Patient- and Surgeon-Level Variation in Patient-Reported Sexual Function Outcomes Following Radical Prostatectomy Over 2 Years: Results From a Statewide Surgical Improvement Collaborative.

Importance: Of patient-reported outcomes for individuals undergoing radical prostatectomy, sexual function outcomes are among the most reported and the most detrimental to quality of life. Understanding variations at the patient and surgeon level may inform collaborative quality improvement. Objective: To describe patient- and surgeon-level sexual function outcomes for patients undergoing radical prostatectomy in the Michigan Urological Surgery Improvement Collaborative (MUSIC) and to examine the correlation between surgeon case volume and sexual function outcomes. Design, Setting, and Participants: This is a prospective cohort study using the MUSIC registry and patient-reported sexual function outcome data. Patient- and surgeon-level variation in sexual function outcomes were examined among patients undergoing radical prostatectomy from May 2014 to August 2019. Sexual function outcome data were collected using validated questionnaires, which were completed before surgery and at 3, 6, 12, and 24 months' follow-up following surgery. All participants were male. Race and ethnicity data were self-reported and were included to examine potential variation in outcomes by race and/or ethnicity. Data were analyzed from January 2021 to March 2021. Main Outcomes and Measures: There were 4 outcomes in this study, including the 26-item Expanded Prostate Cancer Index Composite (EPIC-26) sexual function scores at 3, 6, 12, and 24 months' follow-up; patient-level sexual function recovery at 12- and 24-month follow-up; surgeon-level variation in sexual function outcomes at 12- and 24-month follow-up; and correlation between surgeon case volume and sexual function outcomes. Results: A total of 1426 male patients met inclusion criteria for this study. The median (IQR) age was 64 (58-68) years. A total of 115 participants (8%) were Black, 1197 (84%) were White, 25 (2%) were of another race or ethnicity (consolidated owing to low numbers), and 89 (6%) were of unknown race or ethnicity. Among patients undergoing bilateral nerve-sparing radical prostatectomy, mean (SD) EPIC-26 sexual function scores at 12- and 24-month follow-up (12 months, 39 [28]; 24 months, 63 [29]) did not return to baseline levels. There was wide variation in EPIC-26 sexual function scores at both 12-month follow-up (range, 23-69; P < .001) and 24-month follow-up (range, 27-64; P < .001). Similar variations were found in EPIC-26 sexual function scores and recovery of sexual function by surgeon. Recovery rates ranged from 0% to 40% of patients at 12-month follow-up (18 surgeons; P < .001) and 3% to 44% of patients at 24-month follow-up (12 surgeons; P < .001). Surgeon case volume and sexual function outcomes were not significantly correlated. On multivariable analysis, the following variables were associated with better recovery at 24-month follow-up: younger age (P < .001), lower baseline EPIC-26 sexual function score (P < .001), lower Gleason score (P = .05), and nonobesity (P = .03). Conclusions and Relevance: In this study, there was significant patient- and surgeon-level variation in sexual function recovery over 2 years following radical prostatectomy. Variation in surgeon-level sexual function outcomes presents an opportunity and model for surgical collaborative quality improvement.

Evaluation of Patient- and Surgeon-Specific Variations in Patient-Reported Urinary Outcomes 3 Months After Radical Prostatectomy From a Statewide Improvement Collaborative.

Importance: Understanding variation in patient-reported outcomes following radical prostatectomy may inform efforts to reduce morbidity after this procedure. Objective: To describe patient-reported urinary outcomes following radical prostatectomy in the diverse practice settings of a statewide quality improvement program and to explore whether surgeon-specific variations in observed outcomes persist after accounting for patient-level factors. Design, Setting, and Participants: This prospective population-based cohort study included 4582 men in the Michigan Urological Surgery Improvement Collaborative who underwent radical prostatectomy as primary management of localized prostate cancer between April 2014 and July 2018 and who agreed to complete validated questionnaires prior to surgery and at 3, 6, and 12 months after surgery. Data were analyzed from 2019 to June 2019. Exposures: Radical prostatectomy. Main Outcomes and Measures: Patient- and surgeon-level analyses of patient-reported urinary function 3 months after radical prostatectomy. Outcomes were measured using validated questionnaires with results standardized using previously published methods. Urinary function survey scores are reported on a scale from 0 to 100 with good function established as a score of 74 or higher. Results: For the 4582 men undergoing radical prostatectomy within the Michigan Urological Surgery Improvement Collaborative who agreed to complete surveys, mean (SD) age was 63.3 (7.1) years. Survey response rates varied: 3791 of 4582 (83%) responded at baseline, 3282 of 4137 (79%) at 3 months, 2975 of 3770 (79%) at 6 months, and 2213 of 2882 (77%) at 12 months. Mean (SD) urinary function scores were 88.5 (14.3) at baseline, 53.6 (27.5) at 3 months, 68.0 (25.1) at 6 months, and 73.7 (23.0) at 12 months. Regression analysis demonstrated that older age, lower baseline urinary function score, body mass index (calculated as weight in kilograms divided by height in meters squared) of 30 or higher, clinical stage T2 or higher, and lack of bilateral nerve-sparing surgery were associated with a lower probability of reporting good urinary function 3 months after surgery. When evaluating patients with good baseline function, the rate at which individual surgeons' patients reported good urinary function 3 months after surgery varied broadly (0% to 54.5%; P < .001). Patients receiving surgery from top-performing surgeons were more likely to report good 3-month function. This finding persisted after accounting for patient risk factors. Conclusions and Relevance: In this study, patient- and surgeon-level urinary outcomes following prostatectomy varied substantially. Documenting surgeon-specific variations after accounting for patient factors may facilitate identification of surgical factors associated with superior outcomes.

Delayed Urological Cancer Care during the COVID-19 Pandemic: Urologists' Experience.

INTRODUCTION: The arrival of coronavirus disrupted health care systems and forced delays in cancer treatment. We explored the experience of urologists who had to delay their patients' cancer care. METHODS: Urologists who treat prostate, bladder, and renal cancers, selected through purposive sampling, responded to a survey about cancer treatment delay. They were asked about their practice setting, decision making and interactions with patients, and they were asked to reflect on their personal experience. A 0 to 10 point scale, modeled on the National Comprehensive Cancer Network' Distress Thermometer (NCCN-DT), validated for cancer patients with cancer, was used to estimate physician distress. We used descriptive statistics to analyze survey results. RESULTS: Of the 64 participating urologists, 98% delayed surgical treatment; fewer delayed cases of advanced cancers (42% for ≥T3/T4 or Gleason ≥8 prostate cancers, 58% for muscle invasive bladder cancer, 61% for ≥T2 renal cancers). They reported feeling anxious (44%) and helpless (29%), and their median distress score was 5 (range 0-10). They relied on their own risk assessments (67%) and consulted colleagues (56%) and national guidelines (53%) when making treatment deferral decisions. They identified a number of concerns as they resumed surgeries. CONCLUSIONS: Based on a comparison to the NCCN-DT clinical cutoff distress level of 4, urologists experienced moderately high levels of distress as they delayed cancer care during the COVID-19 pandemic and expressed concerns going forward. While the focus on patient care is paramount in a pandemic, it is important to recognize physician distress and develop practical and psychological strategies for distress mitigation.

Using video review to understand the technical variation of robot-assisted radical prostatectomy in a statewide surgical collaborative.

PURPOSE: Video assessment is an emerging tool for understanding surgical technique. Patient outcomes after robot-assisted radical prostatectomy (RARP) may be linked to technical aspects of the procedure. In an effort to refine surgical approaches and improve outcomes, we sought to understand technical variation for the key steps of RARP in a surgical collaborative. METHODS: The Michigan Urological Surgery Improvement Collaborative (MUSIC) is a statewide quality improvement collaborative with the aim of improving prostate cancer care. MUSIC surgeons were invited to submit representative complete videos of nerve-sparing RARP for blinded analysis. We also analyzed peri-operative outcomes from these surgeons in the registry. RESULTS: Surgical video data from 20 unique surgeons identified many variations in technique and time to complete different steps. Common to all surgeons was a transperitoneal approach and a running urethrovesical anastomosis. Prior to anastomosis, 25% surgeons undertook a posterior reconstruction and 30% employed urethral suspension. 65% surgeons approached the seminal vesicle anteriorly. For control of the dorsal vein complex, suture ligation was used in 60%, and vascular stapler was 15%. The majority (80%) of surgeons employed clips for managing pedicles. In examining patient outcomes for surgeons, peri-operative outcomes were not correlated with surgeon's operative time; however, surgeons with an EBL > 400 ml had significant difference among the five different techniques employed. CONCLUSIONS: Despite the worldwide popularity of RARP, the operation is still far from standardized. Correlating variation in technique with clinical outcomes may help provide objective data to support best practices with the goal to improve patient outcomes.

Survey of Abdominal Access and Associated Morbidity for Robot-Assisted Radical Prostatectomy: Does Palmer's Point Warrant Further Awareness and Study?

INTRODUCTION: Laparoscopic access for robot-assisted radical prostatectomy (RARP) is often initiated in the periumbilical location. Palmer's point, located in the left upper quadrant, has been reported as an alternative access site for pelvic laparoscopy to reduce morbidity, but not widely reported among urologists. To better understand surgeons' preferences for access and its associated morbidity during RARP, we surveyed surgeons from two urologic organizations. METHODS: An anonymous online questionnaire (SurveyMonkey) consisting of 17 questions that assessed training, experience, and preferences for RARP was emailed in December 2014 and collected until February 2015 to members performing RARP of the Endourology Society (ES) and the Michigan Urological Society Improvement Collaborative (MUSIC). Surgeons were also asked to share their personal experience with a vascular, death or life-threatening event (DOLTE), or bowel injury during RARP. RESULTS: Questionnaires were answered by 111 surgeons in total (ES, n = 71 and MUSIC, n = 40) with an estimated total response rate of 5.5%. In total, 77% reported prior experience with the Veress needle method before exposure to RARP and 71% of respondents primarily use the Veress needle for RARP, with 73% reporting access primarily at the periumbilical location. A personal experience with a vascular or a bowel injury during Veress needle insertion was reported in 18% and 9% of surgeons, respectively; furthermore, 26% of respondents were personally aware of at least 1 DOLTE among colleagues (5% reported 3 or more). The majority (56%) of respondents were unaware of Palmer's point, while among the minority aware of Palmer's point, only 33% reported ever using this location. CONCLUSION: In this survey, surgeons most commonly access the abdomen at the periumbilical location with a Veress needle for RARP with the majority not aware or utilizing Palmer's point. Nearly one in five surgeons reported a personal experience with a vascular injury during access for RARP. Palmer's point, located away from major vasculature, may reduce the morbidity of access for RARP and warrants further awareness and study.

Upper quadrant port placement for robot-assisted renal surgery: implementation of the Floating Arm and the XL Protype.

UNLABELLED: Abstract Background and Purpose: Placement of the fourth arm (4th arm) in the lower quadrant (LQ) is commonly described for robot-assisted renal surgical procedures but has anatomic restrictions and limited ergonomics. An alternative, upper quadrant (UQ) location is desirable, but patient habitus and spacing may restrict robotic attachment. We investigate current trends in 4th arm port placement and propose an alternative method at attaching the robot-the "Floating Arm" (FLA). METHODS: Robotic surgeons from the Endourological Society were surveyed. A 20-cm extra-long (XL Protype) da Vinci instrument was developed for the FLA technique. A dry lab allowed quantitative comparison of spacing and ranges of motion for standard da Vinci ports (dVP), bariatric dVP, telescoping dVP, and FLA. RESULTS: There were 108 respondents who participated. Half of the respondents avoid using the 4th arm (30% lack of need and 20% because of interference). The majority (90%) typically positions the 4th arm in the LQ, but many reported limitations in this location. Few (5%) place 4th arm in the UQ, while most (73%) have never heard of UQ placement. Existing techniques may increase shoulder height clearance but inversely shorten the working length of the instrument intracorporeally. Alternatively, the XL Protype significantly increased the shoulder length and maintained available working distances intracorporeally. Adjacent arm interference angle was essentially identical (27 degrees) for all ports except a greater range of movement for the XL Protype (35 degrees). CONCLUSION: Few surgeons are using an UQ positioning or use techniques to improve attachment of the 4th arm. The greatest freedom may be obtained by implementing the FLA, but this necessitates production of a longer instrument.

Improvised method to retrieve a proximally displaced ureteral stent in a remote surgical setting.

PURPOSE: To present an improvised method for repositioning a proximally displaced stent using only a cystoscope and a guidewire. METHODS: A Glidewire guidewire (Boston Scientific) was passed through a cystoscope and into the distal ureter, and manipulated up the ureteral stent into the renal pelvis, reflected, and passed antegrade down the ureter and into the bladder. The guidewire was then grasped in the bladder, clamped at the penis, and retracted, pulling the stent back into the bladder. RESULTS: The patient proceeded with lithotripsy, and the stent was removed in 2 weeks without complication. CONCLUSION: Methods at retrieving proximally displaced ureteral stents after deployment have been previously reported; however, these methods necessitated access to a ureteroscope and special graspers/baskets that may not be available in an outpatient surgical center setting. Here, an improvised method for stent repositioning using only a cystoscope and a guidewire allowed successful retrieval of a proximally migrated stent.

A multi-institutional study on the safety and efficacy of specimen morcellation after laparoscopic radical nephrectomy for clinical stage T1 or T2 renal cell carcinoma.

INTRODUCTION AND OBJECTIVE: Specimen morcellation during laparoscopic radical nephrectomy (LRN) for renal cell carcinoma (RCC) is controversial. We seek to evaluate the safety and efficacy of specimen morcellation and LRN for treatment of presumed malignant renal lesions. METHODS: We retrospectively reviewed all patients who underwent LRN at three academic institutions from 1996 to 2007. One hundred eighty-eight patients underwent specimen morcellation after LRN for enhancing solid or cystic renal masses. RESULTS: LRN was successfully performed on all the patients. Patient age ranged from 36 to 94. One hundred sixty-seven patients were in clinical stage T1, 19 patients T2, and unknown in two. The specimen was manually morcellated within a Cook Lap Sac or Endocatch II bag under laparoscopic or direct observation. On histological review of morcellated specimens, 165 patients were confirmed to have RCC, 17 had an oncocytoma, and 2 had benign cysts. At least 13 patients with RCC were pathologically upgraded to stage T3. Mean operative time was 225 minutes (range 94-650). Mean hospital stay was 2.5 days (range 1-8). In patients with RCC, 11 developed recurrent disease with mean follow-up of 21 months (range 0.3-111). In one patient, a port site recurrence occurred in concert with renal fossa and lymph node metastases. CONCLUSIONS: Intracorporeal mechanical morcellation after LRN appears to be safe and effective in clinical stage T1 and T2 RCC. This supports the use of morcellation as an alternative for intact specimen removal in properly selected patients.

Safety and efficacy of laparoscopic radical nephrectomy with manual specimen morcellation for stage cT1 renal-cell carcinoma.

BACKGROUND AND PURPOSE: Specimen morcellation during laparoscopic radical nephrectomy for renal-cell carcinoma is controversial, and supporting literature remains sparse. We seek to evaluate the safety and efficacy of morcellation for specimen removal after laparoscopic radical nephrectomy for management of renal lesions of malignant potential at a single institution. MATERIALS AND METHODS: We retrospectively reviewed the records of all patients who underwent laparoscopic radical nephrectomy at Northwestern Memorial and Evanston Hospital from 2001 to 2006. Twenty-two patients were identified who underwent specimen morcellation for extraction after laparoscopic nephrectomy that was performed for enhancing solid or cystic renal masses. RESULTS: Laparoscopic radical nephrectomy was performed on all the patients. Patient age ranged from 36 to 96 years old. All patients were clinical stage T(1)N(0)M(0). The specimen was mechanically morcellated within Cook Lap Sac under direct and laparoscopic vision. Average tumor size after morcellation was 3.0 cm. On histologic review of the morcellated specimen, 18 patients were confirmed to have renal-cell carcinoma, 2 had an oncocytoma, and 2 had benign cysts. One patient with renal-cell carcinoma had a pathologic upgrade to stage T(3b). Average operating time was 268 minutes (range 110 to 389 min). With the exception of the patient who became anephric after nephrectomy, average hospital stay was 2.6 days. A mean clinical and radiographic follow-up of 434 days failed to show any known disease progression or port site recurrence in patients with renal-cell carcinoma. CONCLUSIONS: Intracorporeal, mechanical morcellation after laparoscopic radical nephrectomy appears to be safe and effective in clinical stage T1 renal-cell carcinoma. This study adds to current literature that promotes the use of morcellation as an alternative for intact specimen removal in properly selected patients. Further prospective studies are necessary to show long-term oncologic outcomes.

Measuring convalescence after laparoscopic surgery.

OBJECTIVES: To better understand the relationships between case-mix, processes of care, and recovery after laparoscopic surgery. METHODS: Patient recovery was prospectively measured among patients undergoing laparoscopic nephrectomy (n = 308), partial nephrectomy (n = 81), nephroureterectomy (n = 30), and cyst decortication (n = 46). Convalescence was measured using the SF-12 and visual analog pain scales administered preoperatively and at 2 and 6 weeks postoperatively. Patient-reported time to events (eg, driving, normal, nonstrenuous activity) were also measured. Mixed models (SF-12 and pain scores) and Cox proportional hazards models (time to event) were fit to determine the association of case-mix and processes of care with the recovery measures. RESULTS: With the exception of mental health, all convalescence measures demonstrated significant variability across procedure type. The time to return to normal, nonstrenuous activity was 12.8 +/- 9.8, 11.9 +/- 9.2, 21.6 +/- 11.9, and 12.0 +/- 9.0 days for patients undergoing nephrectomy, partial nephrectomy, nephroureterectomy, and cyst decortication, respectively (P < 0.01). The baseline scores were robust predictors of physical, mental, and pain recovery (all P < 0.01). The surgical approach was associated with postoperative pain recovery and return to normal activity (all P < 0.05). Compared with the preoperative characteristics, the perioperative processes of care did not explain the additional variation in any of the recovery measures. CONCLUSIONS: The variation in recovery among the various laparoscopic kidney procedures is significant. The baseline health status of the patient and the preoperative processes (planned procedure, planned surgical approach) strongly influence postoperative recovery.

Growth rates of renal cell carcinoma and oncocytoma under surveillance are similar.

OBJECTIVE: Through examining our experience with renal mass surveillance, we hoped to determine factors suggestive of renal cell carcinoma. METHODS: We followed for at least 1 year 41 patients with 47 solid renal masses (mean diameter 2.0 cm, range 0.8-5). Mean surveillance duration was 29 months and was more than 2 years for 23 masses (49%). RESULTS: Overall mean increase in diameter was 0.27 cm/year, but 21 (45%) did not grow, and mean growth rate was 0.5 cm/year in the 26 that did grow. Of the masses, 14 have been treated, 33 continue to be followed, and pathology is known in 16 (34%). Growth was seen in all 6 known oncocytomas (mean 0.52 cm/year), 80% of the 10 biopsy proven renal cell carcinomas grew (mean 0.71 cm/year), but only 12 (39%) of the masses with unknown pathology (0.08 cm/year). There was no factor that distinguished oncocytomas from renal cell carcinomas. In 1 patient, a 3-cm mass that had not changed in size for 6 years doubled in size over 6 months, and metastatic disease developed. CONCLUSIONS: Although growth of most renal masses is slow, some grow quickly, and delayed growth with metastases can occur. No factor distinguished renal cell carcinomas from oncocytomas. Surveillance for renal masses remains an option but must be rigorous and continuous, and is not without risk of progression.

Acute integrity of closure for partial nephrectomy: comparison of 7 agents in a hypertensive porcine model.

PURPOSE: We assessed the acute effectiveness of closure after partial nephrectomy of 7 techniques in a large hypertensive porcine model using shallow and deep resections to approximate clinical situations. MATERIALS AND METHODS: Open surgical partial nephrectomy with hilar clamping was performed in pigs weighing 150 to 200 lbs, including small-a quarter length and a quarter width of kidney, medium-a third length and a third width of kidney, and into the renal sinus and up to the collecting system, and large-lower pole heminephrectomy at the renal sinus. Seven agents were compared after a single application, namely thrombin/collagen granules, polyethylene glycol hydrogel, fibrin glue, thrombin/gelatin granules, cyanoacrylate glue, fibrin glue/gelatin sponge and sutured bolster. Failure and success were determined by the presence or absence of bleeding, respectively, after unclamping and by an increase in SBP to 100 and then to 200 mm Hg with dopamine infusion. RESULTS: Of 70 partial nephrectomies the success rates were 33% and 14% for thrombin/collagen granules, and 67% and 0% for polyethylene glycol hydrogel in small and medium resections; 100%, 71% and 0% for fibrin glue, and 100%, 86% and 0% for thrombin/gelatin granules in small, medium and large resections; and 67% and 80% for cyanoacrylate glue, 100% and 20% for fibrin glue/gelatin sponge, and 100% for sutured bolster in medium and large resections, respectively. Of the kidneys that did not bleed at an SBP of 100 mm Hg 31% bled at 200 mm Hg. CONCLUSIONS: There is considerable variability among agents. Most were effective for small resections and some worked for medium resections but for large resections only sutured bolster was consistently effective. SBP also appears to be an important factor. These results bear on the selection of techniques during laparoscopic partial nephrectomy.

200 consecutive hand assisted laparoscopic donor nephrectomies: evolution of operative technique and outcomes.

PURPOSE: Despite the popularity of hand assisted laparoscopic donor nephrectomy published experience is less than that with standard laparoscopic donor nephrectomy and few critical assessments of operative maneuvers have been described. MATERIALS AND METHODS: We describe the impact of changes in operative technique made by a single surgeon during 200 hand assisted laparoscopic donor nephrectomies. RESULTS: With a mean operative time of 229 minutes and hospital stay of 1.9 days the rates of conversion to open surgery, intraoperative complications and major postoperative complications were 1%, 1.5% and 6%, respectively. Lasting changes in technique were dissection of a ureteral/gonadal packet, bipolar cautery use on gonadal/adrenal/lumbar veins and resting the kidney before removal. The incidence of ureteral complications decreased from 8% to 5.1% with dissection of the ureter in conjunction with the gonadal vein rather than isolating it. Warm ischemia time decreased from a mean of 186 to 143 seconds with bipolar electrocautery instead of clips to control gonadal/adrenal/lumbar veins. After starting to rest the kidney before removal the incidence of primary graft nonfunction and delayed function decreased from 6.7% to 0% and 30% to 11.8%, respectively, with a corresponding improvement in 2-year graft survival from 83% to 95%. CONCLUSIONS: This large series of hand assisted donor laparoscopic nephrectomies with a mean followup approaching 3 years demonstrates that the procedure is safe for the donor and procures a good specimen. Decreases in ureteral complications, warm ischemia time and graft dysfunction might be attributable to specific changes in our operative technique.

Wound complications after hand assisted laparoscopic surgery.

PURPOSE: Hand assisted laparoscopic surgery (HALS) provides benefits similar to standard laparoscopy but generally requires a larger incision. We assessed the nature of and risk factors for incisional complications after HALS. MATERIALS AND METHODS: All patients who underwent HALS at our institution from February 1997 through December 2003 were included in a prospective and retrospective review to assess postoperative wound complications. Literature regarding wound complications associated with open surgery and standard laparoscopy was reviewed. RESULTS: A total of 424 consecutive procedures performed on 422 patients were evaluated. Postoperative HALS incision site complications included 29 infections (6.8%), 15 hernias (3.5%) and 2 dehiscences (0.5%). Multivariate logistic regression models revealed that HALS incision site hernias were associated with current or past tobacco smoking (6.0%, p = 0.04), with a trend toward significance for diabetes mellitus (14%, p = 0.07), male gender (5.3%, p = 0.08) and renal failure (16%, p = 0.08). HALS incision site infections were associated with omission of perioperative antibiotics (13%, p = 0.007), obesity (12%, p = 0.03) and increased operative time (252 vs 222 minutes in patients with and without infection, respectively, p = 0.001). CONCLUSIONS: Our findings suggest that wound infections and hernias occur less frequently with HALS than with open surgery, but more often than with standard laparoscopy. Certain patient comorbidities (eg obesity), modifiable risk factors (eg smoking status) and procedural variables (eg omission of perioperative antibiotics or length of procedure) may adversely influence HALS wound complications. This information can be used to decide between HALS and standard laparoscopic approaches in particular patients.

Fibrin glue v sutured bolster: lessons learned during 100 laparoscopic partial nephrectomies.

PURPOSE: Laparoscopic partial nephrectomy (LPN) is performed with marked technical variations. We defined the limits of sutureless LPN and determined which closure technique is best in a particular situation. MATERIALS AND METHODS: During 100 consecutive LPNs fibrin glue products were used for closure in the first 75 (group 1) and sutured bolsters were applied when the collecting system (CS) or renal sinus was entered in the final 25 (group 2). RESULTS: In groups 1 and 2 hand assisted laparoscopy was used in 72% vs 40% of cases and hilar clamping was used in 27% vs 92%, respectively. Mean tumor size was 25 vs 26 mm, tumor depth was 11 vs 13 mm, distance to the renal sinus was 9 vs 5 mm, operating room time was 185 vs 210 minutes, estimated blood loss was 398 vs 247 cc and hospital stay was 2.9 vs 2.6 days in groups 1 and 2, respectively. Overall postoperative hemorrhage and urine leakage occurred in 9% and 2% of patients, respectively. Tumors associated with postoperative hemorrhage/leakage tended to be larger (35 vs 24 mm, p = 0.007) and closer to the renal sinus (0.5 vs 8.2 mm, p = 0.02). Postoperative hemorrhage or urine leakage occurred in 41% of the 17 patients in group 1 with CS or renal sinus entry but in only 2 of the 58 (3.4%) without entry (p <0.0001). In group 2 hemorrhage/leakage occurred in 11% of the 18 patients with CS or renal sinus entry (vs same subset in group 1, p = 0.04). CONCLUSIONS: LPN with closure using fibrin glue products provides adequate hemostasis when the CS or renal sinus is not entered. When the CS or renal sinus is entered, a sutured bolster is recommended.

Comparison of neuromuscular injuries to the surgeon during hand-assisted and standard laparoscopic urologic surgery.

BACKGROUND AND PURPOSE: Hand-assisted procedures have assumed a greater role in the practice of many laparoscopists. We surveyed major laparoscopy program directors to compare the incidence and location of neuromuscular injury to the surgeon during hand-assisted laparoscopic (HAL) and standard laparoscopic (SL) surgery. MATERIALS AND METHODS: A questionnaire on neuromuscular injuries was e-mailed to 42 laparoscopic program directors. Respondents were instructed to report only injuries or pain associated with laparoscopic surgery when they were the primary responsible surgeon and not during open or endoscopic procedures. RESULTS: Surveys were returned from 23 attending laparoscopic surgeons and 2 laparoscopic fellows. Surgeons reported an average of 3.9 HAL and 6.3 SL cases per month as the primary surgeon. The HAL was completed with the GelPort, LapDisk, Omniport, or a combination of devices 55%, 22%, 5%, and 14%, respectively, of the time. Comparing HAL with SL, there was significantly more hand/wrist, forearm, and shoulder pain/injuries associated with HAL (P < 0.004). There was significantly more neck pain associated with SL than HAL (P < 0.003), but no significant difference in lower-back pain (P = 0.40). Comparing the two most commonly used hand-assist devices (GelPort and LapDisk), the LapDisk demonstrated significantly more hand/wrist pain or injury (P = 0.001). CONCLUSION: Hand-assisted laparoscopy is associated with more frequent neuromuscular strain to the upper extremity than SL, but SL surgeons experience more neck pain or injury. Surgeon discomfort is also dependent on the type of hand-assist device. The long-term consequences of physical strain on the laparoscopic surgeon are unknown currently, but measures to minimize neuromuscular strain should be considered.