Background: The prone laparoscopic approach to the kidney has been described in the pediatric urologic literature. However, there are no reports of adult prone laparoscopic renal surgery. We present here, a video, of the initial prone laparoscopic partial nephrectomy
Methods:The patient was placed in the prone position. Retroperitoneal access was obtained through a 12mm incision inferior to the medial aspect of the 12^th rib and just lateral to the paraspinous muscles. Blunt dissection freed the peritoneum from the psoas. A second 12mm port was placed inferior to the lateral aspect of the 12^th rib and a PDB balloon dilator (USSC) was inserted medially to insufflate the retroperitoneum under direct visualization. Dissection of the retroperitoneal space was then completed with the harmonic scalpel and a third port was placed just above the iliac crest lateral to the paraspinous muscles. The tumor and hilum were exposed. After clamping the hilum with a laparoscopic Satinsky, the tumor was excised with laparoscopic scissors under direct visualization. Renal bed biopsies were performed for frozen section analysis. Hemostasis was obtained with the aid of a Vicryl mesh patch and fibrin glue
Results: The patient recovered uneventfully. Operative time was 323 minutes and estimated blood loss 100 cc. Final pathology confirmed a 1.6 cm clear cell carcinoma with negative surgical margins.
Conclusions: The prone position offers good access for select posterior tumors. Limitations of this approach include increased difficulty in converting to an open procedure and the confined retroperitoneal space.

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