Radical Nephrectomy

There have been four retrospective series comparing hand-assisted laparoscopy and standard laparoscopic radical nephrectomy (Table 6) (15,16,18,22). An additional small series reported by Okeke et al. (64) is described below in the section on nephroureterec-tomy. Of 38 laparoscopic radical nephrectomies in the study of Nelson and Wolf (16), 16 were performed with standard transperitoneal laparoscopy and 22 with transperitoneal hand-assisted laparoscopy. Cases were performed during the same time period, with those selected for hand-assisted laparoscopy being based primarily upon greater tumor size, specimen weight, and body mass index. Despite this, hand-assisted laparoscopy was 1.5 hours faster than standard laparoscopy during the first half of the series and 30 minutes faster in the second half (overall 65 minutes faster). The intensity and duration of convalescence was similar between the two groups, although there was a trend toward more abdominal pain with hand assistance. The other three series all found that hand-assisted laparoscopy improved operative time only minimally, and that there was a trend (not statistically significant) toward greater estimated blood loss, more analgesic use, and/or longer hospital stay in the hand-assisted laparoscopy group. Unfortunately, all four studies had factors that confound the comparisons. In that of Batler et al. (15), the comparison was with retroperitoneoscopic nephrectomy rather than standard transperi-toneal laparoscopic nephrectomy as in the others. The greater tumor size, specimen weight, and body mass index in the hand-assisted laparoscopy group in the study of Nelson and Wolf would tend to make the hand-assisted laparoscopy results less favorable in comparison to standard laparoscopy. The responsible surgeon in the series of Baldwin et al. (18) had more than five years prior experience with standard laparoscopic nephrectomy. Finally, Hayakawa et al. (22) performed the hand-assisted laparoscopy radical nephrectomies before the standard laparoscopic radical nephrectomies, rather than concurrently. Although these factors preclude an unbiased comparison between standard laparoscopy and hand-assisted laparoscopy for radical nephrectomy, important information can nonetheless be gleaned.

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