Background

and time-consuming; moreover, it is important to note that the application pertained solely to extirpative laparoscopy for benign uterine diseases and morcellation was performed without specimen isolation. Thus, issues of tumor dissemination have been secondary in the removal of uterine tissue.

Several principles and lessons emerge from the existing experience. First, little data address the application of laparoscopy to the removal of solid organs harboring tumor. The majority of minimally invasive procedures involved either the uterus or spleen, where malignant diseases were excluded. In most cases, simple morcellation without an entrapment sac was performed. Second, previous studies raise significant concerns regarding cellular seeding or spillage. Cases of endometriosis and retained tissue fragments, as well as splenosis, have been reported after intraperitoneal morcella-tion of the uterus and spleen, respectively (14-16). In addition, dissemination of uterine cancer has been reported after morcellation of a specimen with unsuspected adenocar-cinoma (17). Third, one must be cautious and adhere to basic oncologic principles. Although laparoscopic hysterectomy is increasingly applied for lower stage endometrial, cervical, and ovarian carcinoma, additional studies are needed to confirm the efficacy and appropriateness. However, what is clear is that essential elements cannot be overlooked, including lymphadenectomy and careful pathologic examination of the specimen. Thus, laparoscopic hysterectomy for endometrial cancer entails intact specimen retrieval through the vagina and accurate staging, impacting subsequent therapy. The role of specimen morcellation for laparoscopic nephrectomy remains to be completely evaluated. Fourth, adjacent structures must be protected and iatrogenic injury considered during the morcellation process. Injuries have been reported to vasculature, bladder, ureter, and bowel during both manual and electrical morcellation of the uterus.

DESCRIPTION OF METHOD

TABLE 1 ■ LapSac® Specifications

Dimensions

Volume

(inches)

(mL)

2 X 5

50

4 X 6

200

5 X 8

750

8 X 10

1500

To date, morcellation within the EndoCatch® cannot be advocated, and we recommend using the LapSac® for this purpose.

Over the past decade, the operative techniques of laparoscopic nephrectomy and nephroureterectomy have evolved, with reductions in operative time and morbidity. This has been facilitated by advances in instrumentation as well as surgeon experience. However, the methods of specimen morcellation and extraction have changed very little and are described in the following sections.

Entrapment Devices

Two primary devices are commercially available for containing the kidney specimen— the LapSac® and EndoCatch Gold®d. The LapSac is available in several sizes, summarized in Table 1. The bag is constructed of two layers, an outer nylon and an inner polyurethane coating, with a polypropylene drawstring. In addition, integral tabs are located on opposite sides of the bag. The LapSac is supplied sterile and intended for one-time use only. The disposable EndoCatch system consists of a pouch contained within a shaft, 11.5 inch in length. The mouth of the pouch is 2.5 inch wide, attached to a continuous ring to facilitate opening, and 6 in. in length. The device is available with shaft diameters of both 10 and 15 mm, with a larger bag.

Both devices are currently used to entrap renal specimens; the use of other, homemade tools (e.g., gloves and sealable bags) has been reported but may only have the benefit of reduced costs and is untested. Advantages of the EndoCatch include the ease of introduction through a trocar, and the deployment mechanism and ring to open the mouth and keep it open. The choice of device for entrapment during intact specimen removal is a matter of surgeon preference. However, to date, morcellation within the EndoCatch cannot be advocated, and we recommend using the LapSac for this purpose.

In our experience, as well as that of others, the dual layer construction of the LapSac is more resistant to perforations. While the EndoCatch pouch is slightly distensible and susceptible to tearing, the LapSac material is more rigid. The manufacturers of the EndoCatch report that the material is impervious to "infectious cells of 0.027 microns in diameter," but the permeability to cancer cells is unknown (18). Urban et al. have examined this issue for the LapSac. After high-speed electrical tissue morcellation of a porcine kidney, a total of 20 apparently intact LapSacs were tested for permeability to bovine serum albumin, indigo carmine, or murine bladder tumor cells (19). In all tests, cCook Urological, Spencer, IN. dU.S. Surgical, Corp., Norwalk, CT.

there was no increase in dialysis of substance through the bag over time, up to 18 hours. In one case, a single tumor cell was noted on the hemocytometer at both one and three hours, and was thought to represent contamination given the lack of increasing numbers of cells over time as would be expected from ongoing leakage via a perforation.

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