We invented a new surgical approach to the kidney through the flank to perform a radical nephrectomy for renal cell carcinoma. With the patient in usual lateral decubitus position keeping the dorsum vertical to the operating table, a skin incision is made over the XII rib from the posterior axillary line to the lateral edge of the rectus muscle. After the tip of XII rib is resected by about 5cm, the retroperitoneal space is entered. Blunt dissection of the posterior aspect of Gerota's fascia from fasciae of the quadratus lumborum and psoas muscle is easily carried out with a liver retractor or intestinal spatula. The pulsating renal artery can be identified through Gerota's fascia when the renal hilus is exposed. Following ligation and division of the artery, renal vein is exposed. On the left side, adrenal, gonadal and occasionally lumbar veins are also ligated and severed in addition to the renal vein. Then, the kidney in Gerota's fascia is removed en bloc with perinephric adipose tissue and adrenal gland.
Of 21 patients with renal cell carcinoma seen during 1 year and 3 months from June 1987, 11 underwent this operation, and other 10 patients transperitoneal radical nephrectomy because of the possible tumor extension into the renal vein, inferior vena cava or adjacent organ, the severe spinal deformity or metastases and the necessity of additional surgical procedures for concomitant benign intraperitoneal diseases. The blood loss was smaller and operating time was shorter significantly in the translumbar group than the evaluable transperitoneal group. None of those in the translumbar group received blood transfusion. As complications, pneumothorax due to pleural injury during operation and postoperative incisional hernia occurred each in one patient, but no other serious one was found. From the above results, this approach seems to be one of choices for the surgical treatment of renal cell carcinoma, as long as the tumor is not likely to extend to adjacent organs, ipsilateral nodes or the inferior vena cava.