OBJECTIVE: To improve the surgical technique of radical transumbilical nephrectomy for renal cancer and to improve surgical safety and surgical cure rate. METHODS: Improved radical kidney cancer surgery, including anatomical and sharp separation of the posterior and anterior perinephric fascial gaps, freeing the kidney in the order of posterior, superior pole and anterior kidney, isolating the renal vessels separately, ligating the renal artery and renal vein separately, and placing drainage tubes in the renal fossa at the end of surgery, was performed to retrospectively analyze the clinical data of 386 patients. RESULTS: There were 386 cases of kidney cancer in this group, accounting for 91% of kidney cancer in the same period (386/425). All tumors were ≤10 cm in diameter, including 69% of stage I, 30% of stage II, 1% of stage III, and 3% of stage IV; the operative time was 60~145 min, with an average of 90 min; the bleeding volume was 10-100 ml, with an average of 25 ml; 5 cases had complications, including 3 cases of pleural injury, 1 case of bleeding from vena cava injury, which was stopped by repair, and 1 case of chronic bleeding shock in the renal fossa 4~6 h after surgery, which was improved by blood transfusion There was no organ damage and no retroperitoneal infection in this group. 348 patients (90%) were followed up for 3 to 60 months, with one case of renal fossa recurrence and one case of pulmonary metastasis. Conclusion: The improved radical nephrectomy can effectively remove the tumor radically, which can reduce intraoperative and postoperative bleeding and decrease the complication rate. Clinical data in recent years show that the incidence of kidney cancer still has a growing trend. Currently, there are more and more reports of laparoscopic radical kidney cancer resection, however, most of the literature [1, 3] still treats open radical kidney cancer as one of the preferred treatment modalities for limited kidney cancer. The transumbilical approach has significantly fewer perioperative complications than the transabdominal approach and has become the main procedure for radical treatment of open renal cancer. However, there are insufficient exhaustive technical references on how to safely and early ligate the renal hilum in the transumbilical approach and how to reduce bleeding and avoid surgical complications. From May 2002 to May 2007, we treated 386 cases of kidney cancer patients with satisfactory results using the improved radical kidney cancer resection technique, which are reported below. 1. Information and methods 1.1. General information In this group of 386 cases, there were 262 male and 124 female cases. Nineteen cases were seen for lumbar discomfort, 35 cases were hospitalized for carnal hematuria, and 332 cases were found by ultrasound or CT due to health checkup or other systemic diseases. The tumors were located in the upper pole of the kidney in 125 cases, in the middle pole of the kidney in 109 cases and in the lower pole of the kidney in 152 cases. 95% of the patients underwent ultrasound and CT (or MRI) examination and reported the nature and size of the tumor. The IVU indicated normal renal function on the healthy side. All cases of adrenal resection were patients with renal tumors located in the upper pole of the kidney, and pathology reported one case (1/105) of invasion of the adrenal gland. Immunotherapy was routinely applied postoperatively. 1.2. Surgical methods and techniques After epidural and intravenous inhalation compound general anesthesia, the patient was placed in the healthy-side position, padded at the waist, and fixed after the head and feet were rocked low. According to the location of the kidney suggested by IVP, choose to make an incision through the 11th rib, 12th rib or 11th intercostal incision, and sequentially incise the skin, all layers of muscles or part of the ribs to reveal the kidney area. The procedure of anatomic sharp separation of kidney and tumor: on the dorsal side of the kidney area, the lateral cone fascia and the continuation of the lumbar fascia are incised longitudinally along the outer edge of the lumbar square muscle to reveal the lumbar square muscle and the posterior lobe of the renal fascia in front of it, and the superior pole of the kidney (or including the adrenal gland) and the anterior perinephric space are freed upward along this gap. The renal artery is freed, ligated and sutured proximally; the renal vein is separated, ligated and sutured proximally. (Sometimes, the renal artery can be directly exposed from the posterior renal space and ligated when the operative field is in good condition.) To confirm the absence of ectopic vessels, the kidney and surrounding tissues are lifted and sharply separated toward the distal ureter, and the kidney and tumor are completely removed. Close to the pelvic cavity, the ureter and surrounding tissues are cut. The surgical procedure requires familiarity with the perirenal fascia and peritoneal gap, sharp separation by electric knife in this gap, clear operative field, gentle operation, and electrocoagulation or ligation at the encountered blood vessels. 1.3 Follow-up Outpatient review of ultrasound, CT of renal area, X-ray chest film, liver and kidney function and blood and urine routine at 3, 6, 9 and 12 months after surgery, and review every six months after 1 year, adhering to 3-5 years. 2.Results There were 386 cases of kidney cancer in this group, accounting for 91% (386/425) of kidney cancer in the same period, tumor diameter ≤10cm, according to the clinical stage of AJCC kidney cancer in 2002, stage I (69%), stage II (30%), stage III (1%), stage IV (3%); clear cell carcinoma 84%, suspicious cell carcinoma 7%, papillary cell carcinoma 4%, cystic cell carcinoma 3%, collecting duct carcinoma and undifferentiated carcinoma 2 %, and 0.3 % of renal vascular smooth muscle tumors. The average operating time was 60~145 min, with an average of 90 min; the bleeding volume was 10-100 ml, with an average of 25 ml. 5 cases had complications, including 3 cases of pleural injury, in which the pleura was repaired or closed chest drainage was placed; 1 case of bleeding from vena cava injury, which was repaired and stopped; 1 case of chronic bleeding shock in the renal fossa 4~6 h after surgery, which was improved by blood transfusion and reoperation; there was no organ damage in this group, and no posterior peritoneal infection in 1 case. 348 patients (90%) were followed up for 3~60 months, with 1 case of renal fossa recurrence and 1 case of pulmonary metastasis. 3. Discussion 3.1. The radicality and reasonable practicality of this procedure: radical nephrectomy is currently the only method recognized as a possible cure for limited renal cancer, and was proposed by Robson [1] in 1969, who emphasized that early ligation of renal vessels could avoid the spread of cancer cells caused by tumor extrusion during surgery, and that the transabdominal approach could easily and quickly reveal renal vessels, and transabdominal incision has been used as the standard entry point for renal cancer surgery for many years. The transabdominal incision has been used as the standard approach for kidney cancer surgery for many years. In the following years, several authors reported [2, 3] that radical kidney cancer treatment by transumbilical approach has no difference in treatment outcome with transabdominal approach, and the postoperative complications of transumbilical approach are significantly reduced, making this procedure the main treatment modality for non-large kidney cancer. However, in clinical practice, we can easily find that due to the position of the body, the location of renal vessels in the transumbilical approach incision is deeply hidden. If we follow the transabdominal approach to directly search for the renal tip, complications such as peritoneal injury, vascular misligation, hemorrhage, and surrounding organ damage will easily occur. Choosing a simple, safe and effective route is a question we often think about. The classical radical resection of kidney cancer includes: perirenal fascia, perirenal fat, affected kidney, ipsilateral adrenal gland, hilar lymph nodes and ureter above the bifurcation of iliac vessels. We applied a modified radical kidney cancer resection that can accomplish the radical treatment requirements well and demonstrate safety, simplicity and ease of management. After entering the posterior peritoneal space to reveal the renal area, this procedure involves a longitudinal incision along the lateral conus fascia and the continuation of the lumbar fascia, revealing the lumbar fascia and the posterior lobe of the renal fascia in front of it, and then freeing the superior pole of the kidney or including the adrenal gland and the perinephric space along this gap. This pathway, in the order of posterior, superior and anterior, is in accordance with the applied anatomy of perirenal fascia because (i) the artery is posteriorly superior and the vein is anteriorly inferior in the position of the renal tip; (ii) the anterior lobe fascia of the perirenal anterior gap is closely connected with the fused fascia and peritoneum, and it is not easy to distinguish the boundary. Therefore, an incision from the confluence of the posterior lobe fascia and the lumbar musculofascial is chosen to easily access the posterior aspect of the renal hilum, and the renal artery is easily approached and separated and ligated. Sometimes, the renal artery can be ligated by directly revealing the renal artery from the posterior renal hiatus in a good state of the operative field. In addition, the choice of sharp resection to separate the tissues and ligation or electrocoagulation of the encountered vessels ensures that bleeding is reduced while maintaining a clear view, and such conditions allow us to steadily operate gently to avoid squeezing the tumor. In our group of 386 cases, accounting for 91% of kidney cancers in the same period, we performed radical kidney cancer surgery according to the above mentioned ideas and procedures, with an average operative time of 60-145 min and an average of 90 min; bleeding volume of 10-100 ml and an average of 25 ml; 281 patients (91%) were followed up for 1 to 36 months, and there was no recurrence in one renal fossa. Compared with the relevant literature, it showed practicality and radicality. 3. 2. Indications for this procedure and adrenal management: Radical nephrectomy can be performed via open or laparoscopic surgery. It is generally considered that tumors less than 5 cm are indications for laparoscopic radical nephrectomy for renal cancer. We believe that this procedure can be chosen for tumors less than 10 cm or tumors less than 5 cm without conditions for laparoscopy. Because the size of the revealed field is generally positively correlated with the degree of operational safety. We roughly estimate that the maximum volume of the renal area that can be exposed by transumbilical incision cannot exceed 16×15×12 cm3, therefore, if the tumor is too large, such as the diameter exceeds 10 cm, it will be difficult to sharply separate and reveal the perinephric space, and it will be more difficult to control the nephron tip, so it is better to choose transabdominal incision, therefore, all of the cases in this group chose the renal cancer with tumor diameter below 10 cm. At present, there are still different opinions on the treatment of the ipsilateral adrenal gland during radical surgery, and some advocate [4] that adrenalectomy should be performed for tumors larger than 5 cm in diameter. In our group, all cases with resected adrenal glands were patients with renal tumors located in the upper pole of the kidney, and pathology reported only one case (1/105) invading the adrenal gland. The issue of adrenal gland management still needs to be decided in a large sample. 3.3. Surgical complications: bleeding, perirenal organ injury, pleural injury, and retroperitoneal infection of the renal fossa may occur in either open or laparoscopic surgery for renal cancer [5, 6]. Since all the tissues and organs in this group were freed anatomically, the operative field was clear and operated under direct vision, there was no one case of abdominal organ injury. Early ligation of the renal artery cut off the vascular supply of the renal tumor, and the bleeding during the operation was low, averaging 25 ml. sharp separation of the retroperitoneal space, removal of the kidney and tumor, the renal fossa would have certain exudation, so we routinely placed a drainage tube at the end of the operation and removed it in 2-3 days, and there was no case of retroperitoneal infection in the renal fossa in our group after the operation. Five cases in this group had perioperative complications, including two cases of pleural injury, one case of bleeding from vena cava injury, and two cases of chronic bleeding shock from the renal fossa at 4-6 h after surgery. The pleural injury was resolved by repair or closed drainage, the vena cava injury was hemostatic after repair by expanding the exposure field, and the bleeding from the renal fossa was improved by hemostasis of the reoperative wound. Analyzing the causes, the pleural injury was related to the patient’s low pleural position and lack of care during the operation; the chronic bleeding shock in the renal fossa was related to the patient’s hypertensive quality and coagulation dysfunction; and the vena cava bleeding was related to ligating the renal vein too much at the root and pulling the vena cava. In conclusion, with the development of laparoscopic and minimally invasive techniques [7], we have gained further insight into the local anatomy of the perirenal fascial structures and contents. The identification of the renal fascia, fused fascia and lateral vertebral fascia is of anatomical importance for the localization and freeing of this procedure. The present data confirm that the improved transumbilical anatomical acute radical kidney cancer surgery is a safe, simple and practical radical procedure.