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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.

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.

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.

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.

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., (Copyright 2000 by W.B. Saunders Company)

The aim of this study was to compare live donor nephrectomy by hand-assisted laparoscopy to standard laparoscopy in a canine model. Fourteen dogs underwent a left laparoscopic nephrectomy; a standard laparoscopic nephrectomy technique was utilized in seven dogs. In a second group of seven dogs, a hand-assisted laparoscopic technique was used with a Dexterity Pneumo Sleeve hand port. All nephrectomies were performed as "donor" nephrectomies, dividing the vessels last. Total blood loss, operative warm ischemia, time and organ retrieval times were assessed for each group. The average operative time was significantly shorter for hand-assisted laparoscopic donor nephrectomy (32 +/- 8 minutes vs. 61 +/- 8 minutes; p = .02) than for the standard technique. The average warm ischemia (86 +/- 24 seconds vs. 224 +/- 52 seconds; p = .03) and average organ delivery times (4 +/- 3 seconds vs. 45 +/- 9 seconds; p < .01) also were shorter using the hand-assisted laparoscopic technique. No significant differences in average blood loss were found between the two groups (9 +/- 2 cc vs. 6 +/- 1 cc; p = 0.16, NS). Good parenchymal, ureteral, and vascular preservation was achieved by both techniques. Hand-assisted laparoscopy permits shorter operating times and warm ischemia times than standard laparoscopy in a canine model of donor nephrectomy. Hand assistance makes donor laparoscopic nephrectomy technically easier and significantly quicker to perform. If hand-assisted laparoscopy donor nephrectomy is confirmed to be a rapid and safe technique for removing an intact organ, laparoscopic nephrectomy will be a more widely accepted technique among urologists who participate in living related donor kidney transplantation.