Comparison of Hand Assisted and Standard Laparoscopic Radical Nephroureterectomy for the Management of Localized Transitional Cell Carcinoma

Surgical outcome predictor analysis following hand-assisted or pure laparoscopic transperitoneal nephroureterectomy using the Taiwan upper urinary tract urothelial carcinoma database

Purpose

Taiwan has a high incidence of upper tract urothelial carcinoma (UTUC). This study aimed to compare the surgical outcomes following transperitoneal hand-assisted laparoscopic nephroureterectomy (TP-HALNU) and transperitoneal pure laparoscopic nephroureterectomy (TP-LNU) from the Taiwan nationwide UTUC collaboration database using different parameters, including surgical volumes.

Materials and methods

The nationwide UTUC collaboration database includes 14 hospitals in Taiwan from the Taiwan Cancer Registry. We retrospectively reviewed the records of 622 patients who underwent laparoscopic nephroureterectomy between July 1988 and September 2020. In total, 322 patients who received TP-LNU or TP-HALNU were included in the final analysis. Clinical and pathological data and oncological outcomes were compared.

Results

Of the 322 patients, 181 and 141 received TP-LNU and TP-HALNU, respectively. There were no differences in clinical and histopathological data between the two groups. No differences were observed in perioperative and postoperative complications. There were no significant differences in oncological outcomes between the two surgical approaches. In the multivariate analysis, the cohort showed that age ≥70 years, positive pathological lymph node metastasis, tumors located in the upper ureter, and male sex were predictive factors associated with an increased risk of adverse oncological outcomes. A surgical volume of ≥20 cases showed a trend toward favorable outcomes on cancer-specific survival [hazard ratio (HR) 0.154, p = 0.052] and marginal benefit for overall survival (HR 0.326, p = 0.019) in the multivariate analysis.

Conclusion

Although different approaches to transperitoneal laparoscopic nephroureterectomy showed no significant differences in surgical outcomes, age, sex, lymph node metastasis, and tumor in the upper ureter in the following period were predictive factors for oncological outcomes. Higher surgical volume did not impact disease-free survival and bladder recurrence-free survival but was associated with improved overall survival and cancer-specific survival. Exploration of unknown influencing factors is warranted.

Comparison of oncological outcomes for hand-assisted and pure laparoscopic radical nephroureterectomy: results from the Taiwan Upper Tract Urothelial Cancer Collaboration Group

PURPOSE

Laparoscopic radical nephroureterectomy (LNU) has gradually become the new standard treatment for localized upper tract urothelial cancer (UTUC). With more blunt dissection and tactile sensation, hand-assisted LNU might shorten the operative time compared with the pure laparoscopic approach. However, whether the use of the hand-assisted or the pure laparoscopic approach has an effect on oncological outcomes remains unclear.

METHODS

We retrospectively identified 629 patients with non-metastatic UTUC who underwent hand-assisted (n = 515) or pure LNU (n = 114) at 9 hospitals in Taiwan between 2004 and 2019. Overall survival, cancer-specific survival, recurrence-free survival, and bladder recurrence-free survival were compared between these two groups using inverse-probability of treatment weighting (IPTW) derived from the propensity scores for baseline covariate adjustment.

RESULTS

The median follow-up period was 32.9 and 28.7 months in the hand-assisted and the pure groups, respectively. IPTW-adjusted Cox proportional hazards models showed that the laparoscopic approach (pure vs. hand-assisted) was not significantly associated with all-cause mortality (HR 0.79, 95% CI 0.49-1.24, p = 0.304), cancer-specific mortality (HR 0.88, 95% CI 0.51-1.51, p = 0.634), or extra-vesical recurrence (HR 0.65, 95% CI 0.41-1.04, p = 0.071). However, the pure laparoscopic approach was significantly associated with lower intra-vescial recurrence (HR 0.64, 95% CI 0.43-0.96, p = 0.029) for patients who underwent LNU. Kaplan-Meier curves also revealed that the pure laparoscopic approach was associated with better bladder recurrence-free survival compared with the hand-assisted laparoscopic approach in both the original cohort and the IPTW-adjusted cohort (log-rank p = 0.042 and 0.027, respectively).

CONCLUSIONS

The performance of hand-assisted or pure LNU does not significantly affect the all-cause mortality, cancer-specific mortality, or extra-vesical recurrence for patients with non-metastatic UTUC. However, the hand-assisted laparoscopic approach could increase the risk of intra-vesical recurrence for patients who undergo LNU.

Distal Ureter Management During Nephroureterectomy: Evidence from a Systematic Review and Cumulative Analysis

INTRODUCTION AND OBJECTIVES

Standard of care in upper tract urothelial cancer is nephroureterectomy with bladder cuff excision (BCE). However, alternative techniques such as transurethral incision/resection have been used to simplify distal ureterectomy. The optimum strategy is unclear, and current guidelines do not specify a gold standard technique. The objective of this study was to perform a systematic review of the literature, to compare BCE and transurethral distal ureter methods.

MATERIALS AND METHODS

A Cochrane and PRISMA-guided systematic literature search was conducted on English language articles from January 2000 to present, reporting on centers' experience with either BCE or transurethral distal ureterectomy. A cumulative meta-analysis comparison between the two procedures was performed. Primary outcome was intravesical recurrence. Secondary outcomes were local/distant recurrence, surgical margins, and disease-specific mortality (DSM). Groups were compared using chi-square analysis.

RESULTS

In total, 66 studies were included after excluding 1795. BCE and transurethral groups contained 6130 and 1183 patients, respectively. Mean/median age ranged from 57.5 to 75.2 years, and follow-up from 6.1 to 78 months. Level of evidence was low, with high risk of bias and small sample size (<100 patients) in 41 (62%) and 52 (79%) studies, respectively. Baseline cancer demographic analysis identified significantly higher rates of high grade, advanced stage, node-positive and carcinoma in situ disease in the BCE group. However, intravesical recurrence (23.6% vs 28.7%, p = 0.0002) and local/distant recurrence (17.9% vs 21.6%, p = 0.02) were significantly lower than the transurethral group. No difference was seen regarding surgical margins (3.1% vs 2.4%, p = 0.27) or DSM (16.8% vs 14.3%, p = 0.06).

CONCLUSIONS

No prospective, randomized comparisons exist for distal ureterectomy at nephroureterectomy. In this analysis, patients undergoing BCE had more advanced disease burden compared with the transurethral group. Despite this, the BCE group had statistically lower intravesical and local/distant recurrence. Further prospective research should be encouraged to identify gold standard ureter management.

Robot-Assisted Laparoscopic Nephroureterectomy versus Hand-Assisted Laparoscopic Nephroureterectomy for Upper Urinary Tract Urothelial Carcinoma: A Matched Comparison Study

Objectives. To investigate the perioperative and oncological outcomes of hand-assisted laparoscopic nephroureterectomy (HANU) and robotic-assisted nephroureterectomy (RANU). Methods. Patients who underwent RANU were matched by sex, age (±5 years), and tumor location to those who underwent HANU; 18 matched pairs were included. Results. Each group consisted of five men and 13 women. The mean age was 70.4 years in RANU group and 69.6 years in HANU group (p = 0.646). Each group contained 10 patients with tumor location in the renal pelvis, five in the ureter, and three in both sites. The median follow-up time was 6.1 months for the RANU group and 47.8 months for the HANU group. The demographic and pathological data did not differ significantly. The RANU group had significantly less blood loss (p < 0.001), resumed oral intake earlier (p = 0.043), and had shorter hospital stays (p = 0.014) but higher pain scores associated with their wounds (p = 0.043). The oncological outcomes were comparable with those of the HANU group. Conclusions. Our results show that the RANU and HANU groups have comparable operative, early postoperative, and functional outcomes. A longer follow-up period would be needed for final comparison of oncological outcome.

Upper tract urothelial carcinoma: current treatment and outcomes

The reference standard treatment of upper tract urothelial carcinoma is open radical nephroureterectomy. Many centers have advocated less-invasive treatment modalities. We reviewed contemporary treatments of upper tract urothelial carcinoma and their outcomes. A MEDLINE search was conducted for all relevant published data during the past 15 years. Endoscopic management is feasible for low-grade disease with strict surveillance protocols. Radical nephroureterectomy remains the reference standard for upper tract urothelial carcinoma. The intermediate-term oncologic outcomes are similar between the laparoscopic and open approaches. Controversies still exist regarding the optimal management of the distal ureter, the utility of topical therapy, and the role of lymphadenectomy.

Surgical management for upper urinary tract transitional cell carcinoma

BACKGROUND

Upper tract transitional cell carcinomas (TCC) are uncommon and aggressive tumours. There are a number of surgical approaches to manage this condition including open radical nephroureterectomy and laparoscopic procedures.

OBJECTIVES

To determine the best surgical management option for upper tract transitional cell carcinoma.

SEARCH STRATEGY

A sensitive search strategy was developed to identify relevant studies for inclusion in this review. The following databases were searched for randomised trials evaluating surgical approaches to the management of upper tract TCC: Medline EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, British Nursing Index, AMED, LILACS, Web of Science®, Scopus, Biosis, TRIP, Biomed Central, Dissertation Abstracts, and ISI Proceedings.

SELECTION CRITERIA

The following criteria that were considered for this review.Types of studies - All randomised or quasi-randomised controlled trials comparing the various surgical methods and approaches for the management of localised upper tract transitional cell carcinoma. Types of participants - All adult patients with localised transitional cell carcinoma. Localised disease was defined as limited to the kidney or ureter with no gross regional lymph nodal enlargement on imaging. Types of interventions - Any surgical method or approach for managing localised upper tract transitional cell carcinoma. Types of outcome measures - Overall and cancer-specific survival were primary outcomes. Surgery-related morbidity. Quality of life and health economics outcomes were secondary outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors examined the search results independently to identify trials for inclusion.

MAIN RESULTS

We identified one randomised controlled trial that met our inclusion criteria. The trial showed that the laparoscopic approach had superior peri-operative outcomes compared to open approach. Laparoscopic was superior and statistically significant for blood loss (104 mL (millilitres) versus 430 mL, P < 0.001) and mean time to discharge (2.3 days versus 3.7, P < 0.001). Oncological outcomes (bladder tumour-free survival, metastasis-free survival, cancer-specific survival curves), at a median follow up of 44 months and in organ-confined disease, were comparable for both groups.

AUTHORS' CONCLUSIONS

There is no high quality evidence available from adequately controlled trials to determine the best surgical management of upper tract transitional cell carcinoma. However, one small randomised trial and observational data suggests that laparoscopic approach is associated with less blood loss and early recovery from surgery with similar cancer outcomes when compared to open approach.

Consequences of peritoneal tears during hand-assisted retroperitoneoscopic nephroureterectomy

OBJECTIVE

To evaluate the possible effects of peritoneal tears during hand-assisted retroperitoneoscopic nephroureterectomy (HARN).

MATERIALS AND METHODS

Between October 2003 and June 2008, HARN and open bladder cuff excision were performed in 110 patients, 20 of whom had peritoneal tears during the operation. Our policy is not to close the peritoneal defect. We compared the intraoperative and postoperative criteria among the peritoneum-preserved or peritoneum-violated group to evaluate the impacts of peritoneal tears during and after HARN.

RESULTS

All procedures were successful except 2 open conversions in cases without peritoneal tears because of vascular injuries. There was no significant difference in age, American Society of Anesthesiologists class, or body mass index between the 2 groups. Both groups were similar in terms of total operative time (166 vs 137 minutes, P = .06), estimated blood loss (196 vs 268 mL, P = .51), hospital stay (9.1 vs 12.1 days, P = .41), and postoperative analgesia requirements (28.6 vs 28.5 mg morphine equivalent, P = .51). Compared with the peritoneum-preserved group, peritoneal violation during HARN was associated with a heavier specimen weight (308 vs 193 g, P = .01), and 1 patient in the violation group developed small bowel obstruction 3 weeks after the surgery.

CONCLUSIONS

Most peritoneal tears during HARN may be safely managed without peritoneal closure. Bowel obstruction from internal herniation is rare but is too significant to be ignored. To prevent this morbidity, peritoneal tears of a selected size need either repair or enlargement.

Treatment of upper urinary tract urothelial carcinoma

Upper urinary tract urothelial carcinoma (UUTUC) is relatively rare, occurring in only 5% of all urothelial cancers. It has not been as extensively studied and reviewed as carcinoma of the bladder. UUTUC has a propensity for multifocality, local recurrence, and development of metastases, which argues for an aggressive treatment approach. Open radical nephroureterectomy (ORNU) with removal of an ipsilateral bladder cuff still remains the gold standard treatment for patients with UUTUC and a normal contralateral kidney, which, however, is being challenged by minimally invasive approaches, such as endoscopic and laparoscopic approaches. They are rapidly evolving as reasonable alternatives of care depending on grade and stage of disease. Adjuvant therapy seems to be safe, although its efficacy is debatable. Immunotherapy appears to be most effective in patients with upper-tract carcinoma in situ. Chemotherapy and radiotherapy also show some improvement in recurrence rates, but there have been no randomized, prospective trials. Gene and molecular-targeted therapy is expected. Several controversies remain in our management, including a selection of endoscopic versus laparoscopic approaches, management strategies on the distal ureter, the role of lymphadenectomy, and the value of immunotherapy, chemotherapy, radiotherapy and genetics and molecular markers in UUTUC. Aims of this paper are to critically review the treatment of UUTUC.

Intermediate-term oncological outcomes of hand-assisted laparoscopic versus open bilateral nephroureterectomy for dialysis and kidney transplant patients with upper urinary tract urothelial carcinoma

PURPOSE

To compare the outcomes of hand-assisted laparoscopic bilateral nephroureterectomy (HALBNU) for dialysis and kidney transplant patients with clinically localized upper urinary tract urothelial carcinoma (UUT-UC) with those achieved by open bilateral nephroureterectomy (OBNU).

MATERIALS AND METHODS

Between 1995 and 2006, 49 patients under dialysis or after kidney transplantation underwent simultaneous bilateral nephroureterectomy for clinically presumed localized UUT-UC at our institute. Of those, 33 underwent HALBNU and 16 received conventional open surgery. Perioperative and pathological data and oncological outcomes were collected by chart review. Bladder recurrence, metastasis, and cancer-specific and overall survival were analyzed and compared between both groups.

RESULTS

The median follow-up for HALBNU and OBNU group was 35 and 46 months, respectively. Totally, 40 patients were identified to have pathologically confirmed urothelial carcinoma of upper urinary tract. HALBNU group was associated with less blood loss, earlier bowel recovery, less narcotic use, shorter hospital stay, and earlier convalescence. The operative time and complication rate were comparable between the two groups. There was no open conversion in the HALBNU group. The two groups were similar in regard to bladder recurrence rate. The overall, cancer-specific, and bladder-recurrence-free survival were also equivalent between the HALBNU and OBNU group (all p > 0.05).

CONCLUSION

In dialysis and kidney transplant patients with localized UUT-UC, simultaneous bilateral nephroureterectomy with hand-assisted laparoscopic approach offered less perioperative morbidity and, most importantly, comparable intermediate-term oncological and survival results when compared with its open counterpart. A longer follow-up is required to demonstrate the oncological efficacy of this minimally invasive procedure.

Laparoscopic nephroureterectomy and management of the distal ureter: a review of current techniques and outcomes

Laparoscopic nephroureterectomy (LNU) is becoming an increasingly common alternative treatment for transitional cell carcinoma (TCC) of the renal pelvis and ureter due to decreased perioperative morbidity, shorter hospitalization, and comparable oncologic control with open nephroureterectomy (ONU). Mobilization of the kidney and proximal ureter may be performed through a transperitoneal, retroperitoneal, or hand-assisted approach. Each technique is associated with its own benefits and limitations, and the optimal approach is often dictated by surgeon preference. Our analysis of the literature reflects equivalent cancer control between LPN and OPN at intermediate follow-up with significantly improved perioperative morbidity following LPN. Several methods for bladder cuff excision have been advocated, however, no individual technique for management of the distal ureter proved superior. Overall, complete en-bloc resection with minimal disruption of the urinary tract should be optimized to maintain oncologic outcomes. Longer follow-up and prospective studies are needed to fully evaluate these techniques.

Comprehensive management of upper tract urothelial carcinoma

Urothelial carcinoma of the upper urinary tract represents only 5% of all urothelial cancers. The 5-year cancer-specific survival in the United States is roughly 75% with grade and stage being the most powerful predictors of survival. Nephroureterectomy with excision of the ipsilateral ureteral orifice and bladder cuff en bloc remains the gold standard treatment of the upper urinary tract urothelial cancers, while endoscopic and laparoscopic approaches are rapidly evolving as reasonable alternatives of care depending on grade and stage of disease. Several controversies remain in their management, including a selection of endoscopic versus laparoscopic approaches, management strategies on the distal ureter, the role of lymphadenectomy, and the value of chemotherapy in upper tract disease. Aims of this paper are to critically review the management of such tumors, including endoscopic management, laparoscopic nephroureterectomy and management of the distal ureter, the role of lymphadenectomy, and the emerging role of chemotherapy in their treatment.

Transitional cell carcinomas of the renal pelvis and the ureter: comparative demographic characteristics, pathological grade and stage and 5-year survival in a Taiwanese population

OBJECTIVE

To compare the predictive value for 5-year survival of demographic characteristics, pathological grade and stage between upper tract urothelial carcinoma (UTUC) of the renal pelvis (RPUC) and ureter (UUC) in a Taiwanese population.

PATIENTS AND METHODS

In this study (1986-98) we analysed 141 patients with UTUC, including 71 with RPUC and 70 with UUC (median age 59 years; median follow-up 54 months, SD 2.5). Prognostic indicators were examined by univariate and multivariate logistic regression analyses.

RESULTS

A significant percentage of patients had tumour on the right side and a high proportion of those with UUC were women. Gross haematuria and hypertension were the most common symptoms of RPUC. The sensitivity of intravenous pyelography in diagnosing RPUC and UUC was 49% (34/69) and 36% (25/70), respectively. However, in patients assessed by retrograde pyelography the diagnostic sensitivity was 85% (60/71) for RPUC and 89% (55/62) for UUC. The incidence of tumour recurrence after nephroureterectomy with bladder cuff excision was significantly higher in those with UUC (13%) than RPUC (3.6%). Distant metastasis was detected in 37 of 141 (26%) patients, the most common sites being bone (46%), lung (22%), liver (14%) and colon (8%). Univariate logistic regression analysis showed significant differences in the prognosis for high-grade and high-stage tumours. The prognosis was particularly poor in patients aged >60 years. According to the multivariate logistic regression analysis, tumour stage and grade were the best outcome predictors for RPUC, but stage and age were the best outcome predictors for UUC.

CONCLUSION

UUC is more common in women and has a more aggressive clinical outcome than RPUC after nephroureterectomy with bladder cuff incision. Tumour stage and grade are the best predictors of survival in patients with RPUC. Also, in patients with UUC the prognosis is poor in older patients and those with advanced stages of cancer.

Urothelial carcinoma of the upper urinary tract: surgical approach and prognostic factors

OBJECTIVES

Open radical nephroureterectomy (O-RNU) has been the gold standard for the treatment of upper urinary tract urothelial carcinoma (UUT-UC) for decades. With the advances in laparoscopic techniques and endourologic procedures, this concept has been increasingly challenged. Oncologic outcome prediction is mainly based on stage and grade. With progress in medical treatment, adjuvant therapies may gain importance in the future. This review assesses the values of the variety of available treatments as well as prognostic factors that may become relevant regarding patient selection for future adjuvant treatment trials.

METHODS

We performed a systematic literature research using MEDLINE with emphasis on open surgical, laparoscopic, and endourologic (ureteroscopic or percutaneous) techniques and prognostic contents.

RESULTS

Overall, no evidence level 1 information from prospective randomised trials is available for treatment of UUT-UC. Laparoscopic radical nephroureterectomy (L-RNU) is increasingly challenging open surgery. Currently, L-RNU should be reserved for low-stage, low-grade tumours. Ureteroscopy and percutaneous nephron-sparing techniques show favourable survival data but high local recurrence rates. Regarding prognosis, estimation of outcome still relies mainly on stage and grade because no additional parameters have been introduced in a routine clinical setting.

CONCLUSIONS

O-RNU still represents the gold standard for the treatment of UUT-UC. The laparoscopic approach is not yet standard of care and should be reserved for low-stage, low-grade tumours. Endourologic nephron-sparing treatments are still experimental in elective indications due to high local recurrence rates. For prognosis, no parameters in addition to stage and grade have been standardised.

Management of patients with upper urinary tract transitional cell carcinoma

Multiple therapeutic options are available for the management of patients with upper urinary tract transitional cell carcinoma (TCC). Radical nephroureterectomy with an ipsilateral bladder cuff is the gold-standard therapy for upper-tract cancers. However, less invasive alternatives have a role in the treatment of this disease. Endoscopic management of upper-tract TCC is a reasonable strategy for patients with anatomic or functional solitary kidneys, bilateral upper-tract TCC, baseline renal insufficiency, and significant comorbid diseases. Select patients with a normal contralateral kidney who have small, low-grade lesions might also be candidates for endoscopic ablation. Distal ureterectomy is an option for patients with high-grade, invasive, or bulky tumors of the distal ureter not amenable to endoscopic management. In appropriately selected patients, outcomes following distal ureterectomy are similar to that of radical nephroureterectomy. Bladder cancer is a common occurrence following the management of upper-tract TCC. Currently, there are no variables that consistently predict which patients will develop intravesical recurrences. As such, surveillance with cystoscopy and cytology following surgical management of upper-tract TCC is essential. Extrapolating from data on bladder TCC, both regional lymphadenectomy and neoadjuvant chemotherapy regimens are likely to be beneficial for patients with upper-tract TCC, particularly in the setting of bulky disease.

Intermediate follow-up of hand-assisted retroperitoneoscopic nephroureterectomy for management of upper urinary tract urothelial carcinoma: comparison with open nephroureterectomy

OBJECTIVES

To evaluate the oncologic outcomes of hand-assisted retroperitoneoscopic nephroureterectomy (HARNU) for upper urinary tract urothelial carcinoma and compare them with the data from conventional open surgery.

METHODS

We collected the data from 25 patients who underwent HARNU at our institution from January 1999 to December 2003 for upper urinary tract urothelial carcinoma. The clinical data were collected retrospectively by reviewing the medical records. The convalescence results and oncologic outcomes were analyzed and compared with the corresponding data from 41 contemporary conventional open nephroureterectomy (ONU) procedures.

RESULTS

The median follow-up period in the HARNU group was 32 months (range 21 to 43) and was 62 months (range 8 to 88) in the ONU group. Patient age, sex, body mass index, tumor size, specimen weight, and American Society of Anesthesiologists classification showed no significant differences between the two groups. The HARNU group required a longer operation time (252 versus 212 minutes; P = 0.02). Significantly less blood loss (212 versus 408 mL; P = 0.03) was noted in the HARNU group. The complication rates between the HARNU group and ONU group were similar (12% and 7.3%, respectively, P = 0.67). No open conversion was required in the HARNU group. The average hospital stay, days to oral intake, days to ambulation, and dose of parenteral narcotic analgesics were significantly less in the HARNU group. No significant differences were found in the 3-year bladder recurrence-free survival rate, cancer-specific survival rate, or overall survival rate between the two groups.

CONCLUSIONS

The results of our study have shown that HARNU, with an open method for the removal of the distal ureter and bladder cuff, is a less-invasive technique and provides comparable oncologic outcomes as ONU for upper urinary tract urothelial carcinoma.

Long-Term Outcome of Hand-Assisted Laparoscopic Radical Nephroureterectomy for Upper-Tract Urothelial Carcinoma: Comparison with Open Surgery

PURPOSE

To evaluate the efficacy and long-term outcome of hand-assisted laparoscopic radical nephroureterectomy (HALNU) in treating upper urinary-tract transitional-cell carcinoma (UT-TCC).

PATIENTS AND METHODS

We analyzed the data from 39 patients who underwent HALNU in our institution between January 1999 and December 2002 for urothelial carcinoma of the ureter or kidney. Preoperative and perioperative data were collected retrospectively by reviewing medical records. The oncologic outcomes, including bladder recurrence-free survival, cancer-specific survival, and overall survival, were compared with those of 36 contemporary patients undergoing conventional open radical nephroureterectomy (ONU). The median follow-up was 48 months (range 6 2 months) in the HALNU group and 59.5 months in the ONU group (range 8 8 months). Patients ages, sex, body mass index, pathologic parameters, and American Society of Anesthesiologists (ASA) classification showed no significant difference between the groups.

RESULTS

The HALNU group had statistically less blood loss (183 mL v 422 mL; P = 0.02). The average hospital stay and dose of narcotic analgesics were significantly less in the HALNU group. The complication rates were similar (12.8% for HALNU and 8.3% for ONU; P = 0.53). The 5-year bladder recurrence-free survival, cancer-specific survival, and overall survival were similar in the two groups.

CONCLUSIONS

The HALNU is a less-invasive technique with 5-year bladder recurrence-free survival, cancer-specific survival, and overall survival rates similar to those of ONU for patients with UT-TCC.

Oncologic Control After Open or Laparoscopic Nephroureterectomy for Upper Urinary Tract Transitional Cell Carcinoma: A Single Center Experience

OBJECTIVES

To determine the surgical and oncologic outcomes in patients who underwent either open nephroureterectomy (ONU) or laparoscopic nephroureterectomy (LNU) for upper urinary tract transitional cell carcinoma.

METHODS

We performed a retrospective review of data for patients who underwent ONU or LNU for upper urinary tract transitional cell carcinoma from 1994 to 2004 at one institution. The recorded data included sex, age, mode of diagnosis, smoking, history of bladder cancer, type of surgery, complications, tumor site, tumor size, tumor stage, tumor grade, length of hospital stay, recurrence, and progression. We also determined the recurrence and survival rates.

RESULTS

We reviewed the data for 46 patients. The median age was 70 years. Seven patients had a history of bladder cancer. Overall, 26 patients underwent ONU and 20 LNU. No differences in the complication rate (15% versus 15%) were observed. The median hospital stay was 4 days (range 3 to 6) after LNU and 9 (range 7 to 12) after ONU (P <0.001). The tumor stage and grade were independent prognostic factors for survival on multivariate analysis (P <0.05). The 5-year disease-specific survival rate was 89.4% for low-grade tumors and 63.1% for high-grade tumors (P = 0.04). ONU was associated with high-grade (P = 0.02) or invasive (P = 0.001) tumors. The 5-year tumor-free survival rate after ONU and LNU was 51.2% and 71.6%, respectively (P = 0.59).

CONCLUSIONS

LNU does not affect the mid-term oncologic control and enables a shorter hospital stay. It can be recommended as an alternative to ONU in the management of low-risk upper urinary tract transitional cell carcinoma (Stage T1-T2 and/or low-grade disease). However, long-term follow-up is necessary to recommend it for highly invasive tumors (Stage T3-T4 or N+).

A modified supine position to speed hand assisted retroperitoneoscopic nephroureterectomy: the Johnnie Walker position

PURPOSE

To minimize the operative time of hand assisted retroperitoneoscopic nephroureterectomy by avoiding position change we report an especially designed surgical position.

MATERIALS AND METHODS

A total of 41 patients with upper tract transitional cell carcinoma who underwent hand assisted retroperitoneoscopic nephroureterectomy and bladder cuff resection were enrolled. Patients lay supine, and the flank and hip on the lesion side were elevated 30 degrees. The legs were extended and abducted in the Johnnie Walker position, allowing the operator to stand between them. Operation was completed via a 7 to 8 cm Gibson incision and 2 additional laparoscopic ports.

RESULTS

All procedures were successful except 1 open conversion due to bleeding, in which there was no need to reposition the patient. Average patient age was 65.2 years (range 34 to 85), mean operative time was 207.6 minutes (range 130 to 345) and mean estimated blood loss was 166 ml (range 50 to 900). Simultaneous transurethral endoscopic procedures were performed in 11 patients in the same position. Time to oral intake and ambulation was 2.1 and 2.0 days, respectively. Two patients had postoperative complications, including pneumonia and wound hematoma in 1 each. No complication was related to the position.

CONCLUSIONS

The Johnnie Walker position minimizes operative time by eliminating the delay caused by patient positioning and draping changes, allowing better coordination for the surgeon and assistant, and permitting more efficient use of the nondominant hand. The retroperitoneal approach prevents bowel interference in the visual field, making laparoscopic surgery in this modified supine position possible. Nephroureterectomy, bladder cuff resection and endoscopic procedures can be done with ease with the patient in this position.

Conventional and Hand-Assisted Laparoscopic Radical Nephrectomy: Comparative Analysis of 271 Cases

PURPOSE

To compare the outcomes of patients undergoing conventional laparoscopic radical nephrectomy (CLRN) and hand-assisted laparoscopic radical nephrectomy (HALRN) at our institution.

PATIENTS AND METHODS

We prospectively and retrospectively reviewed the files of consecutive patients who underwent HALRN (N = 158 patients) from April 2001 to May 2005 and CLRN (N = 113) from August 2002 to May 2005 for clinical stage T(1-3)N(0-1)M(0-1) renal-cell carcinoma. Clinical and perioperative variables of the two groups were compared. Patients were well matched with regard to baseline parameters except that patients undergoing CLRN were 8 years older (P < 0.001) and had higher American Society of Anesthesiologists scores (P = 0.001).

RESULTS

Significantly different outcomes were faster operative time (P < 0.001), greater use of narcotic analgesia (P < 0.001), and longer hospitalization (P < 0.001) with HALRN. For the other variables analyzed, including blood loss, incision size, and complication rates, the two approaches were not significantly different.

CONCLUSIONS

Within the limitations of a retrospective study, HALRN was a faster operation than CLRN but was associated with greater use of narcotic analgesia and longer hospitalization. Overall, the similarities between these two approaches outnumber the differences, some of which may be explained by surgeon-specific practices. Both modalities offer patients excellent immediate cancer control while minimizing perioperative morbidity.

[Hand-assisted laparoscopic nephrectomy]

INTRODUCTION AND OBJECTIVES

To present the number of cases of hand-assisted laparoscopic nephrectomy. This study evaluates our results and difficulties of starting a progresive programme of laparoscopy.

MATERIAL AND METHOD

Between november 2003 and november 2005, 35 hand-assisted laparoscopic nephrectomies were carried out, of a total of 45 laparoscopic nephrectomies. 22 radical nephrectomies, 3 simple nephrectomies and 10 nephroureterectomies. The average age of patients was 66 years (47-89). On average, they were overweight (IMC 28,3), with approximately 38% being obese. ASA 2.3 (1-4). The tumors measured 4.8cm on average, and 80% of these were T1. In 28.6% of the cases, they had previously undergone abdominal surgery.

RESULTS

One was undertaken in 2003, 17 in 2004, and 17 in 2005. The surgery time was 140 minutes, 130 minutes (80-210) in radical nephrectomies, 135 minutes (120-150) in simple nephrectomies and 163 minutes (80-240) in the nephroureterectomy. Patients began an oral diet 1.7 days later, and were able to get up 1.7 days later. In the case of obese patients, they began an oral diet 2.3 days later and were able to get up (2.4 days) later than those non obese cases. (1.5 and 1.4 days respectively). The average stay has been 5.8 days (3-15). The average stay of the cases without complications was 4.2 days and those that encountered complications 9.7 days. In no cases was there a need for a blood transfusion. In 11.4% we had major complications with an average stay of 11.7 days. In 5.7% of cases there were reconversions, and 5.7% of cases were reoperated. 17.1% had minor complications, with an average stay of 8.8 days

CONCLUSIONS

The advantage of hand-assisted nephrectomy is that it allows one to begin a laparoscopy, with a reduced learning time, and with satisfactory results, allowing the incorporation of laparoscopy surgery in hospitals with a reduced annual volume.

Meta-analysis of the complications of laparoscopic renal surgery: comparison of procedures and techniques

PURPOSE

We performed a meta-analysis of the literature to define the current expectations of complications during laparoscopic renal surgery.

MATERIALS AND METHODS

References were searched in the MEDLINE database from 1995 to 2004 using the terms complications and laparoscopic nephrectomy. Inclusion criteria were any series with greater than 20 cases, patient age older than 16 years and any complications listed for certain procedures, including laparoscopic radical nephrectomy, HA laparoscopic radical nephrectomy, LPN, HALPN, laparoscopic donor nephrectomy, HA laparoscopic donor nephrectomy, laparoscopic simple nephrectomy, laparoscopic nephroureterectomy and retroperitoneal laparoscopic nephrectomy. A data extraction form was created to categorize major or minor complications. A 5 member panel adhered to the strict criteria and extracted data from articles that met inclusion criteria. Data were entered into a spreadsheet and a meta-analysis was performed.

RESULTS

Initial review identified 73 of 405 references that were acceptable for retrieval and data extraction, of which 56 met inclusion criteria. The overall major and minor complication rates of laparoscopic renal surgery were 9.5% and 1.9%, respectively. There was a significant difference between the major complication rates of LPN and HALPN (21.0% vs 3.3%, p <0.05).

CONCLUSIONS

Our results show that patients who undergo laparoscopic renal surgery may have an overall major complication rate of 9.5%. The highest major complication rate is associated with technically challenging LPN (21%). There appears to be a significantly higher wound complication rate associated with HA surgery in comparison to that of standard laparoscopy (1.9% vs 0.2%, p <0.05).

Survey of urological laparoscopic practice patterns in the midwest

PURPOSE

Laparoscopic surgery is assuming a greater role in the management of many urological disorders. We performed a survey of urologists in the Midwest United States to define laparoscopic practice patterns regarding urological disease.

MATERIALS AND METHODS

Surveys were mailed to 1,450 members of the North Central Section of the American Urological Association. Questions pertained to age, practice demographics, residency training and amount of laparoscopy performed.

RESULTS

A response rate of 33% was obtained. A total of 49% of urologists perform no laparoscopy, 30% devote less than 5% of their practice and 21% devote 5% or more of their practice to laparoscopy. Of the responders 15% believed they were adequately trained during residency to perform laparoscopy. Among those who performed hand assisted laparoscopy (HAL), 52% used it to gain familiarity with laparoscopic techniques. There was an inverse correlation between time in practice and amount of laparoscopy performed (p <0.0001). Urologists in academia perform laparoscopy at a greater proportion versus those in private practice (p <0.01). Urologists who incorporated laparoscopy during fellowship performed the most laparoscopy (p = 0.003). Those who considered themselves adequately trained during residency were more likely to perform laparoscopy (p <0.0001). Urologists who perform HAL devote more of their operating time to laparoscopy than those who do not (p <0.0001). The number of laparoscopic cases performed correlated with decreased time in practice (p <0.0001), academic setting (p = 0.001) and use of HAL (p <0.0001).

CONCLUSIONS

Urological laparoscopic surgery remains at an early stage of development in the Midwestern United States. Although HAL has widened the scope of laparoscopy among urologists, increased training for urologists and residents is necessary.

Hand-assisted laparoscopic nephroureterectomy: Analysis of distal ureterectomy technique, margin status, and surgical outcomes

OBJECTIVES

To review our experience with various techniques used to manage the distal ureter during hand-assisted laparoscopic nephroureterectomy and to evaluate the surgical outcomes, including pathologic margin status and the incidence of disease recurrence.

METHODS

We retrospectively analyzed 55 hand-assisted laparoscopic nephroureterectomies performed to treat transitional cell carcinoma (TCC), with the distal ureter managed as follows: cystoscopic disarticulation in 16 patients, stapled division in 7, open distal ureterectomy in 3, and hand-assisted laparoscopic extravesical en bloc distal ureterectomy with bladder cuff in 29. The cystotomy was not closed in 7 patients.

RESULTS

The coexistence of renal pelvic and ureteral tumors was common but in 27% of cases was not recognized preoperatively. One outer and four distal ureteral margins were positive for tumor (n = 2) or carcinoma in situ (n = 3). Two (29%) of the seven cystotomies that were not closed and only 1 (2%) of the 42 that were closed demonstrated extravasation. The operative time was 60 to 90 minutes longer and the estimated blood loss, open conversion rate, and indwelling catheterization time were two to three times greater for the cystoscopic ureteral disarticulation cohort. The stapled division cohort had a greater positive margin rate (29%) than the other cohorts (10% or less). With a mean follow-up of 24 months, 19 patients had developed bladder cancer, 1 prostate cancer, 1 an extravesical malignancy with synchronous liver metastasis, and 4 distant recurrence (lung in 2 and the retroperitoneum and spine in 1 each).

CONCLUSIONS

The results of our study have shown that distal ureteral tumors have the greatest likelihood for a positive margin. Cystoscopic ureteral disarticulation increased the operative time and estimated blood loss. Cystotomy closure reduced the extravasation rate. We favor hand-assisted laparoscopic en bloc distal ureterectomy followed by cystotomy closure to minimize the risk of distal ureteral or extravesical recurrence.

Laparoscopic nephrectomy: new standard of care?

OBJECTIVE

The pace of implementation of a laparoscopic nephrectomy programme is affected by factors including surgical expertise, case load, learning curves and outcome audits. We report our experience in introducing a laparoscopic nephrectomy programme over a 3-year period.

METHODS

From January 2001 to December 2003, 187 nephrectomies were performed (105 by conventional surgery, 82 by laparoscopy). Hand-assisted laparoscopy was used predominantly. The indications for surgery, factors affecting the approach and outcome parameters were studied. A cost comparison was made between patients with similar-sized renal tumours undergoing laparoscopic versus open surgery.

RESULTS

Most operations were performed for malignancy in both the open (70%) and laparoscopic (67%) surgery groups. The laparoscopic approach was most commonly used in upper tract transitional cell cancers (TCCs; 70% of 30 patients) and benign pathologies (49% of 35 patients), followed by radical nephrectomies (34% of 99 patients) and donor nephrectomies (44% of 23 patients). There was a rapid rise in laparoscopic surgeries, from 30% in 2001 to 58% in 2002. The median hospital stay was 5.8 days in the laparoscopic group and 8.1 days in the open surgery group. The procedure cost for laparoscopic surgery was 4,943 dollars compared with 4,479 dollars for open surgery. However, due to a shorter hospital stay, the total hospital cost was slightly lower in the laparoscopic group (7,500 dollars versus 7,907 dollars).

CONCLUSION

The laparoscopic approach for various renal pathologies was quickly established with a rapid increase in the number of laparoscopic procedures.

Hand-assisted retroperitoneoscopic nephroureterectomy without hand-assisted device

Various laparoscopic nephroureterectomy techniques for urothelial carcinoma of the upper urinary tract have been developed to minimize postoperative discomfort and the necessity for a lengthy convalescence. We performed hand-assisted retroperitoneoscopic nephroureterectomy without hand-assisted device in 3 male patients with urothelial carcinoma of the distal ureter. Average operative time and estimated blood loss were 251 min (range 235 to 280) and 250 mL (range 200 to 300), respectively. Complication did not occur and conversion to open surgery was not necessary in all cases. Postoperative analgesic requirements were moderate and the time to regular diet intake averaged 3 days (range 2 to 4). None of the patients had a positive margin on the final pathologic specimen. At the average follow-up of 8.1 months, no regional recurrence, port-site metastasis, bladder recurrence, or distant metastasis were noted in any patient. We described our initial experience with the described technique, which obviates the need for midprocedural patient repositioning.

Determination of Cell Viability after Laparoscopic Tissue Stapling in a Porcine Model

BACKGROUND AND PURPOSE

Surgical stapling devices are often used to secure the distal ureter along with a cuff of bladder during laparoscopic nephroureterectomy. As the viability of cells within the stapled tissue would be important in patients with upper urinary-tract transitional-cell carcinoma, we determined the viability of cells within the lines of various commercially available staplers in a porcine model.

MATERIALS AND METHODS

Four laparoscopic stapling devices were used: two vascular and two tissue designs (US Surgical, Norwalk, CT, and Ethicon, Cincinnati, OH). The devices were deployed across a portion of the bladder, much as they would be during a nephroureterectomy to create a bladder cuff while excising the distal ureter. The animals were sacrificed 6 weeks later, and the stapled sites were harvested for histopathologic examination by an experienced genitourinary pathologist (PH).

RESULTS

Grossly, there were no visible staples at harvest of the stapled bladder and the ureterovesical junction, with a completely healed bladder being seen in all four animals. On histologic examination with hematoxylin and eosin staining, there were distinctly viable cells within the staple lines of the ureterovesical junction and the bladder wall, similar to the unstapled control tissue. There were viable cells in all samples of tissues stapled by either vascular or tissue staplers.

CONCLUSIONS

Deployment of both vascular and tissue staplers resulted in viable cells within the staple lines at the ureterovesical junction and bladder wall in this porcine model. There is a potential risk of tumor recurrence at the stapled site in patients who have the ureter and bladder cuff secured with these devices during laparoscopic nephroureterectomy for upper-tract transitional-cell carcinoma. Despite this concern, to date, over a period of 13 years, clinical experience has not revealed a single case of tumor recurrence within the stapled cuff of bladder. Careful endoscopic evaluation of the stapled bladder-cuff site after laparoscopic nephroureterectomy should minimize the potential for local tumor recurrence.

Laparoscopic Nephroureterectomy with Bladder-Cuff Resection: Techniques and Outcomes

Advancements in minimally invasive instrumentation and technique have provided the impetus to performing urologic procedures with reduced perioperative morbidity, shorter hospital stays, and, most importantly, efficacious oncologic results. At multiple centers of excellence, laparoscopic nephroureterectomy (LNU) has evolved into a new standard for the management of upper-tract transitional-cell carcinoma (TCC) that is not amenable to endoscopic resection. An LNU may be performed via a transperitoneal or retroperitoneal approach together with excision of the distal ureter and a bladder cuff. Analysis of present-day studies comparing LNU with open techniques demonstrates equivalent oncologic outcomes. In addition, those patients undergoing LNU fare better than their counterparts having open surgery with respect to hospital stay, analgesic requirements, and convalescence. With multiple options for excision of a cuff of bladder, a consensus has not been established. However, LNU has emerged as the new standard of care for the treatment of upper- tract TCC. Review of the techniques and outcomes of LNU from the minimally invasive urology community are described.

INTERMEDIATE FOLLOWUP OF HAND ASSISTED LAPAROSCOPIC NEPHROURETERECTOMY FOR UROTHELIAL CARCINOMA:: FACTORS ASSOCIATED WITH OUTCOMES

PURPOSE

We report our experience with hand assisted laparoscopic (HALS) nephroureterectomy and describe the associations of preoperative, operative and pathological factors with outcome.

MATERIALS AND METHODS

HALS nephroureterectomy was performed in 54 consecutive patients using modified transurethral resection of the ureteral orifice (TURUO) or a 1 port transvesical endoscopic cuff technique for the distal ureter in all except 8. Data were collected prospectively and retrospectively, and followup was distinguished for bladder, contralateral upper tract and nonurothelial (local recurrence and distant metastases) sites.

RESULTS

The endoscopic cuff was associated with significantly shorter mean operative time than the transurethral resection of the ureteral orifice method (234 vs 295 minutes, p = 0.002) but the comparison was confounded by the effect of experience. With 28% of patients having stage II or greater tumors and 49% having high grade bladder disease, contralateral upper tract and nonurothelial recurrences developed in 55%, 11% and 25% of evaluable patients at a median followup of 25.1, 24.4 and 24.9 months, respectively, in those without recurrence. At a median followup of 25.0 months cancer specific survival was 94%, 86% and 80% at 1 to 3 years, respectively. Three-year cancer specific survival was 100% in patents with grade 1 or 2, or stage 0 or I tumors but only 57% and 36% in patients with grade 3 and stage II or IV tumors, respectively.

CONCLUSIONS

HALS nephroureterectomy is associated with 3-year outcomes that are strongly associated with stage and grade. We prefer the endoscopic cuff method for the distal ureter because it is performed after nephrectomy, does not require patient repositioning and is expedient.

Outcomes of hand-assisted laparoscopic nephroureterectomy for managing upper urinary tract transitional cell carcinoma—China Medical University Hospital experience

OBJECTIVES

To report our experience with hand-assisted laparoscopic nephroureterectomy (HALNU) to treat upper urinary tract transitional cell carcinoma (TCC). In addition, we report the treatment of 4 patients with upper urinary tract TCC and synchronous superficial urinary bladder TCC by HALNU and simultaneous transurethral resection of bladder tumor (TURBT).

METHODS

We retrospectively reviewed 33 patients who had undergone HALNU. Recovery was evaluated according to the Eastern Cooperative Oncology Group performance status. Four patients had concomitant superficial urinary bladder cancer and underwent simultaneous TURBT at the beginning of surgery. We compared our data with those of our open surgery group and previously published data.

RESULTS

Partial recovery had occurred by 1 week and complete recovery by 4 weeks postoperatively. Conversion to open surgery was required in 2 (6%) of the 33 patients. The complication rate was 24% (8 of 33) without any mortality. The recurrence rate of urinary bladder TCC was 6% (2 of 33). Both patients with recurrent tumor were treated successfully by TURBT and bacille Calmette-Guérin instillation. All 4 patients with synchronous superficial urinary bladder TCC had undergone simultaneous transurethral resection of bladder tumor, and all 4 were disease free at the last follow-up visit.

CONCLUSIONS

Hand-assisted procedures are appropriate for surgeons with limited experience with laparoscopic surgery. In our study, the convalescence of patients was excellent, and the postoperative results were compatible with those of previous studies. To treat upper urinary tract TCC with synchronous urinary bladder TCC, HALNU and TURBT together seems to be a safe and efficient technique.

Endoscopic treatment of upper tract transitional cell carcinoma

PURPOSE

To review the current literature and data describing primary endoscopic treatment of upper tract transitional cell carcinoma (TCC).

MATERIALS AND METHODS

Published, peer-reviewed articles on ureteroscopic, percutaneous, and laparoscopic treatment of upper tract TCC were identified using the MEDLINE database.

RESULTS

Nephroureterectomy has been considered the "gold standard" for upper tract TCC. Minimally invasive approaches, initially advocated for patients requiring a nephron sparing approach (i.e., solitary kidney or renal insufficiency) or those with significant comorbidities precluding definitive surgery, have been increasingly used with the further refinement of ureteroscopy, percutaneous renal surgery, and laparoscopy. Ureteroscopy has been used successfully, resulting in recurrence rates ranging from 31% to 65% and disease-free rates of 35% to 86%. Progression and metastatic rates are low and correlate with tumor grade. Likewise, percutaneous approaches show disease specific survival and recurrence rates correlating with tumor grade. Patients with low-grade tumors (Grades 1-2) do well with this approach with recurrence rates and disease specific survival rates of 26% to 28% and 96% to 100%, respectively. For those patients requiring complete extirpation of the kidney and ureter, laparoscopic nephroureterectomy results in decreased postoperative pain, shorter hospital stay, and more rapid convalescence without compromising cancer control.

CONCLUSIONS

Nephron sparing approaches in well-selected patients with low stage and low-grade disease can be treated endoscopically with ureteroscopy and percutaneous renal surgery. Laparoscopic nephroureterectomy offers a safe, minimally invasive alternative to traditional open surgical techniques for patients with TCC of the upper urinary tract.

Laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma: is it better than open surgery?

OBJECTIVE

In 1991, laparoscopic nephroureterectomy has been introduced as a treatment option for upper tract transitional cell carcinoma. Based on the review of the current literature and personal experience we want to analyze the actual results of this technique in comparison to open surgery.

MATERIALS AND METHODS

We performed a MEDLINE/PubMed search and reviewed the literature on laparoscopic and open nephroureterectomy between 1991 and 2004 (n = 1365 patients) including the results of 45 patients who underwent either laparoscopic (n = 23) or open nephroureterectomy (n = 21) during the same period of time at the Klinikum Heilbronn. Demographic, perioperative and follow-up data were compared.

RESULTS

The analysis revealed a slightly longer OR-time (276.6 vs. 220.1 min), and significantly lower blood loss (240.9 vs. 462.9 ml) in the laparoscopic series. No differences of minor (12.9 vs. 14.1%) or major complication rate (5.6 vs. 8.3%) were observed. All nine comparative studies revealed a significant dose reduction of the morphine-equivalents after laparoscopy. In all ten comparative series the hospital stay was shorter after laparoscopy, but only in 6 series the difference was statistically significant. The frequency of bladder recurrence (24.0 vs. 24.7%), local recurrence (4.4 vs. 6.3%), and distant metastases (15.5% vs. 15.2) did not differ significantly in both groups. The actual disease-free two-year survival rates (75.2 vs. 76.2%) were similar. The five-year survival rates averaged 81.2% in the three laparoscopic (n = 113 pat.) and 61% in the ten open series (n = 681 pat.) Six port site metastases were reported in 377 (1.6%) analyzed patients occurring 3 to 12 months following laparoscopy.

CONCLUSION

Open radical nephroureterectomy still represents the golden standard for the management of upper tract transitional cell carcinoma, however, laparoscopic radical nephroureterectomy offers the advantages of minimally invasive surgery without deteriorating the oncological outcome. In case of advanced tumors (pT3,N+) open surgery is still recommended.

Selection of Patients for Hand-Assisted Laparoscopic Surgery

Each of the well-established approaches to laparoscopy-standard transperitoneal, standard retroperitoneal, and transperitoneal hand-assisted-has its advantages and disadvantages. In order to maximize efficiency and patient benefit, each approach should be used selectively. This paper offers recommendations for the selective use of the hand-assisted technique, which is particularly useful when intact specimen removal is required, the surgeon has limited experience, the situation is expected to be difficult (e.g., prior surgery, fibrosis, inflammation), or the patient's other medical comorbidities mandate a rapid procedure.

Hand-Assisted Laparoscopic Nephroureterectomy for Upper Urinary-Tract Transitional-Cell Carcinoma

Hand-assisted laparoscopic nephroureterectomy with laparoscopic, cystoscopic, or open management of the distal ureter and bladder cuff allow anyone from the novice to the advanced laparoscopic surgeon to perform en-bloc resection of the kidney, ureter, and bladder cuff without compromising oncologic principles. Patients receive significant benefits in the form of less pain, shorter hospital stay, and rapid convalescence. As more urologic surgeons develop skills with this procedure, a more critical analysis of early and long-term results will be possible. As operative times decrease, hand-assisted laparoscopic nephroureterectomy may become the procedure of choice for upper-tract transitional-cell carcinoma. The techniques and early results are described.

Trocar Arrangement for HALS

The appropriate position of the hand-access device and trocars for hand-assisted laparoscopic surgery depends on several factors, including the surgeon's preference, physical stature, and handedness; the patient's anatomy; and the type of procedure being performed. This article reviews the options, including measures for special circumstances such as patient obesity.

Hand-Assisted Retroperitoneoscopic Radical Nephrectomy and Nephroureterectomy

In laparoscopic operations for renal tumor and upper urinary-tract transitional-cell carcinoma (TCC), three approaches - the transperitoneal, retroperitoneal, and transperitoneal hand-assisted - have been reported. We have performed hand-assisted retroperitoneoscopic radical nephrectomy (RN) since 1999 and nephroureterectomy (NU) since 2000. The surgical techniques and the operative results of 95 cases of RN and 54 cases of NU are described and analyzed. These procedures were effective and safe for renal tumors and upper urinary-tract TCC.

The advantages of hand-assisted laparoscopy

The technical challenges of performing laparoscopic renal surgery require fellowship training and are associated with a steep learning curve. For the established urologist in practice, fellowship training is not a reality. As a result of these obstacles, in the late 1990s, laparoscopic renal surgery was entering the domain of the general surgeons who had a large number of laparoscopic procedures at their disposal to develop laparoscopic skills. Hand-assisted laparoscopic renal surgery is a hybrid procedure combining the most salient features of open renal surgery and laparoscopic renal surgery. By allowing the surgeons to place their non-dominant hand into the abdominal cavity, palpation and spatial orientation became possible, lessening the learning curve for laparoscopic surgery. Moreover, hand-assisted laparoscopic surgery could be applied to a variety of renal surgeries, extirpative and reconstructive, with results similar to those already achieved by standard laparoscopy. Throughout the past 5 years, hand-assisted laparoscopy has allowed urologists to incorporate laparoscopic renal surgery into their practices to the benefit of their patients and of their specialty. This review article offers a historical review of the development of hand-assisted laparoscopy and describes the procedures commonly performed today using this technique.

Hand-Assisted Surgery Improves Outcomes for Laparoscopic Nephrectomy

Laparoscopy has become the preferred method for nephrectomy in many medical centers. We compared our experience with hand-assisted laparoscopic nephrectomy (HALN) and standard laparoscopic nephrectomy (LN). Data were prospectively collected on 119 consecutive patients undergoing laparoscopic nephrectomy between August 2000 and November 2002. Outcomes were compared for LN versus HALN using Wilcoxon rank sum test for quantitative outcomes and Fisher exact test and x2 for qualitative outcomes. Thirty-nine patients underwent LN: 16 live donor, 16 radical, and 7 simple nephrectomies. Eighty patients were treated with HALN: 47 live donor, 32 radical, and 1 simple nephrectomy. There were no differences in mean age (49.2 years LN vs. 47.7 years HALN, P = 0.60) or weight (192.2 lb LN, 179.2 lb HALN, P = 0.12). Mean tumor size (4.77 cm LN vs. 7.12 cm HALN, P = 0.07) and length of extraction incision (8.37 cm LN vs. 7.87 cm HALN, P = 0.08) were similar. Total hospital charges ($19,352 vs. $18,505, P = 0.29) and length of stay (3.68 days vs. 3.72 days, P = 0.15) were equivalent for LN and HALN. Average operative time for HALN was significantly shorter (202 minutes vs. 258 minutes, P = 0.0001), and blood loss was less for HALN (71.7 cc vs. 113.1 cc, P = 0.007). Wound complications rates were similar (6.5% HALN vs. 13% LN, P = 0.34), but overall morbidity rates were higher after LN (28.2% vs. 6.3%, P = 0.001). Compared with pure laparoscopic nephrectomy, the hand-assisted approach reduces operative time and blood loss without increasing total hospital charges or length of stay. In our patients, HALN was also associated with fewer postoperative complications than standard laparoscopic nephrectomy. Hand-assisted laparoscopy may allow for the performance of increasingly complex procedures while maintaining the benefits of minimally invasive surgery.

Laparoscopic radical excision of urachal sinus

Persistent urachus is a rare congenital anomaly. Various types of remnants have been described including cyst, alternating sinus, patent urachus, diverticulum, and sinus. The most common presenting symptom of urachal sinus is umbilical discharge. Radical excision of the remnant, with or without a bladder cuff, is essential to prevent future malignant degeneration or recurrence of the remnant. Although open surgical excision has been the treatment of choice for many years, the laparoscopic approach has become an attractive alternative because of its association with less postoperative pain, better cosmesis, and rapid convalescence. Laparoscopic radical excision of a urachal sinus was performed in a 16-year-old female patient who presented with umbilical discharge.

Surgical management of renal tumors

Renal cell carcinoma is a relatively rare tumor, accounting for approximately 3% of malignancies in adults, but is the most common tumor of the kidney and the third most common tumor seen by urologists. Renal cell carcinoma is refractory to most traditional oncologic treatments, including chemotherapy, radiation therapy, and hormonal therapy. Because of recent advances in sophisticated radiologic studies, the surgeon can now make an accurate preoperative assessment of the nature and extent of kidney tumors. When evaluating renal tumors, the urologist looks for certain information to help in constructing a management plan. This article explores some of the points that contribute in the surgical decision-making.

Hand assisted retroperitoneoscopic nephroureterectomy: comparison with the open procedure

PURPOSE

We report our initial experience with hand assisted retroperitoneoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma and compared our results to those of a contemporary series of open nephroureterectomy.

MATERIALS AND METHODS

Clinical data on 34 consecutive patients who underwent hand assisted retroperitoneoscopic nephroureterectomy were reviewed and compared with those on 34 who underwent open nephroureterectomy. All specimens were extracted intact.

RESULTS

Total operative time was similar in the 2 groups (233 versus 236 minutes). Estimated blood loss was significantly less in the hand assisted laparoscopy group (236 versus 427 ml.). During convalescence the frequency of parenteral analgesia postoperatively was significantly lower in the laparoscopy group than in the open surgery group. The former patients had a significantly shorter interval to oral intake and ambulation as well as a shorter hospital stay and convalescence compared with those who underwent open surgery. In each group the complication rate was 12% (4 of 34 cases). In the hand assisted laparoscopy group 1 conversion to an open procedure was due to bleeding. There was recurrence in 4 of the 34 patients (12%) in the laparoscopy group, including 2 with bladder recurrence and 2 with metastases, at an average followup of 13.1 months.

CONCLUSIONS

Hand assisted retroperitoneoscopic nephroureterectomy is an effective and safe alternative to open nephroureterectomy for upper urinary tract transitional cell carcinoma.