Hand-assisted Laparoscopic Nephroureterectomy Research Articles

Surgical outcome predictor analysis following hand-assisted or pure laparoscopic transperitoneal nephroureterectomy using the Taiwan upper urinary tract urothelial carcinoma database.

PurposeTaiwan has a high incidence of upper tract urothelial carcinoma (UTUC). This study aimed to compare the surgical outcomes following transperitoneal hand-assisted laparoscopic nephroureterectomy (TP-HALNU) and transperitoneal pure laparoscopic nephroureterectomy (TP-LNU) from the Taiwan nationwide UTUC collaboration database using different parameters, including surgical volumes.Materials and methodsThe nationwide UTUC collaboration database includes 14 hospitals in Taiwan from the Taiwan Cancer Registry. We retrospectively reviewed the records of 622 patients who underwent laparoscopic nephroureterectomy between July 1988 and September 2020. In total, 322 patients who received TP-LNU or TP-HALNU were included in the final analysis. Clinical and pathological data and oncological outcomes were compared.ResultsOf the 322 patients, 181 and 141 received TP-LNU and TP-HALNU, respectively. There were no differences in clinical and histopathological data between the two groups. No differences were observed in perioperative and postoperative complications. There were no significant differences in oncological outcomes between the two surgical approaches. In the multivariate analysis, the cohort showed that age ≥70 years, positive pathological lymph node metastasis, tumors located in the upper ureter, and male sex were predictive factors associated with an increased risk of adverse oncological outcomes. A surgical volume of ≥20 cases showed a trend toward favorable outcomes on cancer-specific survival [hazard ratio (HR) 0.154, p = 0.052] and marginal benefit for overall survival (HR 0.326, p = 0.019) in the multivariate analysis.ConclusionAlthough different approaches to transperitoneal laparoscopic nephroureterectomy showed no significant differences in surgical outcomes, age, sex, lymph node metastasis, and tumor in the upper ureter in the following period were predictive factors for oncological outcomes. Higher surgical volume did not impact disease-free survival and bladder recurrence-free survival but was associated with improved overall survival and cancer-specific survival. Exploration of unknown influencing factors is warranted.

Comparing Oncological Outcomes and Surgical Complications of Hand-Assisted, Laparoscopic and Robotic Nephroureterectomy for Upper Tract Urothelial Carcinoma.

PurposeThis study aimed to compare the oncological outcomes and surgical complications of patients with upper tract urothelial carcinoma (UTUC) treated with different minimally invasive techniques for nephroureterectomy.MethodsFrom the updated data of the Taiwan UTUC Collaboration Group, a total of 3,333 UTUC patients were identified. After excluding ineligible cases, we retrospectively included 1,340 patients from 15 institutions who received hand-assisted laparoscopic nephroureterectomy (HALNU), laparoscopic nephroureterectomy (LNU) or robotic nephroureterectomy (RNU) between 2001 and 2021. Kaplan-Meier estimator and Cox proportional hazards model were used to analyze the survival outcomes, and binary logistic regression model was selected to compare the risks of postoperative complications of different surgical approaches.ResultsAmong the enrolled patients, 741, 458 and 141 patients received HALNU, LNU and RNU, respectively. Compared with RNU (41.1%) and LNU (32.5%), the rate of lymph node dissection in HALNU was the lowest (17.4%). In both Kaplan-Meier and univariate analysis, the type of surgery was significantly associated with overall and cancer-specific survival. The statistical significance of surgical methods on survival outcomes remained in multivariate analysis, where patients undergoing HALNU appeared to have the worst overall (p = 0.007) and cancer-specific (p = 0.047) survival rates among the three groups. In all analyses, the surgical approach was not related to bladder recurrence. In addition, HALNU was significantly associated with longer hospital stay (p = 0.002), and had the highest risk of major Clavien-Dindo complications (p = 0.011), paralytic ileus (p = 0.012), and postoperative end-stage renal disease (p <0.001).ConclusionsMinimally invasive surgery can be safe and feasible. We proved that compared with the HALNU group, the LNU and RNU groups have better survival rates and fewer surgical complications. It is crucial to uphold strict oncological principles with sophisticated technique to improve outcomes. Further prospective studies are needed to validate our findings.

Comparison of Open Versus Laparoscopic Versus Hand-Assisted Laparoscopic Nephroureterectomy: A Systematic Review and Meta-Analysis.

A systematic analysis of the evidence regarding oncological, perioperative and postoperative outcomes of open nephroureterectomy (ONU), laparoscopic nephroureterectomy (LNU), and hand-assisted laparoscopic nephroureterectomy (HALNU) was designed. The summarized data were abstracted from 52 original research articles representing 19,195 patients. PubMed/Medline, Scopus, Google Scholar, EMBASE, and the Cochrane Library were reviewed in March 2017, following PRISMA framework. A total of 52 publications were selected for inclusion. The primary outcomes were 2- and 5-year cancer-specific survival (CSS) rate, overall survival (OS) rate, and recurrence-free survival (RFS) rate. The secondary outcomes were operative time, lengths of hospitalization period, estimated blood loss, transfusions, major Clavien complication rate, metastasis rate, bladder recurrence rate, and positive surgical margin. On comparing LNU versus ONU and HALNU versus ONU, no significant differences between the 5-year CSS rate (P = .25, P = .39), OS rate (P = .06, P = .46), and RFS rate (P = .85, P = .73) were found. On comparing LNU versus ONU and HALNU versus ONU during a 2-year follow-up period, the following were found: CSS rate (P = .61, P = .04) and OS rate (P = .33, P = .19). There were no significant differences between the LNU versus ONU and HALNU versus ONU rates, regarding bladder recurrence (P = .12, P = .85) and metastasis rate (P = .07, P = .27). Significant higher operative time (P = .01, P = .0004), lower length of hospitalization period (P < .001, P < .001), and estimated blood loss (P = .0004, P < .001) were found in comparison to that of LNU versus ONU and HALNU versus ONU. Both LNU and HALNU had comparable oncological and better perioperative and postoperative outcomes, when compared with ONU.

Do Transperitoneal and Retroperitoneal Hand-Assisted Laparoscopic Nephroureterectomy have Different Effects on Intravesical Recurrence?

Objectives: Some studies have shown that in patients with upper tract urothelial carcinoma (UTUC) who have undergone hand-assisted laparoscopic nephroureterectomy (HALNU), the narrow working space and inevitable manipulation that occurs during the retroperitoneal approach (RP-HALNU) enhances tumor cell seeding in the bladder mucosa. This study was an attempt to investigate the differences in intravesical recurrence between transperitoneal HALNU (TP-HALNU) and RP-HALNU. Patients and Methods: From 1999 to 2011, a total of 197 patients with UTUC were enrolled. After excluding those with a previous history of bladder cancer, 170 patients were analyzed. Sixty-five of these underwent RP-HALNU, and 105 of these underwent TP-HALNU. The median follow-up periods were 39.2 and 46.2 months. Tumor location was divided into three groups: In the renal pelvis, in the ureter, and in both the renal pelvis and ureter. Results: There was no significant difference in the intravesical recurrence rate in relation to the different surgical approaches (P = 0.10), but tumor location in both the renal pelvis and ureter significantly increased the risk (hazard ratio [HR] = 3.11, P = 0.01). In addition, advanced T stage (HR = 9.63, P &lt; 0.01) was the only significant risk factor related to death. Conclusions: In patients with UTUC, tumor location in both the renal pelvis and ureter determined higher susceptibility to intravesical recurrence. However, different surgical approaches to HALNU were not a significant risk factor for intravesical recurrence.

Erratum: Do transperitoneal and retroperitoneal hand-assisted laparoscopic nephroureterectomy have different effects on intravesical recurrence?

Erratum: Do transperitoneal and retroperitoneal hand-assisted laparoscopic nephroureterectomy have different effects on intravesical recurrence?

Do transperitoneal and retroperitoneal hand-assisted laparoscopic nephroureterectomy have different effects on intravesical recurrence?

ObjectivesSome studies have shown that in patients with upper tract urothelial carcinoma (UTUC) who have undergone hand-assisted laparoscopic nephroureterectomy (HALNU), the narrow working space and inevitable manipulation that occurs during the retroperitoneal approach (RP-HALNU) enhances tumor cell seeding in the bladder mucosa. This study was an attempt to investigate the differences in intravesical recurrence between transperitoneal HALNU (TP-HALNU) and RP-HALNU. MethodsFrom 1999 to 2011, a total of 197 patients with UTUC were enrolled. After excluding those with a previous history of bladder cancer, 170 patients were analyzed. 65 of these underwent RP-HALNU, and 105 of these underwent TP-HALNU. The median follow-up periods were 39.2 and 46.2 months. Tumor location was divided into three groups: in the renal pelvis, in the ureter, and in both the renal pelvis and ureter. ResultsThere was no significant difference in the intravesical recurrence rate in relation to the different surgical approaches (p = 0.10), but tumor location in both the renal pelvis and ureter significantly increased the risk (Hazard ratio [HR] = 3.11, p = 0.01). In addition, advanced T stage (HR = 9.63, p < 0.01) was the only significant risk factor related to death. ConclusionsIn patients with UTUC, tumor location in both the renal pelvis and ureter determined higher susceptibility to intravesical recurrence. However, different surgical approaches to HALNU were not a significant risk factor for intravesical recurrence.

Robot-Assisted Laparoscopic Nephroureterectomy versus Hand-Assisted Laparoscopic Nephroureterectomy for Upper Urinary Tract Urothelial Carcinoma: A Matched Comparison Study.

Objectives. To investigate the perioperative and oncological outcomes of hand-assisted laparoscopic nephroureterectomy (HANU) and robotic-assisted nephroureterectomy (RANU). Methods. Patients who underwent RANU were matched by sex, age (±5 years), and tumor location to those who underwent HANU; 18 matched pairs were included. Results. Each group consisted of five men and 13 women. The mean age was 70.4 years in RANU group and 69.6 years in HANU group (p = 0.646). Each group contained 10 patients with tumor location in the renal pelvis, five in the ureter, and three in both sites. The median follow-up time was 6.1 months for the RANU group and 47.8 months for the HANU group. The demographic and pathological data did not differ significantly. The RANU group had significantly less blood loss (p < 0.001), resumed oral intake earlier (p = 0.043), and had shorter hospital stays (p = 0.014) but higher pain scores associated with their wounds (p = 0.043). The oncological outcomes were comparable with those of the HANU group. Conclusions. Our results show that the RANU and HANU groups have comparable operative, early postoperative, and functional outcomes. A longer follow-up period would be needed for final comparison of oncological outcome.

22 Does transperitoneal or retroperitoneal hand-assisted laparoscopic nephroureterectomy really matter to bladder recurrence?

22 Does transperitoneal or retroperitoneal hand-assisted laparoscopic nephroureterectomy really matter to bladder recurrence?

Comparison of Laparoscopic, Hand-Assisted, and Open Surgical Nephroureterectomy

Background and Objectives:The aim of this study was to compare oncologic outcomes after laparoscopic nephroureterectomy, hand-assisted laparoscopic nephroureterectomy, and open nephroureterectomy for upper urinary tract urothelial cancer.Methods:Between April 1995 and August 2010, 189 patients underwent laparoscopic nephroureterectomy, hand-assisted laparoscopic nephroureterectomy, or open nephroureterectomy for upper urinary tract urothelial cancer. Of these patients, 110 with no previous or concurrent bladder cancer or any metastatic disease were included in this study. Cancer-specific survival, recurrence-free survival, and intravesical recurrence-free survival rates were analyzed by the Kaplan-Meier method and compared with the log-rank test. The median follow-up period for the cohort was 70 months (range, 6–192 months).Results:The 3 groups were well matched for tumor stage, grade, and the presence of lymphovascular invasion and concomitant carcinoma in situ. The estimated 5-year cancer-specific survival rates were 81.1%, 65.6%, and 65.2% for laparoscopic nephroureterectomy, hand-assisted laparoscopic nephroureterectomy, and open nephroureterectomy, respectively (P = .4179). The estimated 5-year recurrence-free survival rates were 33.8%, 10.0%, and 41.2% for laparoscopic nephroureterectomy, hand-assisted laparoscopic nephroureterectomy, and open nephroureterectomy, respectively (P = .0245). The estimated 5-year intravesical recurrence-free survival rates were 64.8%, 10.0%, and 76.2% for laparoscopic nephroureterectomy, hand-assisted laparoscopic nephroureterectomy, and open nephroureterectomy, respectively (P < .0001).Conclusion:Although there was no significant difference in cancer-specific survival rate among the laparoscopic nephroureterectomy, hand-assisted laparoscopic nephroureterectomy, and open nephroureterectomy groups, hand-assisted laparoscopic nephroureterectomy may be inferior to laparoscopic nephroureterectomy or open nephroureterectomy with regard to recurrence-free survival and intravesical recurrence-free survival rates.

Complications of Hand-assisted Laparoscopic Renal Surgery: Single-center Ten-year Experience

To review our perioperative complications during the first decade of using hand-assisted laparoscopic nephrectomy using a sleeve (HALN). HALN is a minimally invasive procedure first reported by our group in 1997. After institutional review board approval, the charts of the patients who had undergone HALN, hand-assisted laparoscopic partial nephrectomy, or hand-assisted laparoscopic nephroureterectomy from 1997 to 2007, at our institution, were retrospectively reviewed. Standard laparoscopic procedures were not included. The relevant patient characteristics, operative details, American Society of Anesthesiologists score, body mass index, comorbidities, medications, and complications were recorded. A total of 227 consecutive patients had undergone Hand-assisted laparoscopic renal surgery, and all their charts were reviewed. Of these 227, 134 were radical HALN, 37 were nonradical HALN, 42 were hand-assisted laparoscopic partial nephrectomy, and 15 were hand-assisted laparoscopic nephroureterectomy. Complications developed in 59 patients (26%): 8% major and 18% minor. The procedure-specific complication rate was 29% for radical HALN, 27% for nonradical HALN, 33% for hand-assisted laparoscopic nephroureterectomy, and 17% for hand-assisted laparoscopic partial nephrectomy. Complications included blood transfusion in 6%, urinary retention in 4%, ileus in 4%, and wound infection in 4%. From 2003 through 2007 (n = 163), our overall complication rate was 22% (8% major and 13% minor). From 1997 to 2002 (n = 65), the overall complication rate was 38% (P = .02). The American Society of Anesthesiologists score and the use of systemic steroids were associated with the occurrence of perioperative complications. Our results have shown that hand assistance provides a safe, minimally invasive laparoscopic procedure. Our complications rates were comparable to those with other standard and hand-assist series, although the spectrum of complications varied. Hand-assisted laparoscopic renal surgery could be a method by which to improve patient access to minimally invasive nephron-sparing surgery.

Hand-Assisted Laparoscopic Nephroureterectomy with Cystoscopic en-bloc Excision of the Distal Ureter and Bladder Cuff and Isthmusectomy in a Horseshoe Kidney for Invasive Urothelial Carcinoma of the Renal Pelvis

Upper tract invasive urothelial carcinoma and horseshoe kidneys are familiar to the practicing urologist but relatively rare individual entities. The complication of managing them when they coexist in the same patient can be challenging. Herein, we present the first reported case in which an upper tract invasive urothelial carcinoma in a horseshoe kidney was successfully managed with a combined hand-assisted laparoscopic nephroureterectomy and isthmusectomy with cystoscopic en-bloc excision of the distal ureter and bladder cuff. This highlights the fact that complex anatomy can be managed in a completely minimally invasive fashion, and sound oncologic principles can still be maintained.

Osteoclast-Like Giant Cell Carcinoma of the Distal Ureter

Extraskeletal osteoclast-like giant cell (OGC) tumors are uncommon and have mainly been found in the breast and pancreas. OGC neoplasms of the urinary tract are extremely rare. Most cases found in the renal pelvis and bladder are associated with either an in situ urothelial malignancy or a conventional high-grade urothelial carcinoma. These malignancies tend to be associated with a poor prognosis and disease course. To our knowledge, no cases of OGC tumors of the distal ureter only have been published. Here, we present the case of a 76-year-old man who underwent hand-assisted laparoscopic nephroureterectomy because of painless gross hematuria with right flank pain. Pathologic examination showed OGC carcinoma of the right distal ureter. No local tumor recurrence or distant metastasis was found at the 5-month follow-up.

Primary Small Cell Carcinoma of the Upper Urinary Tract

We report a case of primary extrapulmonary small cell carcinoma of the distal ureter, with a synchronous small cell carcinoma of the ipsilateral renal pelvis. These tumors, rarely reported in the urinary tract, are locally aggressive and have a poor prognosis. A 77-year-old male bedridden patient presented with fever and chills with left side-flank pain for 3 days. Following a diagnosis of ureteral urothelial carcinoma, hand-assisted laparoscopic nephroureterectomy with bladder cuff excision was carried out. Adjuvant chemotherapy was given after pathologic report of primary small cell carcinoma of the distal ureter and a synchronous small cell carcinoma of the ipsilateral renal pelvis. After 3 cycles of combination chemotherapy, the patient died 4 months postoperatively due to sepsis.

Nefroureterectomía laparoscópica mediante laparoscopia asistida por la mano para el tratamiento del carcinoma transicional del tracto urinario superior

Objective To report our series of patients undergoing hand-assisted laparoscopic nephroureterectomy (HALNU) using the pluck-off procedure. Materials and methods Twenty patient undergoing HALMU for upper urinary tract urothelial tumors from November 2002 to December 2007 were assessed. Demographic, clinical, surgical, and oncological data were assessed. Results Mean patient age was 69 years. Mean operating time and mean intraoperative bleeding were 176 min and 381 mL respectively. Twenty percent of patients required transfusion of blood products. Conversion to open surgery was not required in any patient. Major and minor complications occurred in 25% and 30% of patients respectively. Mean time to oral intake was 48 hours, and mean hospital stay was 5 days. Pathological study revealed transitional cell carcinoma in all cases: grade I in 5%, grade II in 60%, and grade III in 35% of patients. Clinical stage was pTa in 5%, pT1 in 20%, pT2 in 25%, pT3 in 40%, and pT4 in 10% of patients. A bladder recurrence rate of 30% and a 49% overall survival were seen after a mean followup of 33 months (5-73). Six-year cancer-specific survival was 67%. No patient developed either peritoneal or surgical bed recurrence. Conclusions HALMU using the pluck-off procedure is a feasible, safe, and effective surgery. Both surgical and oncological results are similar to those of open surgery and pure laparoscopy.

Editorial Comment on: Laparoscopic Radical Nephroureterectomy: A Multicenter Analysis in Japan

Upper urinary tract urothelial carcinoma is a disease that often is associated with a high propensity for recurrence and progression. Surgical treatment consists of complete removal of the kidney, the ureter in toto, and the ipsilateral bladder cuff including the ureteral orifice. When performed with an open approach, this operation requires either two incisions or an extended flank incision. The integration of the laparoscopic approach has been successful at reducing postoperative convalescence and improving recovery while maintaining the oncologic outcome [1]. The featured study by Kamihira et al represents a large experience with laparoscopic nephroureterectomy for upper urinary tract urothelial carcinoma from 51 centers in Japan [2]. Such a study, commissioned by the Japanese Society of Endourology and ESWL, is bound to provide a wealth of information and to raise a number of questions. This study establishes that laparoscopic nephroureterectomy can be performed safely with low morbidity and a low complication profile. Most important, it reflects the heterogeneity of surgical practice patterns and brings forth the debate about the following technical issues: (1) the role of lymphadenectomy in the treatment of upper urinary tract urothelial carcinoma and (2) the inability to dissociate total removal of the distal ureter including the ipsilateral ureteral orifice from radical nephroureterectomy. First, the present study [2] and another equally large multicenter study using mainly an open approach [3] report concomitant lymphadenectomy at the time of nephroureterectomy in 43–45% of cases. The indications and the anatomic template explored were at the discretion of the surgeon and, given the retrospective nature of the methodology, will be difficult to analyze. For a disease that shares so much background with urothelial carcinoma of the bladder, one wonders whether it is sound to extrapolate from the evidence supporting the role of a thorough lymphadenectomy in improving survival in bladder cancer until the evidence for upper urinary tract urothelial cancer materializes [4]. Second, total removal of the distal ureter including the ipsilateral ureteral orifice is undissociable from the radical nephroureterectomy. The fact that the present study by Kamihira et al [2] did not find an association between the different modalities of managing the distal ureter does not, by itself, validate an incomplete ureteral resection. Finally, the higher rate of postoperative de novo bladder tumors after hand-assisted laparoscopic nephroureterectomy is an interesting point, bringing to the debate the hypothesis of tumor manipulation.

Long-Term Outcome of Hand-Assisted Laparoscopic Nephroureterectomy for Pathologic T3 Upper Urinary Tract Urothelial Carcinoma

To determine the feasibility and long-term outcomes of hand-assisted laparoscopic nephroureterectomy (HALNU) compared with open nephroureterectomy (ONU) in the management of pT(3)N0 upper urinary tract urothelial carcinoma (UUT-UC). Between January 1994 and December 2005, 21 patients who underwent HALNU for stage pT(3)N0 UTT-UC were matched and compared with 31 patients who underwent ONU. The oncologic out-comes, including bladder recurrence, recurrence-free survival, cancer-specific survival, and overall survival, were statistically analyzed. The median follow-up period in the HALNU group was 72 months (range 33-111 months) and 115 months in the ONU group (range 24-161 months). Patient age, sex, body mass index, tumor size, specimen weight, and American Society of Anesthesiologists classification showed no significant difference between the two groups. The HALNU group had statistically less blood loss than the ONU group (113 mL versus 487 mL; P = 0.02). The average hospital stay and doses of narcotic analgesics were significantly less in the HALNU group than the ONU group. The complication and bladder recurrence rates were similar between the two groups. The 5-year recurrence-free survival, cancer-specific survival, and overall survival were also comparable in both groups. HALNU is a safe and efficacious procedure with comparable long-term oncologic outcomes in comparison with ONU in treating patients with locally advanced pT(3)N0UUT-UC.

Prediction of Postsurgical Pain from Hand-Assisted Laparoscopic Nephroureterectomy

Objective We retrospectively reviewed the medical records of patients who underwent hand-assisted laparoscopic nephroureterectomy using a retroperitoneal or transperitoneal approach at National Taiwan University Hospital. Early postsurgical pain scores and the amount of morphine equivalents consumed were evaluated. Patients and Methods From July 2001 to June 2005, a total of 96 patients who underwent hand-assisted laparoscopic nephroureterectomy and bladder cuff resection were retrospectively evaluated. Perioperative parameters, postoperative opioid dose, and daily pain score based on a 10-point visual analog scale (VAS) were recorded prior to discharge. Potential predictive factors included patient age, gender, body mass index, comorbid conditions, surgical time, patient controlled analgesia (PCA) use and surgical access. These were analyzed with regard to pain based on a daily VAS score and morphine dose (equivalents). Results The daily VAS score decreased from 4.7 ± 1.5 on the day of surgery to 2.0 ± 0.7 on postoperative day (POD) 6. Only the operation time was associated with a high VAS score on POD1 ( p < 0.01). On univariate analysis, a longer operation time ( p = 0.04) and PCA use ( p < 0.01) were associated with higher intake of morphine equivalents. Patients with end-stage renal disease (ESRD) required less morphine postoperatively ( p = 0.02). On multivariate analysis, PCA use ( p = 0.04), ESRD ( p = 0.045), and operation time ( p = 0.049) were independently associated with postoperative morphine dosage. Women had a trend of increased postoperative morphine use ( p = 0.06) The postoperative daily VAS score and opioid dosage were comparable in patients receiving trans-and retroperitoneal access. Conclusion Patients who had a longer operation had a significantly higher POD1 pain score. PCA use and prolonged operation time were predictive factors for a higher dosage of morphine.

Delayed Presentation of Splenic Laceration Due to Remote Trauma in Laparoscopic Surgery

Splenic laceration is a recognized complication of both open and laparoscopic renal and adrenal surgery. Most injuries reported occur intraoperatively via the transperitoneal approach and require immediate management. Herein we report a patient with a delayed presentation of splenic laceration 17 days after undergoing retroperitoneal hand-assisted laparoscopic nephroureterectomy. Emergent splenectomy was performed and the postoperative course was uneventful. To our knowledge, there has not been a similar case reported before. Because laparoscopic renal surgery is becoming the gold standard of treatment, urologists must be aware of the possibility of splenic laceration during this type of surgery.

Laparoscopic renal surgery in the octogenarian

To describe our experience with laparoscopic renal surgery (LRS) in the octogenarian. Octogenarians are generally suboptimal surgical candidates but the recent upsurge of minimally invasive options for the management of kidney lesions, such as laparoscopic excision, cryoablation and radiofrequency ablation (RFA), have changed that perception. In all, 26 patients aged >or=80 years underwent LRS at Brown University and the University of Wisconsin between 2000 and 2006. Demographic information, anatomical location, tumour stage, comorbidities, type of laparoscopic approach, management and outcomes were assessed. Complications during and after LRS, hospital stay, analgesia requirements and return to normal activity were analysed. The mean age of the patients was 81 years. The procedures performed included hand-assisted laparoscopic partial nephrectomy (three patients), hand-assisted laparoscopic radical nephrectomy (10), hand-assisted laparoscopic nephroureterectomy (four), laparoscopic-assisted cryoablation (seven), laparoscopic RFA (one), and laparoscopic unroofing of a renal cyst (one). The mean (range) follow-up was 40 (8-84) months. The mean American Society of Anesthesiologists score was 2.5. The average hospital stay was 5.6 days and the mean time to normal activity after discharge was 19 days. There were two major and five minor complications. Nineteen of 22 patients evaluable had no evidence of disease at the last follow-up. The three deceased patients died of unrelated causes. LRS in the octogenarian is safe to perform in patients with multiple comorbidities. The major and minor complication rates were 7% and 19%, respectively. Recent trends show that ablative procedures are being performed more commonly than surgical excision in this age group.

Hand-Assisted Laparoscopic Nephroureterectomy (HALNU): An Assessment of the Impact of Obesity in 50 Procedures

The aims of this study was to review our experience with hand-assisted laparoscopic nephroureterectomy (HALNU) and to evaluate the impact of body-mass index (BMI) on outcomes. We retrospectively analyzed 50 HALNU patients. Twenty had body mass indices (BMIs) <25 (normal cohort), 18 had BMIs between 25 and 29.9 (overweight cohort), and 12 had BMIs >/=30 (obese cohort). The cohorts had similar operative times: 349, 326, and 320 minutes, respectively. Most patients (38) underwent a total HAL distal ureterectomy, but 9 underwent an initial transurethral ureteral dissection (5 [25%], 2 [11%], and 2 [17%]). Five patients were converted to open and 1 had a planned open ureterectomy. The cystotomy was sutured closed in most but left open in 6 (3 [15%], 2 [11%], and 1 [8%]), and a stapled ureteral division was performed in 7 (3 [15%], 2 [11%], and 2 [17%]). Increased BMI was associated with delayed oral intake (P = 0.034). No significant cohort differences were observed for estimated blood loss (EBL), transfusion rate, complication rate, surgical margin status, distant metastases, or death rate. The obese cohort demonstrated trends toward increased hospitalization and bladder cancer recurrence (P = 0.083, P = 0.097). Patients with prior open surgery had longer hospitalizations (P = 0.024). Patients without prior surgery were more commonly alive with persistent disease (P = 0.027). EBL was greater for patients who had transurethral ureteral dissection (P = 0.030). Patients undergoing a stapled ureteral division had delayed oral intake, bowel function, and discharge (P = <0.001, P = 0.034, and P = 0.034). HALNU is an effective surgical treatment for patients with BMIs as great as 45.