since the first laparoscopic nephrectomy was performed in 1991 , laparoscopic renal surgery has rapidly grown in scope and application . today , this approach is being utilized for a variety of procedures from oncologic renal extirpation to renal reconstruction and donor nephrectomy . herein , we report 4 cases of rhabdomyolysis following laparoscopic nephrectomy performed with the patient in a 45-degree lateral decubitus position . we reviewed the literature to determine the expected frequency of this complication and to produce a better understanding of its origins , treatments , and expected outcomes . a 36-year - old 163 kg male ( body mass index [ bmi ] = 38.6 ) underwent a laparoscopic hand - assisted left donor nephrectomy while in a 45-degree right flank position with the kidney bar raised . the patient complained of right lower back and buttock pain similar in nature to his previously experienced chronic lower back pain . postoperative creatinine was 1.6 mg / dl , increased from his baseline of 1.0 mg / dl . this severe pain continued on postoperative day one , at which time the patient was also noted to have weakness in his right lower extremity , and a neurology consult was obtained . creatinine kinase levels were obtained and found to be markedly elevated at 126,539 iu / l , and a urine myoglobin test confirmed the presence of myoglobin in the urine . a diagnosis of rhabdomyolysis was made . over the next 24 hours , the patient 's urine output , which had been 1.3 l on both postoperative days 0 and 1 , diminished to 325 ml , and his creatinine increased to 4.9 mg / dl . a diagnosis of oliguric acute renal failure was made , and a renal consult was obtained . alkalinization of the urine with intravenous bicarbonate , hydration , and pharmacological diuresis ( mannitol and furosemide ) were ineffective in reversing the oliguric renal failure , and the patient would eventually require 4 weeks of dialysis . his lower extremity weakness improved ; however , he required long - term physical therapy . a 33-year - old , healthy , 81.7 kg male ( bmi = 28.3 ) , underwent a laparoscopic hand - assisted left donor nephrectomy while in a 45-degree right flank position with the kidney bar raised . the immediate postoperative course was significant for complaints of right lower back pain in the postanesthesia care unit . urine myoglobin test on postoperative urine was positive , and creatinine kinase and creatinine levels obtained in the recovery room were found to be 2239 iu / l and 1.3 mg / dl , respectively . a diagnosis of rhabdomyolysis was made , and immediate intravenous hydration with bicarbonate - containing solution was begun . a nephrology consultation was obtained . over the first 24 hours , the patient maintained adequate urine output ( 1.8 l ) . however , during the ensuing 24 hours , the urine output dropped to 687 ml followed by a further decline to 440 ml the next day . additionally , over that time period , the patient developed increasing difficulty maintaining oxygenation due to volume overload . continuous infusion of furosemide was unsuccessful in preventing renal failure in this patient , despite maintenance of reasonable urinary output . the patient 's creatinine continued to rise to 11.7 mg / dl , at which point hemodialysis was initiated . the patient 's pain resolved by postoperative week 6 , and he returned to work without restrictions 8 weeks after surgery . a 60-year - old , 131 kg male ( bmi = 45.3 ) , with a history of asthma , bronchitis , hypertension , and chronic back pain who was found to have a left - upper pole renal mass was taken to the operating room for planned laparoscopic left partial nephrectomy . the patient was placed on the table in a 45-degree lateral decubitus position with the table flexed and the kidney bar raised . after exposure of the renal hilum , dissection was begun to expose the left upper pole mass . dissection was somewhat difficult around the mass secondary to its close approximation to the adrenal gland . nevertheless , over a short period of time during dissection of the tumor , the patient became increasingly difficult to ventilate . specifically , the patient required increasingly elevated ventilatory pressures and demonstrated rising end - tidal co2 levels . the anesthesia team alerted the surgical team of this problem , and the abdominal insufflation and the operation were temporarily suspended while the ventilatory issues were corrected . after correction , an attempt was made to once again continue with the operation . however , shortly after reinstituting abdominal insufflation , the patient again exhibited respiratory changes . because it was thought that the patient could not tolerate continued insufflation for a prolonged period of time , the decision was made to perform a hand - assisted nephrectomy . hand - port access was obtained , and nephrectomy was accomplished shortly thereafter . in the recovery room , the patient complained of significant right lower back and leg pain ; his postoperative creatinine was 2.0 mg / dl . when this continued for several hours , a serum creatinine kinase level was obtained and found to be elevated to 33,140 the patient 's urinary output rapidly declined from 700 ml during the first 6 hours to 230 ml for the next 24 hours . diuresis with furosemide and hydration with alkaline solution were instituted , but the patient progressed to acute oliguric renal failure . the patient suffered prolonged right back and lower extremity pain , with marked weakness in his right upper leg . a 52-year - old , 145 kg male ( bmi = 53 ) , with a history of asthma , hypertension , and glaucoma with an incidentally detected 5.3-cm left renal mass underwent a laparoscopic left radical nephrectomy while in a rotated supine position . though dissection was difficult secondary to body habitus , laparoscopic nephrectomy was achieved in 3.5 hours , and the patient was returned to a supine position . the patient remained intubated until postoperative day # 1 due to concerns over his asthma history and obesity . creatinine kinase level peaked on postoperative day # 3 at 111,470 iu / l , and the patient progressed from oliguric renal failure to anuric renal failure , despite aggressive hydration , induced diuresis , and alkalinization of the urine . the patient required long - term dialysis and remained with severe lower extremity weakness at the time of the most recent follow - up ( 6 weeks ) . a 36-year - old 163 kg male ( body mass index [ bmi ] = 38.6 ) underwent a laparoscopic hand - assisted left donor nephrectomy while in a 45-degree right flank position with the kidney bar raised . the patient complained of right lower back and buttock pain similar in nature to his previously experienced chronic lower back pain . postoperative creatinine was 1.6 mg / dl , increased from his baseline of 1.0 mg / dl . this severe pain continued on postoperative day one , at which time the patient was also noted to have weakness in his right lower extremity , and a neurology consult was obtained . creatinine kinase levels were obtained and found to be markedly elevated at 126,539 iu / l , and a urine myoglobin test confirmed the presence of myoglobin in the urine . a diagnosis of rhabdomyolysis was made . over the next 24 hours , the patient 's urine output , which had been 1.3 l on both postoperative days 0 and 1 , diminished to 325 ml , and his creatinine increased to 4.9 mg / dl . a diagnosis of oliguric acute renal failure was made , and a renal consult was obtained . alkalinization of the urine with intravenous bicarbonate , hydration , and pharmacological diuresis ( mannitol and furosemide ) were ineffective in reversing the oliguric renal failure , and the patient would eventually require 4 weeks of dialysis . his lower extremity weakness improved ; however , he required long - term physical therapy . a 33-year - old , healthy , 81.7 kg male ( bmi = 28.3 ) , underwent a laparoscopic hand - assisted left donor nephrectomy while in a 45-degree right flank position with the kidney bar raised . the immediate postoperative course was significant for complaints of right lower back pain in the postanesthesia care unit . urine myoglobin test on postoperative urine was positive , and creatinine kinase and creatinine levels obtained in the recovery room were found to be 2239 iu / l and 1.3 mg / dl , respectively . a diagnosis of rhabdomyolysis was made , and immediate intravenous hydration with bicarbonate - containing solution was begun . however , during the ensuing 24 hours , the urine output dropped to 687 ml followed by a further decline to 440 ml the next day . additionally , over that time period , the patient developed increasing difficulty maintaining oxygenation due to volume overload . continuous infusion of furosemide was unsuccessful in preventing renal failure in this patient , despite maintenance of reasonable urinary output . the patient 's creatinine continued to rise to 11.7 mg / dl , at which point hemodialysis was initiated . additionally , the patient continued to experience significant right lower back and buttock pain . the patient 's pain resolved by postoperative week 6 , and he returned to work without restrictions 8 weeks after surgery . a 60-year - old , 131 kg male ( bmi = 45.3 ) , with a history of asthma , bronchitis , hypertension , and chronic back pain who was found to have a left - upper pole renal mass was taken to the operating room for planned laparoscopic left partial nephrectomy . the patient was placed on the table in a 45-degree lateral decubitus position with the table flexed and the kidney bar raised . after exposure of the renal hilum , dissection was begun to expose the left upper pole mass . dissection was somewhat difficult around the mass secondary to its close approximation to the adrenal gland . nevertheless , over a short period of time during dissection of the tumor , the patient became increasingly difficult to ventilate . specifically , the patient required increasingly elevated ventilatory pressures and demonstrated rising end - tidal co2 levels . the anesthesia team alerted the surgical team of this problem , and the abdominal insufflation and the operation were temporarily suspended while the ventilatory issues were corrected . after correction , an attempt was made to once again continue with the operation . however , shortly after reinstituting abdominal insufflation , the patient again exhibited respiratory changes . because it was thought that the patient could not tolerate continued insufflation for a prolonged period of time , the decision was made to perform a hand - assisted nephrectomy . hand - port access was obtained , and nephrectomy was accomplished shortly thereafter . in the recovery room , the patient complained of significant right lower back and leg pain ; his postoperative creatinine was 2.0 mg / dl . when this continued for several hours , a serum creatinine kinase level was obtained and found to be elevated to 33,140 the patient 's urinary output rapidly declined from 700 ml during the first 6 hours to 230 ml for the next 24 hours . diuresis with furosemide and hydration with alkaline solution were instituted , but the patient progressed to acute oliguric renal failure . the patient suffered prolonged right back and lower extremity pain , with marked weakness in his right upper leg . a 52-year - old , 145 kg male ( bmi = 53 ) , with a history of asthma , hypertension , and glaucoma with an incidentally detected 5.3-cm left renal mass underwent a laparoscopic left radical nephrectomy while in a rotated supine position . though dissection was difficult secondary to body habitus , laparoscopic nephrectomy was achieved in 3.5 hours , and the patient was returned to a supine position . the patient remained intubated until postoperative day # 1 due to concerns over his asthma history and obesity . creatinine kinase level peaked on postoperative day # 3 at 111,470 iu / l , and the patient progressed from oliguric renal failure to anuric renal failure , despite aggressive hydration , induced diuresis , and alkalinization of the urine . the patient required long - term dialysis and remained with severe lower extremity weakness at the time of the most recent follow - up ( 6 weeks ) . rhabdomyolysis and subsequent renal failure are well - known complications of trauma , particularly in the setting of a crush injury . additionally , it has been reported to occur in the postoperative setting as a complication of general surgical , orthopedic , and urologic procedures performed with the patient in the lithotomy position . at our institution three of these nephrectomies were performed with the patient in a 45-degree flank position with the table in the flexed position and the kidney bar raised ; the last case was performed with the patient in a rotated supine position . our patients exhibited many of the risk factors that have been often proposed to contribute to the development of rhabdomyolysis : male sex , elevated bmi , prolonged or time , and procedure performed with the patient in the lateral decubitus or 45-degree lateral decubitus position . in reviewing the literature , we noted that all but 2 of the patients who developed rhabdomyolysis were male . additional risk factors that have been suggested include preexisting renal disease , extracellular volume depletion , and renal hypoperfusion . the earliest association of rhabdomyolysis and renal failure was described in 1941 . since that time , a better understanding of the risk factors and pathogenesis of this condition have been achieved . in relating it to surgical positioning , it should be considered as representing part of the spectrum of local changes that can occur to skin and underlying soft tissues due to prolonged fixed pressure on these areas . as a disease process , rhabdomyolysis presents 2 separate problems , namely the local effects of tissue injury and the systemic consequences that result from that injury . in rhabdomyolysis occurring in the surgical setting , the predominant initial contributing factor is thought to be the ischemia or partial ischemia that results from direct , prolonged pressure on the soft tissues and overlying skin . experiments by whitesides have suggested that tissue ischemia may begin to occur when tissue pressures approach to within 10 mm hg to 30 mm hg of the diastolic pressure . studies have shown that skeletal muscle tolerates this ischemia for as long as 2 hours , after which time ultrastructural ischemic changes begin to occur . as ischemia persists , these changes become more severe and are noted to be irreversible after about 7 hours . as the problems of pressure and time relate to laparoscopic renal surgery , it is clear why obesity , patient positioning , and operative time could play a role in the development of postsurgical rhabdomyolysis . in reviewing our reported cases and the literature , we would also question whether the additional insult of intraabdominal insufflation ( generally 12 mm hg to 15 mm hg ) might narrow what is already a small perfusion pressure window in our obese patients . when surgical procedures are terminated and the direct pressure on the soft tissue beds is relieved , a secondary pathogenic process occurs in rhabdomyolysis . ischemiareperfusion injury in association with resulting localized tissue edema can result in a continued low perfusion state in the local tissue bed in addition to producing a systemic hypovolemia as intravascular fluids are lost through local capillary beds . further systemic effects are known to occur as myocyte damage leads to liberation of myoglobin into circulation with the potential development of myoglobinuria and subsequent acute renal failure . these systemic effects can be particularly devastating in the setting of renal extirpative surgery where the relative renal hypoperfusion and large myoglobin load must be handled by a solitary renal unit . table 1 lists , in addition to our present cases , all the cases of rhabdomyolysis that developed following laparoscopic renal surgery described in the literature . the rarity of this complication is underscored by review of several large series of laparoscopic nephrectomy for which no cases of rhabdomyolysis were described . the data from our series confirm previously stated risk factors : male sex , long operative time , and high body - mass index . the average length of surgery for all reported cases of rhabdomyolysis that we identified in the literature is 368.7 minutes . note should also be made of the fact that 9/28 ( 32% ) of the cases of postlaparoscopic renal surgery rhabdomyolysis occurred following laparoscopic donor nephrectomy . it may be that this population is particularly susceptible to this complication , as the operative times may be longer and the patients may tend to be younger and with increased muscle mass compared with these things in renal cancer patients . higher perfusion pressures or permissive hypertension may have provided improved perfusion to the dependent soft - tissue beds and may have helped to prevent the development of rhabdomyolysis . patient data from known cases of rhabdomyolysis following laparoscopic renal surgery mean based on 6 patients . na = not available ; ld = lateral decubitus ; mld = 45 lateral decubitus flexed w / kidney bar ; los = length of surgery ; ck = creatinine kinase ; a = alkalinization ; h = hydration ; d = diuretic ; hd = hemodialysis . another consideration in reviewing these data is table positioning and use of the kidney rest . various positions have been demonstrated to put surgical patients at particular risk for rhabdomyolysis , including the lithotomy position and the lateral decubitus position . three of the 4 patients in our series were placed in a 45-degree lateral decubitus position with a soft roll to support the upside hip and shoulder . additionally , we previously put the table in a slightly flexed position with the kidney bar raised . this modification likely produces more focused areas of pressure . after reviewing these cases , we changed our laparoscopic nephrectomy positioning . currently , we have been utilizing a rotated supine position in which the patient is placed supine on the table with a sandbag placed under the shoulder and back ipsilateral to the side of the planned nephrectomy . the patient is then secured to the table , and the entire table is rotated to achieve dependency of the abdominal contents to facilitate dissection . the one patient who developed rhabdomyolysis while in this position had the highest bmi and the shortest total operative time ( 3.5 hours ) , indicating that morbid obesity , even in the absence of an exaggerated position or prolonged operative time , may be the most significant risk factor for this devastating complication . the average bmi combining our series with others in the literature for patients who develop rhabdomyolysis is 33.2 . other authors have suggested that early lowering of the kidney rest may help prevent this complication . whether other devices such as vacuum  bean bags ,  gel cushioning pads , or intraoperative pressure monitoring devices would be helpful in reducing pressure - related muscle ischemia remains to be seen . all of our patients also exhibited induration and erythema of the skin overlying the dependent muscle bed . these findings in concert with lower back or lower extremity pain should suggest the possibility of impending rhabdomyolysis . investigation with serum creatinine kinase levels , urinalysis , microscopic evaluation , and urine myoglobin should confirm the diagnosis . brown or reddish discoloration of the urine , while common in this setting , would not seem to be a reliable predictor of rhabdomyolysis or impending renal failure , as 3/20 ( 15% ) of the patients did not exhibit this finding even though one of these 3 patients went on to develop renal failure . there was a tendency for the eventual development of acute renal failure in patients as peak creatinine kinase increased ( average peak ck for renal failure group , 46 7807200 vs 25 65015 100 for those who did not develop acute renal failure ) . presence of detectable levels of myoglobin in the urine as a predictor for renal failure could not be determined from these data . treatment recommendations for the prevention of renal complications from rhabdomyolysis generally include ample intravenous hydration to overcome hypovolemia and renal hypoperfusion ; bicarbonate infusion to alkalinize the urine and improve myoglobin solubility ; and induced diuresis to assist in flushing the myoglobin out of the renal tubules . diuresis is generally induced with either mannitol or furosemide , which has the potential disadvantage of causing acidification of the urine . despite the use of hydration , alkalinization and diuresis , more specific guidelines as rhabdomyolysis relates to patients with a solitary kidney might be helpful in determining the optimum methods for preventing renal failure . with regards to limiting neuromuscular impairments that result from rhabdomyolysis , unfortunately , no good therapies are available . many of these patients will need prolonged physical therapy and pain management to achieve a good functional outcome . rhabdomyolysis and subsequent renal failure are well - known complications of trauma , particularly in the setting of a crush injury . additionally , it has been reported to occur in the postoperative setting as a complication of general surgical , orthopedic , and urologic procedures performed with the patient in the lithotomy position . at our institution three of these nephrectomies were performed with the patient in a 45-degree flank position with the table in the flexed position and the kidney bar raised ; the last case was performed with the patient in a rotated supine position . our patients exhibited many of the risk factors that have been often proposed to contribute to the development of rhabdomyolysis : male sex , elevated bmi , prolonged or time , and procedure performed with the patient in the lateral decubitus or 45-degree lateral decubitus position . in reviewing the literature , we noted that all but 2 of the patients who developed rhabdomyolysis were male . additional risk factors that have been suggested include preexisting renal disease , extracellular volume depletion , and renal hypoperfusion . the earliest association of rhabdomyolysis and renal failure was described in 1941 . since that time , a better understanding of the risk factors and pathogenesis of this condition have been achieved . in relating it to surgical positioning , it should be considered as representing part of the spectrum of local changes that can occur to skin and underlying soft tissues due to prolonged fixed pressure on these areas . as a disease process , rhabdomyolysis presents 2 separate problems , namely the local effects of tissue injury and the systemic consequences that result from that injury . in rhabdomyolysis occurring in the surgical setting , the predominant initial contributing factor is thought to be the ischemia or partial ischemia that results from direct , prolonged pressure on the soft tissues and overlying skin . experiments by whitesides have suggested that tissue ischemia may begin to occur when tissue pressures approach to within 10 mm hg to 30 mm hg of the diastolic pressure . studies have shown that skeletal muscle tolerates this ischemia for as long as 2 hours , after which time ultrastructural ischemic changes begin to occur . as ischemia persists , these changes become more severe and are noted to be irreversible after about 7 hours . as the problems of pressure and time relate to laparoscopic renal surgery , it is clear why obesity , patient positioning , and operative time could play a role in the development of postsurgical rhabdomyolysis . in reviewing our reported cases and the literature , we would also question whether the additional insult of intraabdominal insufflation ( generally 12 mm hg to 15 mm hg ) might narrow what is already a small perfusion pressure window in our obese patients . when surgical procedures are terminated and the direct pressure on the soft tissue beds is relieved , a secondary pathogenic process occurs in rhabdomyolysis . ischemiareperfusion injury in association with resulting localized tissue edema can result in a continued low perfusion state in the local tissue bed in addition to producing a systemic hypovolemia as intravascular fluids are lost through local capillary beds . further systemic effects are known to occur as myocyte damage leads to liberation of myoglobin into circulation with the potential development of myoglobinuria and subsequent acute renal failure . these systemic effects can be particularly devastating in the setting of renal extirpative surgery where the relative renal hypoperfusion and large myoglobin load must be handled by a solitary renal unit . table 1 lists , in addition to our present cases , all the cases of rhabdomyolysis that developed following laparoscopic renal surgery described in the literature . the rarity of this complication is underscored by review of several large series of laparoscopic nephrectomy for which no cases of rhabdomyolysis were described . the data from our series confirm previously stated risk factors : male sex , long operative time , and high body - mass index . the average length of surgery for all reported cases of rhabdomyolysis that we identified in the literature is 368.7 minutes . note should also be made of the fact that 9/28 ( 32% ) of the cases of postlaparoscopic renal surgery rhabdomyolysis occurred following laparoscopic donor nephrectomy . it may be that this population is particularly susceptible to this complication , as the operative times may be longer and the patients may tend to be younger and with increased muscle mass compared with these things in renal cancer patients . higher perfusion pressures or permissive hypertension may have provided improved perfusion to the dependent soft - tissue beds and may have helped to prevent the development of rhabdomyolysis . patient data from known cases of rhabdomyolysis following laparoscopic renal surgery mean based on 6 patients . na = not available ; ld = lateral decubitus ; mld = 45 lateral decubitus flexed w / kidney bar ; los = length of surgery ; ck = creatinine kinase ; a = alkalinization ; h = hydration ; d = diuretic ; hd = hemodialysis . another consideration in reviewing these data is table positioning and use of the kidney rest . various positions have been demonstrated to put surgical patients at particular risk for rhabdomyolysis , including the lithotomy position and the lateral decubitus position . three of the 4 patients in our series were placed in a 45-degree lateral decubitus position with a soft roll to support the upside hip and shoulder . additionally , we previously put the table in a slightly flexed position with the kidney bar raised . this modification likely produces more focused areas of pressure . after reviewing these cases , we changed our laparoscopic nephrectomy positioning . currently , we have been utilizing a rotated supine position in which the patient is placed supine on the table with a sandbag placed under the shoulder and back ipsilateral to the side of the planned nephrectomy . the patient is then secured to the table , and the entire table is rotated to achieve dependency of the abdominal contents to facilitate dissection . the one patient who developed rhabdomyolysis while in this position had the highest bmi and the shortest total operative time ( 3.5 hours ) , indicating that morbid obesity , even in the absence of an exaggerated position or prolonged operative time , may be the most significant risk factor for this devastating complication . the average bmi combining our series with others in the literature for patients who develop rhabdomyolysis is 33.2 . other authors have suggested that early lowering of the kidney rest may help prevent this complication . whether other devices such as vacuum  bean bags ,  gel cushioning pads , or intraoperative pressure monitoring devices would be helpful in reducing pressure - related muscle ischemia remains to be seen . all of our patients also exhibited induration and erythema of the skin overlying the dependent muscle bed . these findings in concert with lower back or lower extremity pain should suggest the possibility of impending rhabdomyolysis . investigation with serum creatinine kinase levels , urinalysis , microscopic evaluation , and urine myoglobin should confirm the diagnosis . brown or reddish discoloration of the urine , while common in this setting , would not seem to be a reliable predictor of rhabdomyolysis or impending renal failure , as 3/20 ( 15% ) of the patients did not exhibit this finding even though one of these 3 patients went on to develop renal failure . there was a tendency for the eventual development of acute renal failure in patients as peak creatinine kinase increased ( average peak ck for renal failure group , 46 7807200 vs 25 65015 100 for those who did not develop acute renal failure ) . presence of detectable levels of myoglobin in the urine as a predictor for renal failure could not be determined from these data . treatment recommendations for the prevention of renal complications from rhabdomyolysis generally include ample intravenous hydration to overcome hypovolemia and renal hypoperfusion ; bicarbonate infusion to alkalinize the urine and improve myoglobin solubility ; and induced diuresis to assist in flushing the myoglobin out of the renal tubules . diuresis is generally induced with either mannitol or furosemide , which has the potential disadvantage of causing acidification of the urine . despite the use of hydration , alkalinization and diuresis , more specific guidelines as rhabdomyolysis relates to patients with a solitary kidney might be helpful in determining the optimum methods for preventing renal failure . with regards to limiting neuromuscular impairments that result from rhabdomyolysis , unfortunately , no good therapies are available . many of these patients will need prolonged physical therapy and pain management to achieve a good functional outcome . particular care to prevent this complication should be taken in patients with increased bmi and in those patients for whom a protracted operating room time is expected . whether laparoscopic donor nephrectomy patients are at particular risk for this procedure remains to be seen , but ensuring ample padding and minimizing positioning time are presumptively the best ways to prevent this complication . other considerations for preventing this complication include foregoing attempted laparoscopy in susceptible patients or early conversion to open nephrectomy in cases where progress is impeded . furthermore , decreasing the time during which the table is flexed and the kidney bar raised may further diminish the chances of a patient developing rhabdomyolysis . routine measurement of creatinine kinase and urine myoglobin levels in the recovery room for patients at high - risk of rhabdomyolysis may allow for the earlier detection of rhabdomyolysis , and , potentially a better outcome . . the next step would be to more thoroughly evaluate the precipitating events and primary risk factors for the development of rhabdomyolysis postoperatively . to that end , we are initiating a study at our institution to evaluate several intraoperative parameters that have been thought to play a role in the development of rhabdomyolysis . we hope that this will add to our understanding of the pathogenesis of this complication and ultimately its prevention .
background and objectives : laparoscopic renal surgery has become a widely applied technique in recent years . 
 the development of postoperative rhabdomyolysis is a known but rare complication of laparoscopic renal surgery . 
 herein , 4 cases of rhabdomyolysis and a review of the literature are presented with respect to pathogenesis , treatment , and prevention of this dire complication.methods:a retrospective review of over 600 laparoscopic renal operations over the past 8 years was performed . 
 all cases of postoperative rhabdomyolysis were identified . 
 a medline search was performed to find articles related to the development of postoperative rhabdomyolysis . 
 cases of rhabdomyolysis developing after laparoscopic renal surgery and common risk factors between cases were identified.results:the incidence of postoperative rhabdomyolysis in our series is 0.67% . 
 it is similar to the rate reported in other series . 
 male sex , high body mass index , prolonged operative times , and the lateral decubitus position are all risk factors in its development.conclusion:the prevention and optimal management of postoperative rhabdomyolysis following laparoscopic renal surgery has yet to be defined . 
 the risk factors we identified should be carefully addressed and minimized . 
 a better understanding of the pathogenesis of rhabdomyolysis will also be a key component in its prevention .