.
   Spatial target: Reduce the display from 12 to 8 mmHg, inspect all seven bed targets including large-port sites while ports remain in place, and require gauze zero before extraction and closure. Trace: Scenario-authored feature IDs F27, F54 and F55; BAUS laparoscopic radical nephrectomy information is broad patient-information context only. Status: BAUS is not represented as validating the pressure, seven-target sequence and count gate.

Complications and immediate saves

Trigger each of these live in the Animation tab, then read the save: the first move, the escalation trigger, and the line that goes in the op note.

FRCS viva questions

The examiner stems this scene prepares you for. Try to answer out loud first, then reveal, and learn the discriminator, the detail that turns a pass into a strong pass.

Evidence and guidance