Radical Nephrectomy

Radical nephrectomy was first reported using hand-assisted laparoscopy in 1996 (4). Including only the most recent updates of series, nine retrospective series have been published to date (Table 2) (15-23).

Hand-assisted laparoscopy radical nephrectomy has proven to be an excellent approach to remove even larger specimens with reasonable operative times and convalescence similar to that of other minimally invasive nephrectomies (17).

In many ways, the strongest benefit of hand-assisted laparoscopy is the ability to manage large renal specimens intraoperatively, because these can be challenging using the standard approach. While many laparoscopists morcellate cancer specimens, those that select intact removal should consider using hand-assisted laparoscopy as an incision is necessary regardless.

The use of early posterior artery control is effective in laparoscopic radical nephrectomy, a maneuver particularly suited to hand-assisted laparoscopy (9). Although a much newer approach than standard laparoscopic nephrectomy, series have accumulated quickly. The latest report by one of the authors (SYN) showed sustained convalescence, as well as cancer control similar to open nephrectomy at up to five years (23).

In addition, the urologist should consider using an entrapment sack for larger tumors, to minimize the risk of local recurrence at the extraction site.

TABLE 1 ■ Hand-Assisted Laparoscopy Devices: Evolution of Options

Allows

Can use

Hand exchanges

Requires

Requires

One piece

Requires

trocar passage

instrument

without loss of

a sleeve

adhesive

construction

inflation

through device

simultaneously

pneumoperitoneum

PneumoSleevea

Yes

Yes

No

No

No

No

No

Intromit Deviceb

No

Yes

No

No

No

No

No

Handport Device°

No

No

No

Yes

No

No

No

Omniport Deviced

No

No

Yes

Yes

Yes

No

No

Lapdisc Devicee

No

No

Yes

No

Yes

No

No

Gelport Device'

No

No

No

No

Yes

Yes

Yes

aDexterity Surgical, San Antonio,TX; bApplied Medical, Rancho Santa Margarita, CA; cSmith and Nephew, Port Charles, NY; dWeck Surgical, Research Triangle Park, NC; eEthicon Endosurgery, Cinncinati, OH; 'Applied Medical, Rancho Santa Margarita, CA.

There are logical benefits of performing inflammatory nephrectomies using hand-assisted laparoscopy because the normal anatomic planes are not often present.

Another procedure that can be improved by using hand-assisted laparoscopy is laparoscopic nephrectomy for autosomal dominant polycystic kidney disease.

Hand-assisted laparoscopy radical nephrectomy has proven to be an excellent approach to remove even larger specimens with reasonable operative times and convalescence similar to that of other minimally invasive nephrectomies.

In many ways, the strongest benefit of hand-assisted laparoscopy is the ability to manage large renal specimens intra-operatively, because these can be challenging using the standard approach. While many laparoscopists morcellate cancer specimens, those that select intact removal should consider using hand-assisted laparoscopy as an incision is necessary regardless.

TABLE 2 ■ Published Hand-Assisted Laparoscopy Radical Nephrectomy Series

No. of patients (HALS only)

Mean OR time (min)

Mean EBL (mL)

No. of conversion to open surgery

Mean MSO4 equivalents (nig)

No. of pts with minor/major complications

Mean hospital stay (days)

Batler et al.(15)a

12

238

294

0b

35.7

0/1

4.4

Nelson and Wolf (16)

22

205

191

0

31

10/5

2.7

Stifelman et al. (17)

95

158

128

3

34

7/4

3.7

Baldwin et al. (18)

8

168

410

0

42.1

2/0

2.6

Busby et al. (19)

22

265

186

0

11.3

2/1

3.4

Lee et al. (20)

54

195

183

0

-

3/0

6.8

Patel et al. (21)

60

189

119

4

-

2/3

3.1

Hayakawa et al. (22)

14

261

204

1

-

0/1

15.4

Lowry and Nakada (23)

50

233

170

0

-

4/2

4.0

Total

337

198c

165c

2.4%d

31.2c

8.9%/5.0%d

4.5c

aOne case in this series was a simple nephrectomy. bOne case was converted from retroperitoneoscopic to HALS. cWeighted mean.

dPercentage occurrence of summed totals.

Abbreviations: HALS, hand-assisted laparoscopy; OR, operating room; EBL, estimated blood loss.

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