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ENDOUROLOGY
& LAPAROSCOPY
Hand
assisted retroperitoneoscopic nephroureterectomy with the patient spread-eagled:
an approach through a completely supine position
Ou CH, Yang WH
From the Department of Urology, College of Medicine and Hospital, National
Cheng Kung University, Tainan, Taiwan, Republic of China
J Urol. 2008; 180: 1918-22
- Purpose:
We evaluated the feasibility of hand assisted retroperitoneoscopic nephroureterectomy
for transitional cell carcinoma of the upper urinary tract with the
patient completely supine (spread-eagled).
- Materials
and Methods: From October 2006 to January 2008 hand assisted
retroperitoneoscopic nephroureterectomy with open bladder cuff excision
was performed in 32 patients with upper tract transitional cell carcinoma.
The patient was placed supine with the legs extended and abducted at
45 to 60 degrees, and the arms stretched out to the sides in the spread-eagle
position. The patient was secured to the operation table with 3-inch
tapes to permit lateral table tilt. The operation was completed via
a 7 or 8 cm Gibson incision plus 2 laparoscopic ports.
-
Results:
All procedures were successful. The mean time needed for hand assisted
retroperitoneoscopic Nephroureterectomy and bladder cuff resection was
137.6 minutes. Mean estimated blood loss was 200 ml. Simultaneous transurethral
endoscopic procedures were performed in 8 patients. Time to oral intake
was 2.1 days and time to ambulation was 2.0 days. No specific complication
was related to the position. All patients recovered to normal daily
activity uneventfully.
-
Conclusions:
Hand assisted retroperitoneoscopic nephroureterectomy with the patient
completely supine is feasible and safe. The completely supine position
has several advantages, including ease of patient positioning and the
ability to perform simultaneous endoscopic procedures. It not only decreases
the time and cost of changing position, but also avoids potential risks
associated with the lateral decubitus position. Bowel interference with
the visual field and mechanical bowel injury are not a concern using
this approach.
- Editorial
Comment
The laparoscopic radical nephroureterectomy (LRNU) still remains a controversial
subject, from the position of the patient to the optimal techniques
to manage the distal ureter and the bladder cuff. The authors of this
study propose an interesting patient positioning and surgical technique
to perform the LRNU. It is extremely curious that a hand port is used
in an already “tight” retroperitoneal space, creating difficult
surgical maneuvers due to the lack of surgical field/space. Another
interesting point is the preference of the authors for the 0-degrees
laparoscope that can be easy to operate but may not offer the full range
of visualization that a 30-degree or a flexible laparoscope may extend
the view. The authors focused on the positioning of the patient and
the lack of neurological or muscular complications that may occur during
these laparoscopic procedures, fortunately very rare currently, since
the “big” international learning curve has improved and
better laparoscopic instrumentation, as well as, the knowledge of “laparoscopic
anatomy” has been familiarized to the rest of the world through
meetings, publications, etc. The oncological results appear similar
to the other centers with high volume but the focus of the study seemed
skewed towards the possible complications and advantage of not changing
the patients positioning during this complex procedure. The authors
should be congratulated for the attempt of optimizing the surgical technique
of a known intricate procedure.
Dr.
Fernando J. Kim
Chief of Urology, Denver Health Med Ctr
Assistant Professor, Univ Colorado Health Sci Ctr
Denver, Colorado, USA
E-mail: fernando.kim@uchsc.edu |