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Zhao Y, Lu K, Yin ZX, Peng YH, Pei CS. Systematic review and meta-analysis of completely retroperitoneoscopic nephroureterectomy versus traditional retroperitoneoscopic nephroureterectomy in upper tract urothelial carcinoma. Medicine (Baltimore) 2023; 102:e34112. [PMID: 37352043 PMCID: PMC10289752 DOI: 10.1097/md.0000000000034112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/18/2023] [Accepted: 06/05/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND This systematic review and meta-analysis aim to evaluate the efficacy and safety of completely retroperitoneoscopic nephroureterectomy (CRNU) for the treatment of upper urinary tract urothelial carcinoma (UTUC). METHODS A systematic review of PubMed and Web of Science databases was conducted to identify trials comparing the outcomes of CRNU and other surgical procedures. A total of 6 case-control studies were selected for analysis. The efficacy and safety of CRNU were evaluated using mean difference or hazard ratio (HR) with 95% CIs, employing continuous or dichotomous method with a random or fixed-effect model. Meta-analysis was performed using STATA 11.0 software. RESULTS The meta-analysis indicated that CRNU in subjects with UTUC was significantly associated with a shorter operation time (standardized mean difference, -1.36; 95% CI, -1.61 to -1.11, P < .001) and lower blood loss (standardized mean difference, -0.54; 95% CI, -0.77 to -0.31, P < .001) when compared to traditionally retroperitoneoscopic nephroureterectomy (TRNU). No significant difference was observed in the occurrence of grade I & II complications (HR, 1.04; 95% CI, 0.49-2.2, P = .915) and total complications (HR, 0.69; 95% CI, 0.38-1.27, P = .238) between CRNU and TRNU. CONCLUSION The findings suggest that CRNU is an advanced surgical technique that is safe and effective for the treatment of UTUC. We recommend that CRNU be further employed for patients with UTUC. Further randomized, multicenter trials are needed to validate these results, given the limitations of this study.
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Affiliation(s)
- Yan Zhao
- Department of Urology, Xuzhou Cancer Hospital, Affiliated Hospital of Jiangsu University, Xuzhou, Jiangsu, China
- Department of Urology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Ke Lu
- Department of Urology, Changshu Second People’s Hospital, Yangzhou University Fifth Clinical Medical College, Changshu, Jiangsu, China
| | - Zhi-Xiang Yin
- Department of Urology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yu-Hao Peng
- Department of Urology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Chang-Song Pei
- Department of Urology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
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Al-Qudah HS, Rodriguez AR, Sexton WJ. Laparoscopic Management of Kidney Cancer: Updated Review. Cancer Control 2017; 14:218-30. [PMID: 17615527 DOI: 10.1177/107327480701400304] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Laparoscopy has emerged as the preferred option for the surgical management of kidney cancer. Although many reports have been published regarding the operative outcome of renal cell carcinoma (RCC) and upper-tract transitional cell carcinoma (TCCA) treated laparoscopically, few review the oncologic outcome of these pathologies treated with laparoscopic techniques. METHODS We review the literature regarding the laparoscopic approaches, the complications related to laparoscopic surgery, and the long-term oncologic results of laparoscopic radical nephrectomy, partial nephrectomy, and nephroureterectomy. RESULTS Laparoscopic radical nephrectomy has become the new standard of care for most patients with suspected RCCs that are not amenable to nephron-sparing procedures. Laparoscopic techniques for managing RCC and TCCA are safe, follow well-established guidelines for surgical dissection, and meet or exceed perioperative convalescence and oncologic outcomes compared to traditional open procedures. The surgical techniques and the long-term outcome data for laparoscopic partial nephrectomy continue to mature. CONCLUSIONS Laparoscopy is a minimally invasive option available to most patients with kidney cancer. The immediate benefits of laparoscopy are well established and include less estimated blood loss, decreased pain, shorter perioperative convalescence, and improved cosmesis. Long-term oncologic outcomes of patients treated laparoscopically for kidney tumors resemble those of the open surgical approach.
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Affiliation(s)
- Hosam S Al-Qudah
- Genitourinary Oncology Program, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
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Nezakatzgoo N, Colli J, Mutter M, Aranmolate S, Wake R. Retroperitoneal hand-assisted laparoscopic nephrectomy and partial nephrectomy. SURGICAL TECHNIQUES DEVELOPMENT 2013. [DOI: 10.4081/std.2013.e3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The purpose of the present paper is to describe our technique and experience with retroperitoneal hand-assisted laparoscopic (HAL) nephrectomies as an alternative to the transperitoneal approach. Eight retroperitoneal HAL nephrectomies and one partial nephrectomy were performed. Several excisional techniques were employed incorporating the Harmonic scalpel or Ligasure device. Hemostatic agents were used to cover the renal defect. Surgical bolsters were sutured to the renal capsule with pleget reinforcements to aid in hemostasis. The average operative time was 210 min and estimated blood loss 110 mL. Mean change in hematocrit was 3 units and creatinine was 1 point. No patient required a transfusion. There were no major complications, with a mean follow-up of fourteen months. On average, patients resumed oral intake in 2 days, and were discharged in 3 days. Pathological examination revealed that two lesions were benign and seven malignant. Tumor diameter averaged 3 cm. There were no positive surgical margins. In conclusion, we have demonstrated the feasibility of retroperitoneal laparoscopic hand-assisted nephrectomy and partial nephrectomy surgery for solid renal masses.
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Shiong Lee L, Yip SKH, Hong Tan Y, Cheng CWS. Laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma. ACTA ACUST UNITED AC 2009; 40:283-8. [PMID: 16916768 DOI: 10.1080/00365590600641814] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Open radical nephroureterectomy has been the standard treatment for upper urinary tract transitional cell carcinoma (TCC). Laparoscopic nephroureterectomy (LN) offers the advantages of a minimally invasive approach. We report our experience with both hand-assisted LN (HALN) and total LN. MATERIAL AND METHODS A retrospective review was performed of all patients who underwent HALN and LN for the treatment of localized upper urinary tract TCC between 2001 and 2005. Histology of the operative specimen confirmed urothelial carcinoma in all cases. Their demographic data, perioperative parameters and follow-up data were assessed. RESULTS There were 31 patients with a median age of 71 years (range 39-82 years). The mean operating time was 236 min (range 120-350 min) and mean blood loss was 365 ml (range 200-2000 ml). There were no conversions to open surgery. The mean length of hospitalization was 7 days (range 3-30 days). Clear oncological margins were achieved in 27 cases. The mean duration of follow-up was 28 months (range 2-55 months). CONCLUSIONS HALN and LN are safe and effective alternatives to open surgery for the treatment of upper urinary tract TCC. Medium-term follow-up showed favourable oncological results. A larger sample size and a longer follow-up period are required before HALN and LN can be considered standard treatments for upper urinary tract TCC.
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Affiliation(s)
- Lui Shiong Lee
- Department of Urology, Singapore General Hospital, Singapore, Singapore
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5
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Comprehensive management of upper tract urothelial carcinoma. Adv Urol 2008:656521. [PMID: 19096525 PMCID: PMC2600411 DOI: 10.1155/2009/656521] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2008] [Revised: 08/04/2008] [Accepted: 09/15/2008] [Indexed: 11/24/2022] Open
Abstract
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.
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Nadler RB. The Northwestern flexible endoscopic technique of management of the distal ureter during laparoscopic nephroureterectomy. J Endourol 2008; 22:1961-2; discussion 1963. [PMID: 18811507 DOI: 10.1089/end.2008.9767] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Robert B Nadler
- Section of Endourology, Laparoscopy, and Stone Disease, Northwestern University, Feinberg School of Medicine, Chicago, Illinois 60611, USA.
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Ou CH, Yang WH. Hand Assisted Retroperitoneoscopic Nephroureterectomy With the Patient Spread-Eagled: An Approach Through a Completely Supine Position. J Urol 2008; 180:1918-22; discussion 1922. [PMID: 18801531 DOI: 10.1016/j.juro.2008.07.061] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2008] [Indexed: 11/28/2022]
Affiliation(s)
- Chien-Hui Ou
- Department of Urology, College of Medicine and Hospital, National Cheng Kung University, Tainan, Taiwan, Republic of China
| | - Wen-Horng Yang
- Department of Urology, College of Medicine and Hospital, National Cheng Kung University, Tainan, Taiwan, Republic of China
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Comparison Between Hand-assisted Laparoscopic and Retroperitoneoscopic Nephroureterectomy for the Management of Upper Urinary Tract Urothelial Carcinoma: Analysis of an Intermediate Follow-up Period. Surg Laparosc Endosc Percutan Tech 2008; 18:49-53. [DOI: 10.1097/sle.0b013e318159e84b] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Raman JD, Scherr DS. Management of patients with upper urinary tract transitional cell carcinoma. ACTA ACUST UNITED AC 2007; 4:432-43. [PMID: 17673914 DOI: 10.1038/ncpuro0875] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2007] [Accepted: 06/12/2007] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Jay D Raman
- Department of Urology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY 10021, USA
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Finley DS, Melamud O, Ornstein DK. Combined robot-assisted laparoscopic nephroureterectomy and radical prostatectomy. J Endourol 2007; 21:411-4. [PMID: 17451333 DOI: 10.1089/end.2007.0013] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
A 57-year-old man with prostate cancer and transitional-cell carcinoma of the kidney underwent a combined robot-assisted prostatectomy and hand-assisted laparoscopic nephroureterectomy with robot assistance. We describe the initial report of this combined operation and the novel use of the da Vinci robot for extravesical bladder-cuff excision and repair.
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Affiliation(s)
- David S Finley
- Department of Urology, University of California Irvine, Orange, California, USA
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Chung SD, Chueh SC, Lai MK, Huang CY, Pu YS, Yu HJ, Huang KH. Long-Term Outcome of Hand-Assisted Laparoscopic Radical Nephroureterectomy for Upper-Tract Urothelial Carcinoma: Comparison with Open Surgery. J Endourol 2007; 21:595-9. [PMID: 17638552 DOI: 10.1089/end.2006.9948] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Shiu-Dong Chung
- Department of Urology, Far-Eastern Memorial Hospital, Ban-Ciao, Taipei County, Taiwan
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Secin FP, Koppie TM, Salamanca JIM, Bokhari S, Raj GV, Olgac S, Serio A, Vickers A, Bochner BH. Evaluation of regional lymph node dissection in patients with upper urinary tract urothelial cancer. Int J Urol 2007; 14:26-32. [PMID: 17199856 DOI: 10.1111/j.1442-2042.2006.01664.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The role of the lymph node dissection (LND) in conjunction with nephroureterectomy (NU) in upper tract urothelial cell carcinoma (UT-UCC) remains undefined. We evaluated the manner in which the LND was applied at NU, the patterns of lymph node (LN) involvement and the preoperative variables that could identify patients at high risk for lymph node metastasis (LNM). METHODS We examined clinical, radiological and pathological records of patients who underwent NU for UT-UCC between 1985 and 2004. The central pathology laboratory reviewed all specimens and graded tumors using the 2002 World Health Organization/International Society of Urologic Pathologists grading system. RESULTS Of the NU performed in 252 patients for UT-UCC, 105 (42%) were N0, 28 (11%) N+ and 119 (47%) Nx. Some form of LN resection was performed with NU in 53% of patients, with a median of four LN sampled (interquartile range, 2-10). After adjustment for tumor and patient characteristics, surgeon remained a significant predictor of LN resection (P < 0.0005). Of the evaluated variables, suspicious LN on preoperative computed tomography, present in 60% of N+ patients, was the only preoperative variable associated with the pathological finding of LNM (P < 0.0005). CONCLUSIONS LND in patients with UT-UCC is surgeon-dependent. Given the prognostic importance of LN status and the limited accuracy of preoperative staging of the regional LN, surgeons should perform a regional LND at the time of NU.
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Affiliation(s)
- Fernando P Secin
- Department of Urology, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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Busby JE, Matin SF. Laparoscopic radical nephroureterectomy for transitional cell carcinoma: where are we in 2007? Curr Opin Urol 2007; 17:83-7. [PMID: 17285015 DOI: 10.1097/mou.0b013e32802b7081] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Nephroureterectomy has undergone critical changes during the past 15 years with the advent of the laparoscopic approach. New data supporting laparoscopic nephroureterectomy (LNU) continue to emerge as new techniques are developed and current approaches refined. The purpose of this study was to investigate the findings within LNU from the past 2 years as an evolving although proven modality for treatment of upper-tract transitional cell carcinoma (TCC). RECENT FINDINGS Intermediate outcomes continue to be published equating the oncologic efficacy and perioperative parameters (i.e. blood loss and pain medication requirements) of LNU to those of open nephroureterectomy, allaying previous arguments against the minimally invasive approach. Newer approaches to the nephrectomy segment of LNU have been described, including robot assistance in retroperitoneoscopic cases and hand-assisted laparoscopic nephrectomy without the use of a hand-port. Data supporting specific approaches to the distal ureter have been published, including implementing robotics and flexible cystoscopy. SUMMARY Findings over the past 2 years show both the continued progress of LNU and the need for further evolution to optimize patient morbidity and oncologic outcomes. As laparoscopic training is integrated into urologic residency programs, standardizing the variables within LNU will be paramount.
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Affiliation(s)
- J Erik Busby
- Department of Urology, The University of Texas, M. D. Anderson Cancer Center, Houston, Texas 77030, USA
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Ou CH, Yang WH, Tzai TS, Tong YC, Chang CC, Lin YM. A modified supine position to speed hand assisted retroperitoneoscopic nephroureterectomy: the Johnnie Walker position. J Urol 2007; 176:2063-7; discussion 2067. [PMID: 17070259 DOI: 10.1016/j.juro.2006.07.043] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2006] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Chien-Hui Ou
- Department of Urology, Medical College and Hospital, National Cheng Kung University, Tainan, Taiwan, Republic of China
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Gutiérrez Sanz-Gadea C, Mus Malleu A, Briones Mardones G, Hidalgo Pardo F, Rebassa Llull M, Conde Santos G. [Hand-assisted laparoscopic nephrectomy]. Actas Urol Esp 2006; 30:698-706. [PMID: 17058615 DOI: 10.1016/s0210-4806(06)73520-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Pareek G, Hedican SP, Gee JR, Bruskewitz RC, Nakada SY. Meta-analysis of the complications of laparoscopic renal surgery: comparison of procedures and techniques. J Urol 2006; 175:1208-13. [PMID: 16515961 DOI: 10.1016/s0022-5347(05)00639-7] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2005] [Indexed: 02/02/2023]
Abstract
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).
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Affiliation(s)
- Gyan Pareek
- Division of Urology, Department of Surgery, University of Wisconsin Medical School, Madison, Wisconsin, USA.
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Vardi IY, Stern JA, Gonzalez CM, Kimm SY, Nadler RB. Novel technique for management of distal ureter and en block resection of bladder cuff during hand-assisted laparoscopic nephroureterectomy. Urology 2006; 67:89-92. [PMID: 16413339 DOI: 10.1016/j.urology.2005.07.053] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2005] [Revised: 07/07/2005] [Accepted: 07/27/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To report our experience with a novel flexible cystoscopic approach to excise the en block bladder cuff and juxtavesical ureter during hand-assisted laparoscopic nephroureterectomy. The optimal technique for excising the distal ureter and bladder cuff during nephroureterectomy continues to evolve. METHODS Hand-assisted laparoscopic nephroureterectomy was performed in 6 patients. A hand-assist device and two 5 to 12-mm ports were placed in the mid and upper abdomen. Two 10-mm clips were placed on the proximal ureter to occlude it, and the kidney was resected in the usual fashion. An additional 5 to 12-mm port was placed in the midline between the umbilicus and symphysis pubis. The ureter was dissected down into the pelvis to the level of the bladder. Without repositioning the patient, a flexible cystoscope was inserted into the bladder and a 2-cm bladder cuff excised using a 5F electrode on cutting current, with coagulating current used as needed. The specimen was removed intact through the hand port. RESULTS The mean time to resect the distal bladder cuff was 30 minutes (range 22 to 35). The mean estimated blood loss was 254 mL. The mean operating room time was 264 minutes, mean hospital stay 6.3 days, and mean time to a general diet 2.6 days. All patients underwent cystography at 7 to 10 days postoperatively, with no extravasation or diverticula. Cystoscopic and computed tomography follow-up demonstrated no evidence of recurrence. CONCLUSIONS This technique allows for complete resection of the kidney, distal ureter, and a cuff of bladder, avoiding repositioning.
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Affiliation(s)
- Itay Y Vardi
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA
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Abstract
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.
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Affiliation(s)
- Sung Hyun Paick
- Department of Urology, Kon-Kuk University College of Medicine, Seoul, Korea
| | - Ja Hyeon Ku
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea
| | - Cheol Kwak
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Eun Lee
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea
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19
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Tan BJ, Ost MC, Lee BR. Laparoscopic Nephroureterectomy with Bladder-Cuff Resection: Techniques and Outcomes. J Endourol 2005; 19:664-76. [PMID: 16053355 DOI: 10.1089/end.2005.19.664] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
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.
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Affiliation(s)
- Beng Jit Tan
- Department of Urology, Long Island Jewish Medical Center, New Hyde Park, New York 11040, USA
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20
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Chen CH, Wu HC, Chen WC, Yeh CC, Chen CC, Chang CH. Outcomes of hand-assisted laparoscopic nephroureterectomy for managing upper urinary tract transitional cell carcinoma—China Medical University Hospital experience. Urology 2005; 65:687-91. [PMID: 15833509 DOI: 10.1016/j.urology.2004.10.042] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2004] [Revised: 10/01/2004] [Accepted: 10/21/2004] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Chieh-Hsiao Chen
- Department of Urology, China Medical University Hospital, Taichung, Taiwan, ROC
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21
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Matin SF. Radical laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma: current status. BJU Int 2005; 95 Suppl 2:68-74. [PMID: 15720338 DOI: 10.1111/j.1464-410x.2005.05203.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Surena F Matin
- Department of Urology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA.
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22
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Abstract
BACKGROUND AND PURPOSE Hand-assisted laparoscopic (HAL) nephrectomy is an increasingly popular surgical modality. Within the last year, three newly designed second-generation hand-assist devices have emerged with the intention to improve efficacy and ease of use. We prospectively evaluated and compared these with each other and with the first-generation devices. MATERIALS AND METHODS A total of 130 urologists performed two HAL nephrectomies in a porcine laboratory using two different hand devices at an American Urological Association-sponsored learning course. Sixty-three urologists utilized the second-generation devices (Gelport, Omniport, LapDisc), while 67 urologists used the first-generation devices (Handport, Intromit, PneumoSleeve). Each surgeon completed a 12-question survey evaluating the devices. RESULTS Evaluation of the second-generation devices revealed that Gelport was statistically significantly superior in all parameters to the Omniport and in 5 of 10 parameters to the LapDisc. Comparison of the first- and second-generation devices revealed that only the Gelport achieved a significant increase in all ratings. Among the first-generation devices, no device scored better than 8.27 of 10 in any category. Analysis of the second-generation devices demonstrated that the Gelport scored a rating above 8.25 in all parameters with an overall satisfaction score of 8.59. Both the Omniport and the LapDisc attained ratings comparable to those of the first-generation devices. CONCLUSION The HAL procedure relies heavily on devices that allow the hand to be introduced into the laparoscopic environment. The Gelport, when evaluated in a porcine model by training laparoscopic urologists, appears to be significantly better than other devices available to date. Further testing with larger cohorts and human clinical trials are required to confirm these findings.
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Affiliation(s)
- Rupa Patel
- Department of Urology, New York University School of Medicine, New York, New York 10016, USA
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23
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McNeill A, Oakley N, Tolley DA, Gill IS. Laparoscopic nephroureterectomy for upper tract transitional cell carcinoma: a critical appraisal. BJU Int 2004; 94:259-63. [PMID: 15291848 DOI: 10.1111/j.1464-410x.2003.04958.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Alan McNeill
- Western General Hospital, Crewe Road, Edinburgh EH4 2XU, Scotland, UK.
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24
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Abstract
PURPOSE OF REVIEW Laparoscopic nephroureterectomy has recently emerged as a safe, minimally invasive approach to upper tract urothelial cancers. The most controversial and challenging feature of laparoscopic nephroureterectomy is the management of the distal ureter. We review the most common methods of managing the distal ureter, with emphasis on contemporary oncologic outcomes, indications, advantages, and disadvantages. RECENT FINDINGS There are currently in excess of five different approaches to the lower ureter. These techniques often combine features of endoscopic, laparoscopic, or open management. They include open excision, a transvesical laparoscopic detachment and ligation technique, laparoscopic stapling of the distal ureter and bladder cuff, the "pluck" technique, and ureteral intussusception. Each technique has distinct advantages and disadvantages, differing not only in technical approach, but oncological principles as well. While the existing published data do not overwhelmingly support one approach over the others, the open approach remains one of the most reliable and oncologically sound procedures. SUMMARY The principles of surgical oncology dictate that a complete, en-bloc resection, with avoidance of tumor seeding, remains the preferred treatment of all urothelial cancers. The classical open technique of securing the distal ureter and bladder cuff achieves this principle and has withstood the test of time. Transvesical laparoscopic detachment and ligation is an oncologically valid approach in patients without bladder tumors, but is limited by technical considerations. The laparoscopic stapling technique maintains a closed system but risks leaving behind ureteral and bladder cuff segments. Both transurethral resection of the ureteral orifice (pluck) and intussusception techniques should be approached with caution, as the potential for tumor seeding exists. Additional long-term comparative outcomes are needed to solve the dilemma of the distal ureter.
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Affiliation(s)
- Jordan R Steinberg
- Department of Urology, University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, USA
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Munver R, Del Pizzo JJ, Sosa RE. Hand-Assisted Laparoscopic Nephroureterectomy for Upper Urinary-Tract Transitional-Cell Carcinoma. J Endourol 2004; 18:351-8. [PMID: 15253785 DOI: 10.1089/089277904323056898] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
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.
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Affiliation(s)
- Ravi Munver
- The James Buchanan Brady Foundation, Department of Urology, The New York-Presbyterian Hospital-Weill Medical College of Cornell University, New York, New York 10021, USA
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26
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Abstract
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.
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Affiliation(s)
- A Lopez-Pujals
- Department of Urology, University of Miami School of Medicine, Miami, Florida 33126, USA
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27
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Kawauchi A, Fujito A, Soh J, Ukimura O, Mizutani Y, Miki T. Hand-Assisted Retroperitoneoscopic Radical Nephrectomy and Nephroureterectomy. J Endourol 2004; 18:365-9. [PMID: 15253787 DOI: 10.1089/089277904323056915] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Akihiro Kawauchi
- Department of Urology, Kyoto Prefectural University of Medicine, Kyoto, Japan.
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Rané A, Dasgupta P. Prospective experience with a second-generation hand-assisted laparoscopic device and comparison with first-generation devices. J Endourol 2004; 17:895-7. [PMID: 14744357 DOI: 10.1089/089277903772036226] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND PURPOSE The GelPort Hand-Assisted Laparoscopy (HAL) device was licensed for use in the U.K. in September 2001. We compared our experience with this second-generation device with that of first-generation devices; i.e., the Handport, launched in 1999, and the Intromit, first marketed in 1998. MATERIALS AND METHODS We prospectively compared a number of parameters for operations performed using the GelPort (13 radical nephrectomies, 4 nephroureterectomies) with those performed using the Handport (3 radical nephrectomies, 2 nephroureterectomies, 2 simple nephrectomies) and the Intromit (2 radical nephrectomies, 1 nephroureterectomy, 2 simple nephrectomies). The main outcome measures were ease of application, time required to place the device, and perioperative complications specific to the device. RESULTS The device requiring the longest time to place was the Intromit (average 15 minutes) followed by the HandPort (average 10 minutes) and then the GelPort (average 5 minutes). There were two leaks with the Intromit (one major and one minor). Pop-outs were a frequent issue with the HandPort, necessitating repeated replacement and resufflation. There was also a need to resufflate every time the hand was removed for a change of swab. None of these problems was noted with the GelPort, which was also found to be the easiest to use. The major disadvantage of the GelPort was its price, which was about a third more than that of the first-generation devices. CONCLUSION The GelPort is currently a more user-friendly and robust HAL device. It is, however, more expensive than first-generation devices.
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Affiliation(s)
- Abhay Rané
- Department of Urology, East Surrey Hospital, Canada Avenue, Redhill, Surrey RH1 5RH, UK.
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29
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Abstract
From its first use as a diagnostic tool, urologic laparoscopy has developed into a complex therapy for both benign and malignant disease. Most procedures are still performed at large centers with experienced laparoscopists but nonacademic urologists are starting to gain the necessary training and skills. With the clear advantage that laparoscopy shows over open procedures in terms of decreased perioperative morbidity and quicker recovery times, patients are increasingly asking for this approach. The urologic community must meet this challenge and train future urologists to meet the expected demand.
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Affiliation(s)
- Grant D Taylor
- Department of Urology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9110, USA
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30
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Lee DI, Landman J. Novel approach to minimizing trocar sites during challenging hand-assisted laparoscopic surgery utilizing the Gelport: trans-gel instrument insertion and utilization. J Endourol 2003; 17:69-71. [PMID: 12689397 DOI: 10.1089/08927790360587360] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE We present a novel technique for modified application of a hand-assist device, the Gelport (Applied Medical Resources, Rancho Santa Margarita, CA), which uses a gel for intra-abdominal access. MATERIALS AND METHODS A 53-year-old woman with a history of rectal cancer treated by abdominoperineal resection, ileostomy, subsequent reanastomosis, chemotherapy, and radiation presented with a 6-cm upper-pole left renal mass. Staging was negative, and a CT scan showed no evidence of lymphadenopathy or renal vein involvement. The patient elected to undergo a hand-assisted laparoscopic radical nephrectomy. Numerous intra-abdominal adhesions were encountered during initial periumbilical hand port placement. The initial adhesions were taken down in an open fashion; however, the proposed trocar sites still could not be exposed. The Gelport was placed, and a laparoscope was passed directly through the established central opening and the gel. A working instrument was then passed through the gel itself, allowing adhesiolysis under direct laparoscopic vision. RESULTS The nephrectomy was completed laparoscopically in 4 hours and 15 minutes with lysis of adhesion occupying 90 minutes of the operative time. The estimated blood loss was 150 mL. Despite the technical difficulty of the case, the procedure was completed laparoscopically with two standard 12-mm trocars and a 5-mm lateral retraction trocar. CONCLUSION The Gelport permits simultaneous insertion of the surgeon's hand and a working laparoscopic instrument. This allows for maximally efficient utilization of the incision made for hand-assist device placement and may minimize the need for additional trocars during challenging laparoscopic cases.
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Affiliation(s)
- David I Lee
- Division of Urology, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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31
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Kawauchi A, Fujito A, Ukimura O, Yoneda K, Mizutani Y, Miki T. Hand assisted retroperitoneoscopic nephroureterectomy: comparison with the open procedure. J Urol 2003; 169:890-4; discussion 894. [PMID: 12576807 DOI: 10.1097/01.ju.0000046453.38141.dd] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- Akihiro Kawauchi
- Deparment of Urology, Kyoto Prefectural University of Medicine, Kawaramachi-Hirokoji, Japan
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Uozumi J, Fujiyama C, Meiri H, Tsukahara T, Soejima K, Kanou T, Masaki Z. Hand-assisted retroperitoneoscopic nephroureterectomy for upper urinary-tract urothelial tumors. J Endourol 2002; 16:743-7. [PMID: 12542877 DOI: 10.1089/08927790260472890] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE We report our experience with hand-assisted retroperitoneoscopic nephroureterectomy for upper urinary-tract urothelial cancer. PATIENTS AND METHODS Our initial 10 cases of clinical stage T(1)N(0)M(0) renal pelvic and ureteral tumors treated with hand-assisted retroperitoneoscopic nephroureterectomy are included in the present report. Nephrectomy was conducted retroperitoneoscopically with hand assistance via a lower-abdominal midline incision. Resection of the lower ureter together with the bladder cuff was performed as open surgery and the specimen was removed en bloc via the same incision. RESULTS Hand-assisted retroperitoneoscopic nephroureterectomy was completed successfully in all 10 cases. The mean operating time was 456 +/- 90 minutes, and the mean estimated blood loss was 462 +/- 364 mL. The times to oral intake and walking were 1.5 +/- 0.5 days and 2.3 +/- 0.7 days, respectively. One case of renal vein injury, one case of pulmonary embolism, and three cases of wound infection were the complications. CONCLUSION This is the first report of hand-assisted endoscopic nephroureterectomy using the retroperitoneal approach. The surgical technique seems quite reasonable because the lower-abdominal incision can be utilized, not only as a route for hand assistance, but also as a window for open surgery when resecting the distal ureter as well as for extracting the surgical specimen.
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Affiliation(s)
- Jiro Uozumi
- Department of Urology, Saga Medical School, Japan.
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Wong C, Leveillee RJ. Hand-assisted laparoscopic nephroureterectomy with cystoscopic en bloc excision of the distal ureter and bladder cuff. J Endourol 2002; 16:329-32; discussion 332-3. [PMID: 12227903 DOI: 10.1089/089277902760261329] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Various hand-assisted and purely laparoscopic nephroureterectomy techniques have been described in the urologic literature. We describe a technique of hand-assisted laparoscopic nephroureterectomy with cystoscopic en bloc excision of the distal ureter and bladder cuff that duplicates open surgical excision of these structures and obviates bladder trocar placement and midprocedural patient repositioning. The patient is placed in a modified dorsal lithotomy position with the tumor side elevated 30 degrees. Allen stirrups are utilized to allow simultaneous access to the urethra. A transperitoneal hand-assisted laparoscopic nephrectomy is performed. The technique is modified in that the ureter is clipped prior to the kidney dissection to avoid distal migration of tumor cells during kidney manipulation. After the kidney is isolated, the intact ureter is liberated distal to the intramural hiatus. The remaining dissection is completed intravesically under cystoscopic guidance. While the surgeon's intra-abdominal hand places the ureter on tension, the cystoscopist transurethrally excises the bladder cuff and intramural ureter with a Collings knife. The complete surgical specimen is removed en bloc through the hand port. The bladder is not closed. A urethral catheter connected to straight drainage remains until the seventh postoperative day, when a cystogram is performed; if it is normal, the catheter is removed.
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Affiliation(s)
- Carson Wong
- Department of Urology, University of Miami, Florida, 33126, USA
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LANDMAN JAIME, LEV RONANY, BHAYANI SAM, ALBERTS GREGORY, REHMAN JAMIL, PATTARAS JOHNG, FIGENSHAU RSHERBURNE, KIBEL ADAMS, CLAYMAN RALPHV, McDOUGALL ELSPETHM. Comparison of Hand Assisted and Standard Laparoscopic Radical Nephroureterectomy for the Management of Localized Transitional Cell Carcinoma. J Urol 2002. [DOI: 10.1016/s0022-5347(05)64990-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- JAIME LANDMAN
- From the Departments of Surgery (Division of Urology) and Radiology (Mallinkrodt Institute of Radiology), Washington University School of Medicine, St. Louis, Missouri, and Departments of Urology, Vanderbilt University School of Medicine, Nashville, Tennessee, and Emory University School of Medicine, Atlanta, Georgia
| | - RONAN Y. LEV
- From the Departments of Surgery (Division of Urology) and Radiology (Mallinkrodt Institute of Radiology), Washington University School of Medicine, St. Louis, Missouri, and Departments of Urology, Vanderbilt University School of Medicine, Nashville, Tennessee, and Emory University School of Medicine, Atlanta, Georgia
| | - SAM BHAYANI
- From the Departments of Surgery (Division of Urology) and Radiology (Mallinkrodt Institute of Radiology), Washington University School of Medicine, St. Louis, Missouri, and Departments of Urology, Vanderbilt University School of Medicine, Nashville, Tennessee, and Emory University School of Medicine, Atlanta, Georgia
| | - GREGORY ALBERTS
- From the Departments of Surgery (Division of Urology) and Radiology (Mallinkrodt Institute of Radiology), Washington University School of Medicine, St. Louis, Missouri, and Departments of Urology, Vanderbilt University School of Medicine, Nashville, Tennessee, and Emory University School of Medicine, Atlanta, Georgia
| | - JAMIL REHMAN
- From the Departments of Surgery (Division of Urology) and Radiology (Mallinkrodt Institute of Radiology), Washington University School of Medicine, St. Louis, Missouri, and Departments of Urology, Vanderbilt University School of Medicine, Nashville, Tennessee, and Emory University School of Medicine, Atlanta, Georgia
| | - JOHN G. PATTARAS
- From the Departments of Surgery (Division of Urology) and Radiology (Mallinkrodt Institute of Radiology), Washington University School of Medicine, St. Louis, Missouri, and Departments of Urology, Vanderbilt University School of Medicine, Nashville, Tennessee, and Emory University School of Medicine, Atlanta, Georgia
| | - R. SHERBURNE FIGENSHAU
- From the Departments of Surgery (Division of Urology) and Radiology (Mallinkrodt Institute of Radiology), Washington University School of Medicine, St. Louis, Missouri, and Departments of Urology, Vanderbilt University School of Medicine, Nashville, Tennessee, and Emory University School of Medicine, Atlanta, Georgia
| | - ADAM S. KIBEL
- From the Departments of Surgery (Division of Urology) and Radiology (Mallinkrodt Institute of Radiology), Washington University School of Medicine, St. Louis, Missouri, and Departments of Urology, Vanderbilt University School of Medicine, Nashville, Tennessee, and Emory University School of Medicine, Atlanta, Georgia
| | - RALPH V. CLAYMAN
- From the Departments of Surgery (Division of Urology) and Radiology (Mallinkrodt Institute of Radiology), Washington University School of Medicine, St. Louis, Missouri, and Departments of Urology, Vanderbilt University School of Medicine, Nashville, Tennessee, and Emory University School of Medicine, Atlanta, Georgia
| | - ELSPETH M. McDOUGALL
- From the Departments of Surgery (Division of Urology) and Radiology (Mallinkrodt Institute of Radiology), Washington University School of Medicine, St. Louis, Missouri, and Departments of Urology, Vanderbilt University School of Medicine, Nashville, Tennessee, and Emory University School of Medicine, Atlanta, Georgia
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Comparison of Hand Assisted and Standard Laparoscopic Radical Nephroureterectomy for the Management of Localized Transitional Cell Carcinoma. J Urol 2002. [DOI: 10.1097/00005392-200206000-00011] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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37
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Abstract
OBJECTIVES To evaluate and compare the three commercially available first-generation hand-assisted laparoscopic (HAL) devices in a prospective, randomized fashion. HAL nephrectomy has become an increasingly popular surgical modality. METHODS Sixty-seven board-certified urologists each performed two HAL nephrectomies in a porcine laboratory, using two different hand devices, at a learning course sponsored by the American Urological Association. At the completion of the laboratory session, each surgeon was asked to complete a 12-question survey designed to evaluate the different hand-assist devices. RESULTS Thirty-nine surgeons used the HandPort, 47 used the Intromit, and 47 used the Pneumosleeve. No statistical differences were found in the ratings among the three devices within any category. No device scored better than 8.1 in any category, and the overall satisfaction was less than 7.7 in all three groups. Although not statistically significant, the Intromit device had the highest ratings in the following categories: instructions, maintenance of pneumoperitoneum, exchange of laparotomy pads, retrieval of specimens, sturdiness, and overall satisfaction. The HandPort had the highest failure rate. CONCLUSIONS HAL relies heavily on devices that allow the hand to be introduced into the laparoscopic environment. The three available devices are all effective, yet each have their specific advantages and disadvantages. In terms of overall satisfaction, no device scored greater than 7.7. The results of this study suggest that the need for improvement by all three manufacturers is significant and have helped to better identify these areas.
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Affiliation(s)
- Michael Stifelman
- Department of Urology, New York University School of Medicine, New York, New York 10016, USA
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38
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Pascual Regueiro D, Trívez Boned MA, García García MA, García de Jalón Martínez A, Blas Marín M, Rioja Sanz LA. [Endoscopic ureteral resection in radical nephroureterectomy: report of our experience]. Actas Urol Esp 2002; 26:85-90. [PMID: 11989432 DOI: 10.1016/s0210-4806(02)72738-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
We want to present our clinic and chirurgical experience in eight patients, using the radical nephroureterectomy with endoscopical resection of the ureter, as a safe and valid technique, in urothelial tumours localized in the upper urinary tract.
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39
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Chen J, Chueh SC, Hsu WT, Lai MK, Chen SC. Modified approach of hand-assisted laparoscopic nephroureterectomy for transitional cell carcinoma of the upper urinary tract. Urology 2001; 58:930-4. [PMID: 11744461 DOI: 10.1016/s0090-4295(01)01389-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Objectives. To report a modified approach for hand-assisted laparoscopic nephroureterectomy (HALNU).Methods. Seven patients with localized transitional cell carcinoma of the upper urinary tract underwent unilateral HALNU. Patients were placed in a 60 degrees oblique position during the entire procedure. Via a 7-cm Gibson incision on the lesion side, the distal ureterectomy and bladder cuff excision were done by an open method without opening the bladder. Then, with the surgeon's hand inserted into the peritoneal cavity by way of the same wound, HALNU was performed with two to three additional laparoscopic ports. The perioperative parameters were compared with those of 15 cases of conventional open nephroureterectomy.Results. Patients in the HALNU group had significantly less mean blood loss (140 versus 455 mL) and earlier resumption of oral intake (33 versus 61 hours), required fewer narcotics (38 versus 70 mg of morphine sulfate equivalent), and were discharged earlier (7.33 versus 9.1 days), with a faster convalescence to normal activity (3.7 versus 5.6 weeks; all P < 0.05). The total mean surgical time was 3.7 hours for the HALNU group.Conclusions. Our approach used the same incision to both excise the distal ureter and apply the hand-assist device. It also preserved the benefits of the minimal invasiveness of laparoscopic surgery compared with its open counterpart.
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Affiliation(s)
- J Chen
- Department of Urology, National Taiwan University College of Medicine, Taipei, Taiwan, People's Republic of China
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Nakada SY, Fadden P, Jarrard DF, Moon TD. Hand-assisted laparoscopic radical nephrectomy: comparison to open radical nephrectomy. Urology 2001; 58:517-20. [PMID: 11597529 DOI: 10.1016/s0090-4295(01)01321-8] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Hand-assisted laparoscopic surgery is easier to learn than standard laparoscopy and simplifies intact specimen removal. We present our experience performing hand-assisted laparoscopic radical nephrectomy (HALRN) and compare it with contemporary open radical nephrectomy performed at our institution. METHODS We performed 18 HALRNs for renal tumors ranging in size from 2 to 11 cm (average 4.5). Patients ranged in age from 40 to 83 years (average 62.9). All patients underwent HALRN with intact removal through a 7 to 8-cm vertical midline incision through an impermeable wound protector. Two or three working ports were used. We retrospectively compared our results with the results of 18 open radical nephrectomies performed during the same period, with the patients matched for age, body mass index, and American Society of Anesthesiologists' score. RESULTS In the HALRN group, the average operating room time was 220.5 minutes, average length of stay 3.9 days, average time to return to normal activity 15.8 days, and average time to return to work 26.8 days. The median time to return to 100% normal was 28.0 days. No conversions or re-explorations were necessary in the HALRN series. The final pathologic examination revealed renal cell carcinoma in 15, oncocytoma in 1, angiomyolipoma in 1, and a complex cyst in 1. At a maximum of 48 months of follow-up (average 12.2), no recurrences were identified. Three deaths occurred in the series; 2 patients died with no evidence of disease and 1 patient died of metastatic disease (the nephrectomy was palliative). In the open group, the average operating room time was 117.8 minutes, average length of stay 5.1 days, average time to return to normal activity 23.5 days, and average time to return to work 52.2 days. The median time to return to 100% normal was 150 days, with 3 patients never returning to 100% normal. CONCLUSIONS Our series demonstrated that HALRN is a safe, effective, minimally invasive option for treating renal cell carcinoma and provides a shorter hospital stay (P = 0.02), earlier return to work (P = 0.04), and earlier return to 100% normal (P = 0.0002) than open radical nephrectomy.
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Affiliation(s)
- S Y Nakada
- Department of Surgery, Division of Urology, University of Wisconsin Medical School, Madison, Wisconsin 53792-3236, USA
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