Hand assisted laparoscopic donor nephrectomy: a comparison with the open approach.

PURPOSE: Hand assisted laparoscopy combines aspects of open and laparoscopic surgery. A hand in the abdomen may facilitate laparoscopic live donor nephrectomy, allowing more urologists to participate. We report and compare our initial series of hand assisted laparoscopy donor nephrectomy with nephrectomy performed by standard open methods. MATERIALS AND METHODS: In the last 18 months 60 patients at 2 institutions underwent hand assisted laparoscopy donor nephrectomy. This cohort was compared to a contemporary group of 31 patients who underwent open donor nephrectomy via a flank incision at our 2 institutions. Demographic and outcome data were compared retrospectively in a nonrandomized fashion in the 2 groups. RESULTS: Demographic data on patient age, male-to-female ratio and body mass index were similar in the 2 groups. Operative time, transfusion rate, time to oral intake and complications were also similar. However, estimated blood loss, change in hematocrit preoperatively to postoperatively, hospitalization, parenteral and oral narcotic requirement, and donor convalescence were significantly less in the hand assisted laparoscopy versus open groups. In terms of allograft function, nadir creatinine, time to nadir creatinine, creatinine clearance at 6, 12, and 18 months, delayed graft function, episodes of acute rejection and ureteral stricture were similar in the groups. CONCLUSIONS: Hand assisted laparoscopy is safe, efficacious and reproducible for living related donor nephrectomy. Compared with the open technique hand assisted laparoscopy provides the donor with significantly decreased postoperative morbidity, while enabling excellent allograft function. Further randomized prospective studies are warranted.

Hand-assisted laparoscopic nephroureterectomy versus open nephroureterectomy for the treatment of transitional-cell carcinoma of the upper urinary tract.

BACKGROUND AND PURPOSE: For patients with upper tract transitional-cell carcinoma (TCC), nephroureterectomy with removal of a bladder cuff is the standard of care. Historically, it has been performed using two incisions or one large incision extending from the lateral flank to the symphysis pubis. We describe an alternative using endoscopic management of the bladder cuff combined with hand-assisted laparoscopic (HAL) nephroureterectomy. We compared our results using these minimally invasive advances with those of a contemporary open nephroureterectomy series. PATIENTS AND METHODS: Between May 1998 and June 1999, we performed 11 HAL nephroureterectomies with endoscopic management of the bladder cuff for the treatment of upper tract TCC. The results were compared with those in a contemporary series of 11 patients undergoing the traditional open operation at our institution. The patient age, male:female ratio, and ASA classification were similar in the two groups. Intraoperative measures considered were operative time, estimated blood loss, need for transfusion, complications, specimen weight and volume, pathologic stage and grade of the tumor, and the status of the surgical margins. Postoperative endpoints were time to sustained fluid intake; epidural, parenteral, and oral narcotic requirements; length of stay; and complications. Follow-up, specifically disease recurrence and overall survival, was recorded. RESULTS: The mean operative time was 291 minutes for HAL v 232 minutes for the open operation (P = NS). The average blood loss was 144 v 311 mL (P = 0.04), the mean specimen weight 368 v 392 g (P = NS), and the mean specimen volume was 630 v 693 cc (P = NS). No patient in the HAL group had a positive surgical margin, but one patient in the open surgery group did. The time to sustained fluid intake postoperatively averaged 1.4 v 2.3 days for the HAL and open groups, respectively (P = NS). The epidural narcotic requirement was 0 v 2.7 days (P < 0.001), the mean parenteral narcotic requirement was 45 v 44 mg of morphine sulfate equivalent (P = NS), and the oral narcotic requirement was 5.8 v 16 tablets (P < 0.04). The average length of stay was 4.6 days for the HAL group v 6.1 days for the open group (P = 0.04). In both groups, 7 of the 11 patients (63%) were without evidence of disease with a mean follow-up of 13 (HAL) and 17 (open) months. CONCLUSIONS: Hand-assisted laparoscopic nephroureterectomy with endoscopic management of the bladder cuff is an efficacious alternative to open surgery. The operative time, specimen weight and size, and risk of recurrence for the two procedures are similar. However, convalescence, as measured by pain medication requirements and length of stay, is significantly better with laparoscopy. Longer follow-up with larger numbers of patients is in progress.

Hand-assisted laparoscopic partial nephrectomy.

BACKGROUND AND PURPOSE: The indications for partial nephrectomy are expanding as newer and more complete data come forth. A partial nephrectomy has traditionally required a generous flank incision. We report our experience using hand-assisted laparoscopy (HAL) as a less-invasive approach to partial nephrectomies. PATIENTS AND METHODS: Between October 1999 and May 2000, we performed 11 HAL partial nephrectomies. The average age of the patients was 55.7 years, the average body mass index was 25.6, and the average ASA class was 2.2. The indications for partial nephrectomy were enhancing solid renal lesions (N = 9) and nonfunctioning renal moiety in a duplicated system (N = 2). In the majority of cases, access to the renal pedicle was obtained prior to the partial nephrectomy. However, in no case did the renal artery or vein require occlusion. Several excisional techniques were employed, but all relied heavily on the Harmonic Scalpel in conjunction with the argon beam coagulator. Different hemostatic agents were applied to the renal defect, including Surgicel, Avitene, and fibrin-soaked Gelfoam activated by thrombin. In several instances, pledget reinforced sutures were placed in the renal capsule to aid with hemostasis. RESULTS: The average operative time was 273 minutes, the estimated blood loss 319 mL, and the change in hematocrit 7.3 points. No patient required a transfusion, and there was one conversion to open. Postoperatively patients, required an average of 35.6 mg of morphine sulfate equivalent and 8.2 narcotic tablets, resumed oral intake in 1.7 days, and were discharged home in 3.3 days. There were no major complications and only two minor complications. Postoperatively, five lesions were found to be benign, four lesions were confirmed to be malignant, and two lesions were consistent with a nonfunctioning duplicated renal moiety. Specimen size averaged 180 cc, and the tumor diameter averaged 1.9 cm. There were no positive surgical margins. CONCLUSIONS: Hand-assisted laparoscopic partial nephrectomy is feasible and reproducible. The surgeon's hand in the operative field facilitates dissection, vascular control, hemostasis, and suturing. Further long-term and prospective studies are underway.

Hand-assisted laparoscopy in urology.

Hand-assisted laparoscopy (HAL) allows surgeons direct hand contact with the operative field, maximizing tactile feedback and minimizing surgical injury to the patient. Indications for HAL include radical, donor, and partial nephrectomies, nephroureterectomy, and, most recently, dismembered pyeloplasties. The advantages of HAL surgical techniques in comparative experience with standard laparoscopic technique are described.

Hand-assisted laparoscopic nephroureterectomy for the treatment of transitional cell carcinoma of the upper urinary tract.

OBJECTIVES: Nephroureterectomy with removal of the bladder cuff is the standard of care for patients with upper tract transitional cell carcinoma. Historically, it has been performed using two separate incisions or one large incision extending from the lateral flank to the symphysis pubis. We describe an alternative technique using endoscopic and hand-assisted laparoscopic techniques and present our experience. METHODS: During the past 18 months, 22 patients at two institutions underwent hand-assisted laparoscopic nephroureterectomy. In 19 patients, the distal ureter and bladder cuff were managed endoscopically. In 3 patients, the distal ureter and the bladder cuff were removed by an extravesical, laparoscopic technique. The intraoperative parameters assessed included operative time, estimated blood loss, specimen weight, surgical margin status, pathologic grade and stage, and acute complications. Postoperative endpoints included the time to sustained fluid intake, parenteral narcotic requirement (milliequivalents of morphine sulfate), oral narcotic requirement (number of tablets), length of stay, time until return to normal activity, and rate of tumor recurrence. RESULTS: The average age of our patient population was 65 years (range 42 to 86), 10 patients were men and 12 were women, and the average American Society of Anesthesiologists classification was 2.2. All but 2 patients had their specimens removed en bloc. No intraoperative complications occurred. The average operative time was 272 minutes (range 190 to 440), and the average blood loss was 180 mL (range 50 to 400); no patient required a transfusion. The mean specimen weight was 457 g (range 190 to 1420). All 22 patients had negative surgical margins. Postoperatively, the time to sustained fluid intake averaged 2.1 days (range 1 to 7), the mean parenteral narcotic requirement was 55 mEq (range 12 to 107.8) of morphine sulfate, the mean oral narcotic requirement was 5.8 tablets (range 1 to 14), and the average length of stay was 4.1 days (range 3 to 14). One patient developed thrombophlebitis of the right external jugular vein from a central line and required 2 weeks of intravenous antibiotics. The mean time to return to normal activity was 19 days; the mean follow-up was 13 months. Six patients had disease recurrence: four low-grade, low-stage bladder tumors and two metastatic tumors. All patients were alive at 18 months. CONCLUSIONS: Hand-assisted laparoscopic nephroureterectomy with endoscopic management of the bladder cuff is a viable and efficacious alternative to open nephroureterectomy. The technique allows the surgeon to perform an en bloc resection of the kidney, ureter, and bladder cuff without compromising oncologic principles. Patients benefit from a decrease in pain and hospital stay and quicker convalescence. Longer follow-up and comparative studies to standard open techniques are underway.

Hand-assisted laparoscopic surgery.

Hand-assisted laparoscopic surgery has been used to perform nephrectomies. This report contrasts the efficacy, postoperative morbidity, length of stay, analgesic use, and time to recovery for hand-assisted laparoscopic nephrectomy, to standard laparoscopic and open nephrectomy. The technique for hand-assisted laparoscopic nephrectomy used at two institutions is described. The results from these two institutions are contrasted to results in the literature for standard laparoscopic and open nephrectomy. Standard and hand-assisted laparoscopic nephrectomy seem similar in terms of efficacy of surgery, time of surgery, estimated blood loss, length of stay, and time to full recovery. The two laparoscopic techniques seem to show advantage over open surgery in respect to shorter hospital stay, faster full recovery, and less analgesic use. The operative time for the laparoscopic surgeries is longer than the open surgery operating time. Hand-assisted laparoscopic surgery seems to be equivalent to standard laparoscopy. As urologists around the world are trained in hand-assisted laparoscopic nephrectomy, a more refined look at these early results will be possible.

Simple nephrectomy: hand-assisted technique.

Chronic inflammation or prior surgical procedures may complicate the laparoscopic performance of simple nephrectomy. In these difficult cases, hand-assisted laparoscopy may be useful. The position of the hand port depends on the particular situation, but the port must allow flexion of the wrist and access to the entire surgical field. The hand-assisted procedure is similar to standard laparoscopy in analgesic use, time to oral intake, length of stay, and time to full recovery. Hand-assisted laparoscopy allows the inexperienced surgeon to perform laparoscopy with the aid of tactile sensation and three-dimensional spatial orientation. For the experienced surgeon, the technique offers an alternative to open conversion when the laparoscopic procedure fails to progress.

Lateral transperitoneal laparoscopic adrenalectomy.

Several laparoscopic approaches to the adrenal gland have been described. The lateral transperitoneal approach has several distinct advantages when contrasted with other techniques for laparoscopic adrenalectomy (LA). We present our technique and results obtained in 50 consecutive transperitoneal LAs. We review 50 consecutive laparoscopic adrenalectomies (28 female, 19 male) performed from 1993 to 1998 S.J. Shichman or R.E. Sosa was either the primary surgeon or the first assistant for all cases. The lateral transperitoneal approach described below was used in all cases. Indications for adrenalectomy included Cushing's syndrome (13), aldosteronoma (15), pheochromocytoma (7), nonfunctioning adenoma (11), hyperplasia (2), and 1 case each of Carney's syndrome and metastasis to the adrenal gland. We performed 5 bilateral, 22 left, and 18 right laparoscopic adrenalectomies. The average time needed for bilateral adrenalectomy was 503 min (range 298-690 min); for left adrenalectomy, 227 min (range 121-337 min); and for right LA, 210 min (range 135-355 min). We demonstrated a yearly trend in lower operative times. The largest adrenal gland removed measured 13.8 x 6.7 x 3.5 cm. Intraoperative blood loss was low. Only one patient received a blood transfusion. Conversion to open adrenalectomy was not required. Postoperative analgesic requirements were low. The average length of stay was 3.8 days for bilateral LA and 3 days for unilateral LA. Complications occurred in 5 patients (2 wound infections, 2 hematomas, and 1 pleural effusion). There was no mortality. Lateral transperitoneal adrenalectomy is a safe and efficient technique for the removal of functional and nonfunctional adrenal masses. This technique is associated with low morbidity, a minimal postoperative analgesic requirement, and a short hospital stay and, in our opinion, is more versatile than the retroperitoneal approach.

Bilateral laparoscopic adrenalectomy for adrenocorticotropic dependent Cushing's syndrome.

PURPOSE: We report our experience with bilateral laparoscopic adrenalectomy for total adrenal ablation in patients with Cushing's syndrome. MATERIALS AND METHODS: Four women (mean age 63 years) with Cushing's syndrome secondary to nonlocalized ectopic adrenocorticotropic hormone production in 3 and pituitary microadenoma after failed transsphenoidal ablation in 1 underwent bilateral transabdominal laparoscopic adrenalectomy. Preoperatively risk was III or IV according to the American Society of Anesthesiologists classification. RESULTS: In all cases bilateral laparoscopic adrenalectomy was successfully performed. Operative time ranged from 375 to 475 minutes (mean 404) and mean blood loss was 162 cc. All patients resumed oral intake on postoperative day 1, mean number of postoperative parentral narcotic doses was 2.25 and mean postoperative hospital stay was 5.75 days (range 3 to 8). Complications included an abdominal wall hematoma. All patients resumed baseline activity by postoperative day 14. CONCLUSIONS: Our experience in 4 cases of Cushing's syndrome suggests that bilateral laparoscopic adrenalectomy is a safe and effective alternative to open adrenalectomy. Further experience with this technique will likely decrease operative time, and confirm the benefit of a decreased hospital stay and convalescence.

A comparison of open vs laparoscopic adrenalectomy.

BACKGROUND: To compare the outcome of patients who underwent laparoscopic transabdominal adrenalectomy (LA) with those who had open adrenalectomy (OA). METHODS: A retrospective review of consecutive adrenalectomies performed by a single surgical team at a university hospital. Outcome measurements were operative time, operative blood loss, procedure-related complications, postoperative stay, and return to regular activity. RESULTS: Twenty-nine adrenalectomies were done in 23 patients during a 54-month period. There were 12 OAs performed in nine patients and 17 LAs were done in 14 patients. Both groups were similar in their demographics and their indications for operation. All attempted LAs were successfully completed. The mean operative time was longer for LA than for OA (289 vs 201 min; p = 0.042). Resumption of oral intake (1.0 vs 3.0 days; p = 0.002), postoperative hospital stay (3.0 vs 7.9 days; p = 0.002), and return to regular activity (8.9 vs 14.6 days; p = 0.002) were significantly shorter after LA than after OA. There were no postoperative deaths and there was no difference in operative blood loss between the two groups. Procedure-related complications occurred in three patients having LA and in five patients having OA. CONCLUSIONS: Patients having LA had longer operative procedures but shorter hospital stays and faster return to normal activity than patients having OA. Procedure-related complications for LA were due to bleeding into the retroperitoneum or abdominal wall. Significant postoperative cardiac and respiratory complications occurred only in the OA group.

Laparoscopic laser-assisted bladder autoaugmentation.

OBJECTIVES: The purpose of this study is to examine the feasibility of performing a laparoscopic bladder autoaugmentation and to assess the urodynamic characteristics of an autoaugmented bladder. METHODS: Laparoscopic bladder autoaugmentation was performed in 9 female canines (20 to 30 kg). Following laparoscopic access to the peritoneal cavity, a midline bladder seromyotomy was performed using the potassium titanyl phosphate 532 nm laser. This produced a large bladder diverticulum. Changes in bladder volume and compliance were quantified over a 3-month period of follow-up. RESULTS: Urodynamic evaluation demonstrated an increase in bladder capacity 6 weeks postoperatively in 8 of 9 dogs, with an average volume increase of 45%. Bladder compliance improved in 7 of 9 dogs with an average increase in compliance of 67%. Three months postoperatively, bladder capacity remained increased in 5 of 9 dogs, with an average increase in volume of only 5.3%. An improvement in compliance was sustained in 5 of 9 animals with an average increase of 13.9%. Laparoscopic exploration revealed grossly normal bladders with adhesions of omentum to the seromyotomy site in all canines and the anterior abdominal wall in 2 of 9 canines. Histologically, the seromyotomy site was devoid of muscle with an intact urothelium and a proliferation of loose connective tissue. CONCLUSIONS: The technique of laparoscopic bladder autoaugmentation can be performed easily in the canine model. Although results at 6 weeks show significant improvement, the longer term, 3-month results were not statistically significant. This technique has the potential to offer a minimally invasive correction for patients with low-capacity, high-pressure bladders that have failed pharmacologic treatment.

[Complications of laparoscopic surgery in urology]. / Complicaciones de la cirugía laparoscópica en Urología.

More and more laparoscopic procedures are performed in Urology each day. Attempts at reducing the invasiveness of conventional surgical procedures and the possibility of permitting patients to resume their activities earlier have considerably extended the indications for laparoscopy. Laparoscopic access to the urinary system is not simple since it is almost completely located in the retroperitoneal region and peritoneal insufflation with CO2 puts organs that were previously protected within the abdominal cavity at risk. The urologist must operate in a surgical field that was previously unfamiliar to him, with no stereoscopic vision and using instruments without all of the functions of those of conventional surgery. The complications of laparoscopic surgery may present intraoperatively or late postoperatively. Correct patient selection and preparation can prevent many of the complications that arise during trocar insertion. The physiological response to peritoneal insufflation with CO2 must be well understood if the possible complications arising from pneumoperitoneum are to be prevented or correctly treated. The different complications of laparoscopic surgery in Urology are described. The potential problems of the different stages of the procedure, the pathophysiological aspects, prevention and treatment are discussed.

Learned helplessness and depression among Israeli women.

Depressed and nondepressed Ss were exposed to either inescapable noise or no noise conditions in an attempt to replicate a typical learned helplessness study (Miller & Seligman, 1975) with Israeli student nurses. The inescapable noise was presented either as a personally important task or as an unimportant task. When later tested on a series of 20 patterned anagrams, no performance differences were found between depressed and nondepressed Ss as was found in previous studies, nor did the importance manipulation affect performance. Within the depressed group only, it was found that the more the Ss believed they had control over the noise, the better was their performance in the anagrams. Similarly, only among the depressed was the rated aversiveness of the noise positively related to anagram performance. Depressed were only able to assess accurately the number of failures on the anagrams, while nondepressed did equally well in assessing both positive and negative aspects of their performance. The results are discussed in terms of Seligman's learned helplessness model of depression and Beck's cognitive model of depression.