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Risk factors for conversion to hand assisted laparoscopic or open surgery during laparoscopic renal surgery are incompletely defined.We reviewed our institutional database of 759 standard laparoscopic and 833 hand assisted laparoscopic radical, simple, donor and partial nephrectomies, pyeloplasties and nephroureterectomies from June 1996 to February 2009, representing a total of 1,592 cases. We identified the incidence of and indications for conversion to hand assisted laparoscopic and open surgery, and determined risk factors for conversion.Of all 1,592 procedures 20 (1.3%) required conversion to open surgery. Of 759 standard laparoscopic procedures 21 (2.8%) were converted to hand assisted laparoscopic surgery and 1.7% were converted to open surgery for an overall standard laparoscopy conversion rate of 4.6%. Only 0.7% of hand assisted laparoscopic procedures were converted to open surgery. The rate of conversion to open surgery ranged from 0.3% for laparoscopic partial to 2.5% for laparoscopic simple nephrectomy. The rate of conversion to hand assisted laparoscopic surgery ranged from 0% for laparoscopic pyeloplasty to 6.5% for laparoscopic partial nephrectomy. Conversion to open surgery was most likely due to hemorrhage (50% of cases) or failure to progress (40%) while conversion to hand assisted laparoscopic surgery was most likely due to failure to progress (76%) and tumor anatomy (19%). Multivariate analysis revealed that the only significant risk factor for conversion to open surgery was greater American Society of Anesthesiologists score. Conversion to hand assisted laparoscopic surgery was associated with greater body mass index, American Society of Anesthesiologists score and partial nephrectomy.Conversion during laparoscopic renal surgery to open or hand assisted laparoscopic surgery is a rare but important event in laparoscopic surgery. The risk is influenced by the nature of the procedure and overall patient health.