Bilateral Hand-assisted Retroperitoneoscopic Nephroureterectomy (HARN) in the Spread-eagle Position for Dialysis Patients—Low Midline HARN in a Completely Supine Position

Abstract

To evaluate the feasibility of hand-assisted bilateral retroperitoneoscopic nephroureterectomy (HARN) in a completely supine position (spread-eagle position [SEP]) for dialysis patients with bilateral upper urinary tract tumors. From October 2006 to May 2009, bilateral HARN with open bladder cuff excisions were performed in 13 dialysis patients with upper urinary tract tumors. The patient was placed supine with both legs extended and abducted at 45-60 degrees and both arms stretched out to the sides in a SEP. The operation was completed via a 7- to 8-cm lower midline incision and 4 laparoscopic ports (2 on each side). All procedures were successful. The mean operation time of bilateral HARN and open bladder cuff resection was 215 minutes, and the mean estimated blood loss was 216 mL. The time to oral intake was 2.5 days and to ambulation was 4.3 days. All patients recovered uneventfully to normal daily activity. No specific complication was related to the position. Bilateral HARN in a completely supine, SEP position is feasible and safe. SEP has several advantages, including ease in patient positioning, and the feasibility to perform simultaneous bilateral nephroureterectomy without repositioning of the patient. It also avoids potential risks associated with the lateral decubitus position. Bowel interference of the visual field and mechanical bowel injury are not concerns in this approach. Our experience shows that a completely supine position is not only possible but also advantageous to bilateral HARN.