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INTRODUCTION AND OBJECTIVES: Laparoscopy is replacing open surgery in the management of renal masses, but its role for large primary tumors is not clearly established. Our objective is to evaluate the feasibility and outcome of laparoscopic radical nephrectomy (LRN) for renal cell carcinoma (RCC) greater than 7cm. METHODS: The records of patients who underwent laparoscopic (transperitoneal) radical nephrectomy for 7cm or larger RCC from January 2001 to September 2008 at four urologic centers in Northern Italy were reviewed. Demographics, operative, pathologic and follow-up data were evaluated. RESULTS: Overall, 134 patients underwent LRN in the study period. The median tumor size was 8.2cm (range 7-14), operative time 192 minutes (100-310), and blood loss 300ml (range 0-1500). 29 (21%) patients received blood transfusion. 16 (12%) cases in 2 centers were converted to open surgery, due to vascular/hemorrhagic complications (n=6), failure to progress (n=5), oncological concerns regarding the ability to completely resect extensive disease (n=4). Complications included: postoperative renal insufficiency (n=6) or hypertension (n=3), anemization (n=4), abdominal hematoma (n=2), wound diastasis/incisional hernia (n=2), splenectomy (n=1, occurring after open conversion). Pathologic stage was: pT2 in 92, pT3a in 22, pT3b in 18, pT4 in 2; 7 cases were pN+. 113 conventional, 5 chromophobe, 4 papillary, and 12 mixed or sarcomatoid RCC were resected. After a median follow-up time of 27 months (range 3-81), 93 (69%) patients were alive with no evidence of disease, 13 (10%) died of recurrent disease or progression, 22 (16%) are alive with disease. CONCLUSIONS: LRN for large renal tumors is feasible and efficacious without substantial complications and morbidity. However, the conversion rate was significant in our experience. Parasitic vessels and displacement of the surrounding organs by large renal masses can increase the risk of vascular/hemorrhagic complications or inability to completely resect the lesion. LRN for large masses confirms the advantages of laparoscopic surgery, but it remains a technically challenging operation, requiring advanced laparoscopic skills.

A 72-year-old woman with a history of hematuria presented with a three-month history of weight loss and anorexia. Computed tomography (Panel A) and ultrasonography showed a solid mass infiltrating the renal pelvis of the nonfunctioning right kidney. The serum creatinine concentration was 1.1 mg per deciliter (97.2 μmol per liter), and cytologic examination of the urine revealed no abnormalities. Subsequent radical nephrectomy confirmed the presence of the mass at the upper pole and also revealed a complete staghorn pyelocaliceal and ureteral mass (Panel B). Histologic analysis showed that the lesion was a poorly differentiated renal-cell carcinoma (stage pT3aN0M0 according to . . .