ENDOUROLOGY & LAPAROSCOPY

Hand-assisted laparoscopy for large renal specimens: a multi-institutional study
Stifelman MD, Handler T, Nieder AM, Del Pizzo J, Taneja S, Sosa RE, Shichman SJ
Department of Urology, New York University Medical Center, New York, NY, Department of Urology, New York Presbyterian Medical Center - Cornell Campus, New York, NY, Department of Urology, Hartford Hospital, Hartford, Connecticut, USA
Urology 2003; 61:78-82

• Objectives: To present our experience with hand-assisted laparoscopy (HAL) for larger renal specimens. One of the theoretical benefits of HAL is the ability to manage large renal specimens, which we defined as tumors greater than 7 cm, and tumors in obese patients.
• Methods: Between March 1998 and October 2000, 106 HAL radical nephrectomies were performed for enhancing renal masses, for which 95 patients had complete preoperative, intraoperative, and postoperative data. Of the 95 patients, 32 underwent HAL for large tumors (7 cm or greater) and 41 had a body mass index of 31 or greater. The demographic and outcome data of these two groups were compared with 63 patients who underwent HAL for tumors less than 7 cm and 54 patients with a body mass index of less than 31.
• Results: When comparing cohorts by tumor size, the only statistically significant differences were in convalescence and specimen weight. Patients with lesions 7 cm or greater required 21 days to recover compared with 18 days for patients with lesions less than 7 cm. Obese patients had statistically significantly higher American Society of Anesthesiologists classifications, longer operative times (214 versus 176 minutes), and longer convalescences (21 versus 17.5 days) compared with nonobese patients. The estimated blood loss and conversion rate was not different between the groups. Furthermore, no difference was noted between the groups in the incidence of positive margins, local recurrence, or metastatic recurrence at a mean follow-up of 12.2 months.
• Conclusions: HAL provides a safe, reproducible, and minimally invasive technique to remove large renal tumors and renal tumors in the obese.
  
• Editorial Comment
  It is widely recognized that radical nephrectomy, whether open surgical or laparoscopic, is more difficulty in the obese patient or with a very large specimen. It is not the subcutaneous fat or the size of the tumor that matter in most cases, but rather the amount of perinephric fat that is the major determinant of specimen size and therefore operative difficulty. Obesity is considered a relative contra-indication for laparoscopic nephrectomy early in one’s experience. The point of this report is that the hand-assisted approach to laparoscopic nephrectomy allows the surgeon to address very effectively even very large patients with large specimens. The operative times and recovery periods tended to be a bit longer in the larger patients, but I would argue that these differences would have been greater if one compared the operative time and convalescence following open surgical radical nephrectomy in obese and non-obese patients. Laparoscopic nephrectomy in general, and the hand-assistance approach in particular, probably offers more to the obese patient than to the non-obese patient in terms of the recovery advantage over open surgery.

Dr. J. Stuart Wolf Jr.
Associate Professor of Urology
University of Michigan
Ann Arbor, Michigan, USA