Specimen Morcellation Research Articles

Contained specimen morcellation during robotics-assisted laparoscopic supracervical hysterectomy for pelvic organ prolapse.

Robotics-assisted laparoscopic supracervical hysterectomy (RALSH) with concomitant apical robotics-assisted POP repair provides advantages of minimally invasive procedures; however specimen removal without intraperitoneal spillage of potential pathology remains challenging. The primary aim of our study is to determine the factors affecting contained manual morcellation (CMM) of specimens during RALSH for POP surgery. The secondary aim of the study is to report complications associated with CMM and on specimen pathology. A total of 67 sequential patients underwent RALSH with concomitant robotics-assisted sacrocolpopexy or uterosacral vaginal suspension. Factors analyzed to affect CMM were specimen weight, length of skin and fascia incisions, patient age, body mass index (BMI), and estimated blood loss (EBL). Median CMM time was 11min (1 to 46) and specimen weight 62g (19 to 711). Median patient age was 56years (36 to 83), and patient BMI was 28 (18 to 44). Median EBL was 50ml (10 to 150). Median skin and fascial incision lengths were 3cm (1.5 to 7), and 3.5cm (1.5 to 8). CMM time was significantly dependent on specimen weight (p < 0.0001) and length of rectus fascia incision (p < 0.0126). There was no gross tissue spillage or bag ruptures. Uterine pathology revealed normal tissue (26%), leiomyoma (47%), adenomyosis (49%), and endometriosis (14%). 4.5% of specimens had evidence of microscopic neoplasm, and 5years after surgery patients were cancer free. Contained manual extraction of the uterus and/or adnexae at the time of RALSH for POP surgery is a viable, safe, and efficient method of specimen removal.

8724 Routes of Specimen Extraction in Laparoscopic Surgery

<h3>Study Objective</h3> To demonstrate the operative techniques of three entry methods for in-bag, extracorporeal specimen morcellation including vaginal approach, umbilical mini-laparotomy and suprapubic mini-laparotomy. <h3>Design</h3> We present a surgical video with narration which demonstrates three entry techniques for specimen morcellation. <h3>Setting</h3> Morcellation is a surgical technique which has been used for decades to allow removal of the uterus through the vagina or smaller abdominal incisions². Electromechanical morcellation gained popularity in the early 1990s due its ease of use and efficiency, however concern for the spread of cancer cells in cases of uterine sarcomas led to the practice of manual morcellation using containment bags¹. The American College of Obstetricians and Gynecologists continues to endorse a minimally invasive approach to hysterectomy when possible if the specimen is too large to be removed intact or removing the uterus intact through an abdominal incision². <h3>Patients or Participants</h3> Patients undergoing laparoscopic hysterectomy. <h3>Interventions</h3> We demonstrate three entry routes for manual uterine morcellation: vaginally following colpotomy, umbilical mini-laparotomy and suprapubic mini-laparotomy. <h3>Measurements and Main Results</h3> Specimen extraction via minimally invasive routes. <h3>Conclusion</h3> Vaginal entry following colpotomy, umbilical mini-laparotomy and suprapubic mini-laparotomy are three safe, effective entry methods for the morcellation of large, fibroid uteri which offers a minimally invasive approach for the removal of uterine specimens following laparoscopic hysterectomy.

Spigelian Hernia with Small Bowel Obstruction: Lateral Port Site Complication from Laparoscopic Gynecologic Surgery

A 49-year-old underwent laparoscopic right salpingo-oophorectomy and myomectomy for a 5.8-cm solid right ovarian mass (fibrothecoma) and 4-cm uterine myoma. The right lower quadrant (RLQ) port incision was extended for contained specimen morcellation and extraction. The rectus fascia was closed with 0-Vicryl under direct visualization.

Measures to improve the safety of power morcellation in laparoscopic surgery: IMELDA technique

The objective of this study was to explore measures to improve the safety of power morcellation in laparoscopic surgery. In this study of 50 patients, the IMELDA technique for specimen morcellation is presented. This is the first in-bag morcellation study to demonstrate cytologically, and with postoperative blue dye tests, that no intraperitoneal spilling occurs using this morcellation technique. IMELDA stands for inked margins in-bag morcellation extracorporeally ligated for dual port access. IMELDA morcellation enables surgeons to change from intraperitoneal power morcellation to contained bag power morcellation, without making larger incisions, and without changes in port placement and visualization angles. Inked margins enable the pathologist to determine where the section margins were in case of an unexpected malignant or premalignant lesion, even though the specimen is morcellated. IMELDA morcellation uses a selfconstruction technique avoiding the need for expensive commercially available in-bag morcellation kits, for which there still is no scientific proof that they are spill proof. Most standard specimen extraction bags can be used to self-construct an IMELDA bag. The port placement can be adjusted to the surgeon's habits and any available morcellator can be used. For very low resource settings, a surgical glove can be used to construct an endobag for this frugally innovative morcellation technique.

Power Morcellation in the Bag: Surgical Technique and Clinical Applications

Introduction: Morcellation refers to the division of specimens into smaller pieces or fragments to facilitate the removal of tissue through small incisions during minimally invasive procedures. Most commonly it may be performed after laparoscopic hysterectomy (for enlarged uteri) or myomectomy. Recently, the use of power morcellation has been discouraged because of the risk of spreading an unsuspected uterine malignancy. In this video (run time 9:51), the authors demonstrate the surgical technique for laparoscopic power morcellation in the bag and some clinical applications of it. Patients and Methods: In our department, laparoscopic gynecologic procedures are performed using four trocars: one 10-mm umbilical trocar for the zero degree laparoscope and three 5-mm trocars for the instruments, one at the right iliac fossa, 2 cm medial to the right anterior superior iliac spine, another one at the left iliac fossa, 2 cm medial to the left anterior superior iliac spine, and the third one in the midline, 8 to 10 cm below the umbilical trocar. Whenever power morcellation is needed, the 5-mm trocar at the left iliac fossa is replaced by a 15-mm trocar for the morcellator at the end of the procedure, specifically for the step of morcellation. To perform the power morcellation within a bag, the authors use a large tissue retrieval bag (3100 mL). The bag is placed inside the abdominal cavity through the 15-mm trocar. The mouth of the bag is opened and the specimen to be morcellated is put inside the bag. The bag is closed pulling the draw string and it is retrieved from the abdominal cavity through the 15-mm trocar. This allowed for the externalization of the mouth of the bag through the skin incision. Then, the 15-mm trocar is replaced through the mouth of the bag. Pneumoperitoneum is insufflated through the 10-mm umbilical trocar. The assistant grabs the deeper part of the bag and pulls it out through the skin at the right iliac fossa. Finally, the surgeon grabs the closest portion of the bag to the umbilicus and externalizes it through the umbilical trocar. In this way, we have three different sites of the bag outside the abdominal cavity. The trocars are reinserted inside the bag. The insufflation pressure is increased from 12 mm Hg to 15 mm Hg and the insufflation is performed within the specimen bag. In this way, the specimen can be enclosed morcellated under direct visualization. Results: The procedure was effectively performed in four patients with different pathologies: (1) a 40-year-old woman with a 400 g uterus requiring total laparoscopic hysterectomy due to leiomyomas and abnormal uterine bleeding, (2) a 35-year-old woman undergoing laparoscopic myomectomy, (3) a 45-year-old woman undergoing subtotal laparoscopic hysterectomy for a 900 g uterus, and (4) a 49-year-old woman with a 65 mm solid ovarian mass (serous cystadenofibroma). In all patients, power morcellation could be performed safely within the bag. Conclusions: Power morcellation within a bag is a feasible technique. It may be an alternative way to preserve the benefits of minimally invasive surgery while mitigating the risks whenever specimen morcellation is necessary. No competing financial interests exist. Runtime of video: 9 mins 51 secs

Contained power morcellation within an insufflated isolation bag.

To describe a technique for contained power morcellation within an insufflated isolation bag at the time of uterine specimen removal during minimally invasive gynecologic procedures. Over the study period of January 2013 to April 2014, 73 patients underwent morcellation of the uterus or myomas within an insufflated isolation bag at the time of minimally invasive hysterectomy or myomectomy. This technique involves placing the specimen into a large plastic bag within the abdomen, exteriorizing the opening of the bag, insufflating the bag within the peritoneal cavity, and then using a power morcellator within the bag to remove the specimen in a contained fashion. Procedures were performed at four institutions and included multiport laparoscopy, single-site laparoscopy, multiport robot-assisted laparoscopy, or single-site robot-assisted laparoscopy. Demographic and perioperative characteristics were collected for the cases. Surgical specimen morcellation within an insufflated isolation bag was successfully used in all cases. The median operative time was 114 minutes (range 32-380 minutes), median estimated blood loss was 50 mL (range 10-500 mL), and the median specimen weight was 257 g (range 53-1,481 g). There were no complications related to the contained morcellation technique nor was there visual evidence of tissue dissemination outside of the isolation bag. Morcellation within an insufflated isolation bag is a feasible technique. Methods for morcellating uterine tissue in a contained manner may provide an option to minimize the risks of open power morcellation while preserving the benefits of minimally invasive surgery. II.

Port Site Metastasis after Surgery for Renal Cell Carcinoma: Harbinger of Future Metastasis

Port site metastasis is a rare occurrence after minimally invasive treatment for renal cell carcinoma. However, its prognostic implications are unclear because reports in the literature are heterogeneous in detail and followup. We clarify the significance of port site metastasis in cancer specific survival and broaden our understanding of this phenomenon. A MEDLINE® search for published studies of renal cell carcinoma port site metastasis was performed. Contributing factors to port site metastasis, stage, Fuhrman grade, pathology, port site metastasis treatment method, followup protocol and long-term outcomes were collected. The corresponding authors of each publication were contacted to fill in details and provide long-term outcomes. We added 1 case from our recent experience. A total of 16 cases from 12 authors (including ourselves) were found. Of the 12 authors 8 were available for correspondence and 9 cases were updated. Eventual outcomes were available for 11 of the 16 cases and survival curves showed poor prognosis with a 31.8% overall 1-year survival rate. Of the 16 cases 12 were radical nephrectomy and 4 were partial nephrectomy, and 13 involved multiple metastases in addition to the port site metastasis. Nine of the cases hadno identifiable technical reason for port site metastasis formation such as specimen morcellation, absence of entrapment or tumor rupture. These tumors were uniformly aggressive, Fuhrman grade 3 or higher. Port site metastasis after minimally invasive surgery for renal cellcarcinoma is a rare occurrence with a poor prognosis. In most cases port sitemetastasis is not an isolated metastasis but instead is a harbinger of progressive disease. While technical factors can have a role in port site metastasis formation, it appears that biological factors like high tumor grade also contribute.

Dilation of the vaginal cuff using the Bakri Postpartum Balloon to extract the large uterus at the time of robotic hysterectomy for endometrial carcinoma.

Removal of large uterine specimens during robotic or total laparoscopic hysterectomy poses surgical challenges, particularly in cases performed for gynecologic malignancy. A 23-year-old patient with endometrioid adenocarcinoma of the endometrium underwent robotic total laparoscopic hysterectomy with bilateral salpingo-oophorectomy. The large uterine specimen was removed by dilating the colpotomy incision using the Bakri Postpartum Balloon™. Dilation of the colpotomy incision with the uterine tamponade balloon can allow for the intact removal of a large uterine specimen in cases of robotic or total laparoscopic hysterectomy performed for gynecologic malignancy when specimen morcellation is contraindicated.

A Multi-Institutional Study on the Safety and Efficacy of Specimen Morcellation After Laparoscopic Radical Nephrectomy for Clinical Stage T1 or T2 Renal Cell Carcinoma

Specimen morcellation during laparoscopic radical nephrectomy (LRN) for renal cell carcinoma (RCC) is controversial. We seek to evaluate the safety and efficacy of specimen morcellation and LRN for treatment of presumed malignant renal lesions. We retrospectively reviewed all patients who underwent LRN at three academic institutions from 1996 to 2007. One hundred eighty-eight patients underwent specimen morcellation after LRN for enhancing solid or cystic renal masses. LRN was successfully performed on all the patients. Patient age ranged from 36 to 94. One hundred sixty-seven patients were in clinical stage T1, 19 patients T2, and unknown in two. The specimen was manually morcellated within a Cook Lap Sac or Endocatch II bag under laparoscopic or direct observation. On histological review of morcellated specimens, 165 patients were confirmed to have RCC, 17 had an oncocytoma, and 2 had benign cysts. At least 13 patients with RCC were pathologically upgraded to stage T3. Mean operative time was 225 minutes (range 94-650). Mean hospital stay was 2.5 days (range 1-8). In patients with RCC, 11 developed recurrent disease with mean follow-up of 21 months (range 0.3-111). In one patient, a port site recurrence occurred in concert with renal fossa and lymph node metastases. Intracorporeal mechanical morcellation after LRN appears to be safe and effective in clinical stage T1 and T2 RCC. This supports the use of morcellation as an alternative for intact specimen removal in properly selected patients.

Not So “Simple” Laparoscopic Nephrectomy: Outcomes and Complications of a 7-Year Experience

Laparoscopic radical nephrectomy has quickly evolved as an oncologic standard of care. The "Simple" nephrectomy implies an easier procedure than perhaps its radical counterpart and one that budding laparoscopists may approach with more confidence. Though, strict indications for simple nephrectomy are few, these cases tend to have infectious or inflammatory pathology sometimes making the procedure more difficult than its radical counterpart. A retrospective review of our experience with laparoscopic simple nephrectomy (LSN) over a 7-year period was performed. A total of 42 patients (12 males/ 30 females) with a mean age 47.5 years underwent LSN: 25 retroperitoneal (RP), 17 transperitoneal (TP). Indications for nephrectomy included poorly functioning kidneys associated with pain+/-hydronephrosis, recurrent infections, renal arterial stenosis induced malignant hypertension, XGP with stones. Forty-two of 45 attempted simple nephrectomies were completed laparoscopically. Three patients had open conversions: two for non-progression and one endovascular stapler malfunction. Three patients were converted from RP to TP due to severe scarring (two having prior nephrostomy tubes). Median operative time was 202.5 minutes (98-399). Eight patients were discharged within 23 hours with no complications, all having RP approaches and morcellated specimens. Mean post-operative oral intake was 17.8 hours and bowel function return was 1.3 days. Median estimated blood loss 100 ml (30-4500). Creatinine levels did not alter significantly. Median specimen weight was 88.9 grams (28-672). Fourteen complications occurred in nine patients (21.4%): five minor (flank ecchymosis and mild ileus) and nine major (re-intubation, flank hernia, wound opening requiring readmission, retroperitoneal infections, trocar fistula formation, bleed requiring transfusion). Four patients were transfused: one for post-op bleed from the ureteral stump, two for chronic anemia with minimal intraoperative blood loss, and one for intraoperative blood loss. Laparoscopic simple nephrectomy has few indications and includes a complicated patient population. The results show its efficacy and overall safety despite a moderate complication rate. Utilizing a retroperitoneal approach with specimen morcellation can reduce hospital stay. One should approach a laparoscopic nephrectomy for non-malignancy with caution for infectious or inflammatory indications.

Safety and Efficacy of Laparoscopic Radical Nephrectomy with Manual Specimen Morcellation for Stage cT1 Renal-Cell Carcinoma

Specimen morcellation during laparoscopic radical nephrectomy for renal-cell carcinoma is controversial, and supporting literature remains sparse. We seek to evaluate the safety and efficacy of morcellation for specimen removal after laparoscopic radical nephrectomy for management of renal lesions of malignant potential at a single institution. We retrospectively reviewed the records of all patients who underwent laparoscopic radical nephrectomy at Northwestern Memorial and Evanston Hospital from 2001 to 2006. Twenty-two patients were identified who underwent specimen morcellation for extraction after laparoscopic nephrectomy that was performed for enhancing solid or cystic renal masses. Laparoscopic radical nephrectomy was performed on all the patients. Patient age ranged from 36 to 96 years old. All patients were clinical stage T(1)N(0)M(0). The specimen was mechanically morcellated within Cook Lap Sac under direct and laparoscopic vision. Average tumor size after morcellation was 3.0 cm. On histologic review of the morcellated specimen, 18 patients were confirmed to have renal-cell carcinoma, 2 had an oncocytoma, and 2 had benign cysts. One patient with renal-cell carcinoma had a pathologic upgrade to stage T(3b). Average operating time was 268 minutes (range 110 to 389 min). With the exception of the patient who became anephric after nephrectomy, average hospital stay was 2.6 days. A mean clinical and radiographic follow-up of 434 days failed to show any known disease progression or port site recurrence in patients with renal-cell carcinoma. Intracorporeal, mechanical morcellation after laparoscopic radical nephrectomy appears to be safe and effective in clinical stage T1 renal-cell carcinoma. This study adds to current literature that promotes the use of morcellation as an alternative for intact specimen removal in properly selected patients. Further prospective studies are necessary to show long-term oncologic outcomes.

The effect of kidney morcellation on operative time, incision complications, and postoperative analgesia after laparoscopic nephrectomy

Compare the outcomes between kidney morcellation and two types of open specimen extraction incisions, several covariates need to be taken into consideration that have not yet been studied. We retrospectively reviewed 153 consecutive patients who underwent laparoscopic nephrectomy at our institution, 107 who underwent specimen morcellation and 46 with intact specimen removal, either those with connected port sites with a muscle-cutting incision and those with a remote, muscle-splitting incision. Operative time, postoperative analgesia requirements, and incisional complications were evaluated using univariate and multivariate analysis, comparing variables such as patient age, gender, body mass index (BMI), laterality, benign versus cancerous renal conditions, estimated blood loss, specimen weight, overall complications, and length of stay. There was no significant difference for operative time between the 2 treatment groups (p = 0.65). Incision related complications occurred in 2 patients (4.4%) from the intact specimen group but none in the morcellation group (p = 0.03). Overall narcotic requirement was lower in patients with morcellated (41 mg) compared to intact specimen retrieval (66 mg) on univariate (p = 0.03) and multivariate analysis (p = 0.049). Upon further stratification, however, there was no significant difference in mean narcotic requirement between the morcellation and muscle-splitting incision subgroup (p = 0.14). Morcellation does not extend operative time, and is associated with significantly less postoperative pain compared to intact specimen retrieval overall, although this is not statistically significant if a remote, muscle-splitting incision is made. Morcellation markedly reduces the risk of incisional-related complications.

Cytology of morcellated renal specimens: significance in diagnosis and dissemination.

Controversy surrounds the process of morcellation for retrieving laparoscopically removed specimens. The inability to assess tumor stage, increased difficulty in pathological examination and the potential for tumor spillage are cited as significant disadvantages of the technique. We examined cytological findings in bag washings after laparoscopic nephrectomy for benign and malignant diseases. We prospectively obtained cytology washings from the retrieval bag after laparoscopic nephrectomy and manual morcellation. In 22 consecutive cases after specimen fragmentation in a LapSac (Cook Urological, Spencer, Indiana) the bag was thoroughly irrigated with 30 cc normal saline. This wash was then processed by ThinPrep (Cytyc Corp., Marlborough, Massachusetts) and stained with Papanicolaou stain. Standard pathological examination of the morcellated specimen was performed to determine renal histology. The histological diagnosis was clear cell renal carcinoma in 10 cases, multicystic renal carcinoma in 2, papillary renal cell carcinoma in 1, angiomyolipoma in 1, and oncocytoma in 1. Bag cytological results were accurate in 9 of 13 patients with carcinoma (69%), while in 3 cytological study provided additional information. In all 9 cases of benign histology, cytological findings were consistent with benign cellular features. Neoplastic cells were easily detected and classified into type and grade. Cytological examination of LapSac washings after specimen morcellation provided a pathological diagnosis in the majority of patients. This method may complement existing techniques and be useful for increasing the accuracy of pathological analysis of morcellated specimens. In addition, these data suggest that malignant cells are liberated during the morcellation process, which has significant implications for potential tumor dissemination.

EVALUATION OF THE INTACT SPECIMEN AFTER LAPAROSCOPIC RADICAL NEPHRECTOMY FOR CLINICALLY LOCALIZED RENAL CELL CARCINOMA IDENTIFIES A SUBSET OF PATIENTS AT INCREASED RISK FOR RECURRENCE

Laparoscopic radical nephrectomy (LRN) is emerging as a standard approach for low stage renal cell carcinoma (RCC). Some suggest that specimen morcellation for extraction results in less morbidity and a faster recovery. However, morcellation may preclude accurate pathological staging and may hinder precise pathological grading. With pathological evaluation of an intact specimen we identified patients harboring high risk disease that was not anticipated preoperatively, defined as pT2 high grade (G3-4) or lesions greater than pT2. We retrospectively reviewed the records of 192 patients who underwent LRN for renal lesions at The University of Texas M. D. Anderson Cancer Center between April 2002 and April 2004. A total of 192 patients underwent LRN for presumed RCC. In all cases specimens were removed intact. Of these cases 137 were cT1/T2 N0 M0 and had a final pathological diagnosis of RCC. All surgical margins were negative. Of the 137 patients 40 (29.2%) were at increased risk for recurrence based on high risk features. Specifically up staging from cT1-2 to pT3 disease occurred in 30 patients (21.9%) while 12 patients (8.8%) were found to have pT2 G3-4 disease. All 40 patients with high risk disease underwent more intensive surveillance and 17 (43%) participated in adjuvant systemic therapy trials. In our study 21.9% of patients with clinical T1-2 disease were pathologically up staged and 29.2% were identified as being at high risk for recurrence after intact specimen extraction for localized RCC. These patients are candidates for more intensive followup treatment and may benefit from enrollment in adjuvant therapy protocols.

Modified renal morcellation for renal cell carcinoma: laboratory experience and early clinical application

Objectives To present our modified technique to expedite the entrapment and morcellation process. Standard renal morcellation is typically performed using a 12-mm incision, with the specimen entrapped within a durable LapSac. Because the LapSac does not have a deployment mechanism, its application is technically demanding and time consuming. The recent elimination of the electrical morcellator has also made the morcellation process time consuming and tedious. Methods Using an in vitro porcine kidney morcellation model, we compared traditional morcellation (n = 10) with our modified morcellation technique (n = 10). The modified morcellation technique incorporated an EndoCatch entrapment sac and used standard manual morcellation through a 3-cm incision. The 3-cm incision allowed for extracorporeal morcellation, because the specimen could be seen through the abdominal wall defect. Subsequently, we performed 11 laparoscopic radical/total nephrectomies for renal masses using the modified morcellation technique through a 3-cm incision. Results In this in vitro model, renal specimen morcellation with the standard technique required a mean of 9.4 minutes (16.5 g/min) and modified morcellation required 3.24 minutes (51.24 g/min; P <0.0001). The mean fragment size with standard and modified morcellation was 1.47 and 4.46 g, respectively ( P <0.0001). EndoCatch entrapment sack integrity was confirmed in all 10 cases (100%). Clinically, 12 patients underwent modified morcellation of radical nephrectomy specimens. All specimens were renal cell carcinoma, with a mean specimen weight of 724 g. The mean entrapment time was 2 minutes, 40 seconds, and the mean morcellation time was 11 minutes. EndoCatch entrapment sack integrity was confirmed in all cases. At a mean follow-up of 8 months, no trocar site or local recurrences have developed. Conclusions Preliminary laboratory and clinical data have demonstrated that the modified morcellation technique is safe and expeditious. The larger fragments that result from the modified technique may facilitate tumor staging. The technique must be performed with great care to prevent sack perforation. Prospective randomized comparison of the modified and standard morcellation techniques and long-term follow-up are required before routine application of this technique.

Cytology of Morcellated Renal Specimens: Significance in Diagnosis and Dissemination

Controversy surrounds the process of morcellation for retrieving laparoscopically removed specimens. The inability to assess tumor stage, increased difficulty in pathological examination and the potential for tumor spillage are cited as significant disadvantages of the technique. We examined cytological findings in bag washings after laparoscopic nephrectomy for benign and malignant diseases. We prospectively obtained cytology washings from the retrieval bag after laparoscopic nephrectomy and manual morcellation. In 22 consecutive cases after specimen fragmentation in a LapSac (Cook Urological, Spencer, Indiana) the bag was thoroughly irrigated with 30 cc normal saline. This wash was then processed by ThinPrep (Cytyc Corp., Marlborough, Massachusetts) and stained with Papanicolaou stain. Standard pathological examination of the morcellated specimen was performed to determine renal histology. The histological diagnosis was clear cell renal carcinoma in 10 cases, multicystic renal carcinoma in 2, papillary renal cell carcinoma in 1, angiomyolipoma in 1, and oncocytoma in 1. Bag cytological results were accurate in 9 of 13 patients with carcinoma (69%), while in 3 cytological study provided additional information. In all 9 cases of benign histology, cytological findings were consistent with benign cellular features. Neoplastic cells were easily detected and classified into type and grade. Cytological examination of LapSac washings after specimen morcellation provided a pathological diagnosis in the majority of patients. This method may complement existing techniques and be useful for increasing the accuracy of pathological analysis of morcellated specimens. In addition, these data suggest that malignant cells are liberated during the morcellation process, which has significant implications for potential tumor dissemination.

Comparison of Hand Assisted Versus Standard Laparoscopic Radical Nephrectomy for Suspected Renal Cell Carcinoma

We compared standard and hand assisted laparoscopic radical nephrectomy for suspected renal cell carcinoma. We retrospectively reviewed 22 hand assisted and 16 standard laparoscopic radical nephrectomies performed for suspected renal cell carcinoma. Operative and recovery data were collected prospectively and from medical records as part of an institutional review board approved protocol. Patients completed pain, activity and the 12-item short form health related quality of life surveys preoperatively and postoperatively. Although patients undergoing hand assisted laparoscopic nephrectomy had larger tumors (mean 6.3 versus 4.1 cm., p = 0.009), tended toward greater corrected mean specimen weight (658 versus 482 gm., p = 0.111) and had greater medical co-morbidity (p = 0.0228), mean operative time for hand assisted laparoscopic procedures was significantly shorter (205 versus 270 minutes, p = 0.0004). With experience mean operative time decreased for standard but not for hand assisted laparoscopy (293 to 232 minutes, p = 0.0445, versus 206 to 204, p = 0.6162). Procedure type, surgeon experience and adrenal sparing were the only significant predictors of operative time. There was no difference in the groups in terms of the complication rate, hospital cost or stay, return to activity or overall pain score, or in the difference in preoperative and postoperative 12-item short form scores. Hand assisted laparoscopic nephrectomy tended to be associated with more abdominal pain early in convalescence and more wound complications but not significantly so. Hand assisted laparoscopic radical nephrectomy offers recovery, morbidity and cost that are comparable to those of standard laparoscopy. The benefits of the technique include shorter operative times, no need for specimen morcellation and direct manual control of the operative field. It is particularly useful early in surgeon experience, for large specimens or when patient co-morbidities require a rapid procedure.

Specimen morcellation after laparoscopic radical nephrectomy: confirmation of histologic diagnosis using needle biopsy.

Laparoscopic radical nephrectomy (LRN) is being increasingly offered for the management of renal-cell carcinoma (RCC). Specimen removal may be performed through a small or hand-port incision or by specimen morcellation. Limited studies exist addressing the accuracy of histopathologic diagnosis in morcellated renal tumors. Because of concerns about the lack of a diagnosis secondary to the morcellation process, we performed premorcellation needle biopsies to obtain nondisrupted tissue for pathologic analysis. Herein, we compare the histopathologic diagnosis achieved via needle biopsy prior to morcellation with that of the final specimen. Following successful laparoscopic resection, specimens were entrapped in a Lapsac. Needle biopsies were performed manually through the mouth of the Lapsac, and morcellation was then done in some patients using manual and mechanical methods. The histopathologic diagnoses in the needle biopsy specimens and the morcellated material were compared. Laparoscopic radical nephrectomy with specimen morcellation was performed in 15 patients. Nine patients had premorcellation needle biopsies. Eight of these biopsies had sufficient tissue for diagnosis of RCC. This finding correlated with final diagnosis from the morcellated material. Perinephric fat invasion was identified in three morcellated specimens. Needle biopsy prior to specimen morcellation confirmed the histologic diagnosis of the morcellated specimen. This finding suggests that such histopathology material is adequate for diagnosis and may make premorcellation needle biopsy redundant.

Laparoscopic Radical Nephrectomy: Prospective Assessment of Impact of Intact versus Fragmented Specimen Removal on Postoperative Quality of Life

We prospectively compared postoperative recovery and quality of life for groups of patients undergoing laparoscopic radical nephrectomy with intact or fragmented specimen removal. A prospective evaluation of 12 patients having a transperitoneal laparoscopic nephrectomy was completed. In each case, a radical dissection was performed regardless of the surgical indication. Fragmented specimens (N = 7) were extracted at the umbilical port, and intact specimens (N = 5) were extracted through an infraumbilical incision. Demographic and perioperative data including specimen removal incision, narcotic requirements, and recovery interval were recorded. Subjective pain and activity assessments were administered prospectively on postoperative days 1, 2, 7, and 14. The mean incision length for intact specimen removal was 7.6 cm and that for fragmented removal was 1.2 cm (P < 0.05). Pain and activity self-assessments improved over time in each group. No significant differences in pain or activity scores were noted between treatment groups at any queried interval. Time to return of normal activity was not significantly different in the two groups. In this pilot study, no subjective or objective advantage was demonstrated for kidney fragmentation during laparoscopic radical nephrectomy. A larger randomized study is required to better assess any clinical advantage to specimen morcellation.

Laparoscopic nephroureterectomy for the treatment of transitional cell carcinoma of the upper urinary tract

Objectives. To establish the safety and efficacy of laparoscopic and laparoscopic-assisted nephroureterectomy. Methods. Since 1993, 25 patients with a minimum of 12 months of follow-up underwent nephroureterectomy using a total laparoscopic or laparoscopic-assisted technique. Four patients had specimen morcellation for tissue removal. All patients had regular follow-up with physical examinations, interval cystoscopy, and radiographs, depending on the metastatic potential of the tumor. Retrospective chart review was performed and assessed for operative time, blood loss, tumor pathologic stage, complications, and outcome. One patient was excluded because of an open conversion due to multiple previous abdominal surgeries and failure to progress. Results. The mean operating time was 329 minutes but decreased with experience. The median hospital stay was 4 days. Tumor stage was directly related to tumor grade. Associated bladder tumors (prior history or recurrent tumors) occurred in 50% of the patients. Ipsilateral ureteral stump site recurrence occurred in 1 patient. Although no port site seeding occurred, 1 patient, whose tumor was discovered histologically after laparoscopic pyeloplasty for presumed benign disease, developed recurrence in the renal fossa and metastatic disease. Two patients developed liver metastasis. Conclusions. Total laparoscopic and laparoscopic-assisted nephroureterectomy are acceptable alternatives to open surgery in the treatment of transitional cell carcinoma of the upper urinary tract. Tumor morcellation did not appear to adversely affect patient outcome. As with open nephroureterectomy, tumor grade is the most important prognostic indicator of local, bladder, and metastatic recurrence. No port site seeding was observed in either the total laparoscopic or laparoscopic-assisted groups.