It is difficult to attribute the concept of hand-assisted laparoscopy to any single person or report, but rather it may be described as a concept that evolved into a reality due to the rapid insurgence of standard laparoscopy in urology (1). In response to the difficulty of standard laparoscopy, particularly in complex cases, several physicians reported hand-assisted procedures, including nephrectomies, in the mid-1990s (2-4). What was most significant is that these reports revealed shorter operating room times and the removal of larger specimens.

As more urologists began performing hand-assisted laparoscopy, it soon became clear that improvements in the technology were necessary (5). Various approaches were described to troubleshoot hand access devices (6). The essence of an effective hand access device is the ability to maintain the pneumoperitoneum while a hand is inserted in the abdomen. Since the initial report using the PneumoSleeve, several companies and iterations of hand access devices have emerged (4,7,8). What is of clinical interest to most urologists is the evolution of hand access devices, from "sleeveless," to "glueless" and finally to "one-piece, multifunc-tionality" (Table 1).

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