Hand-assisted laparoscopic nephrectomy for inflammatory renal conditions

PURPOSE: Laparoscopic surgery for large renal lesion or kidneys with chronic inflammation has proved to be technically challenging. Hand-assisted laparoscopic surgery might be useful in these complex cases, as it provides surgeons the benefits of tactile feedback, digital retraction, and facilitated dissection of the renal hilar vessels. PATIENTS AND METHODS: Twenty-two patients undergoing hand-assisted laparoscopic (HAL) nephrectomy for benign conditions were compared with patients who underwent HAL radical nephrectomy during the same period. The demographic data, laterality, operative time, estimated blood loss, conversion rate, length of stay, histopathology findings, morbidity, and mortality were reviewed. RESULTS: The main indications for surgery were chronic inflammation and xanthogranulomatous pyelonephritis. Twenty patients had unilateral nephrectomy (10 each on the right and left), and two patients had bilateral nephrectomy. The mean operative times for unilateral and bilateral nephrectomy were 163 minutes (range 55-261 minutes) and 265 minutes (range, 238-291 minutes), respectively. Nine patients (45%) with inflammation had complications (15% major and 30% minor). The mean length of hospitalization for patients undergoing HAL nephrectomy was 7.2 days (range 2-35 days). The patients with inflammatory pathology had longer mean operative times, higher estimated blood loss, longer hospital stay, and higher morbidity than patients undergoing radical nephrectomy. CONCLUSION: Compared with standard laparoscopy, the hand-assisted approach has been reported to reduce operative times and increase safety. The advantages of minimally invasive surgery, such as reduced analgesia, shorter hospital stay, and faster return to normal activity, appear to be similar to those in patients undergoing a pure laparoscopic nephrectomy. Compared with radical nephrectomy for renal tumor, HAL simple nephrectomy can often be more challenging and associated with greater morbidity. For both the community urologist as well as an experienced laparoscopist, this approach is useful in handling these challenging cases.     

Hand-assisted laparoscopic nephrectomy

Introduction and objectivesTo present the number of cases of hand-assisted laparoscopic nephrectomy. This study evaluates our results and difficulties of starting a progresive programme of laparoscopy.Material and MethodBetween november 2003 and november 2005, 35 hand-assisted laparoscopic nephrectomies were carried out, of a total of 45 laparoscopic nephrectomies. 22 radical nephrectomies, 3 simple nephrectomies and 10 nephroureterectomies. The average age of patients was 66 years (47-89). On average, they were overweight (IMC 28,3), with approximately 38% being obese. ASA 2.3 (1-4). The tumors measured 4.8cm on average, and 80% of these were T1. In 28.6% of the cases, they had previously undergone abdominal surgery.ResultsOne was undertaken in 2003, 17 in 2004, and 17 in 2005. The surgery time was 140 minutes, 130 minutes (80-210) in radical nephrectomies, 135 minutes (120-150) in simple nephrectomies and 163 minutes (80-240) in the nephroureterectomy. Patients began an oral diet 1.7 days later, and were able to get up 1.7 days later. In the case of obese patients, they began an oral diet 2.3 days later and were able to get up (2.4 days) later than those non obese cases. (1.5 and 1.4 days respectively). The average stay has been 5.8 days (3-15). The average stay of the cases without complications was 4.2 days and those that encountered complications 9.7 days. In no cases was there a need for a blood transfusion. In 11.4% we had major complications with an average stay of 11.7 days. In 5.7% of cases there were reconversions, and 5.7% of cases were reoperated. 17.1% had minor complications, with an average stay of 8.8 daysConclusionsThe advantage of hand-assisted nephrectomy is that it allows one to begín a laparoscopy, with a reduced learning time, and with satisfactory results, allowing the incorporation of laparoscopy surgery in hospitals with a reduced annual volume.     

Hand-assisted laparoscopic nephrectomy

Hand-assisted surgery enjoys the benefits of open surgery while maintaining the post-operative advantages of laparoscopy. Logical indications for its application largely include those cases that require removal of a large amount of tissue intact. Hand-assisted laparoscopic surgery may find application in complex procedures such as radical, partial and difficult nephrectomies.     

Hand-assisted laparoscopic nephrectomy

The introduction of hand-assisted laparoscopy should benefit every laparoscopic urologist. Hand assistance will shorten the learning curve for many urologists interested in performing laparoscopic renal procedures, including nephrectomy and nephroureterectomy. Advanced laparoscopists will be able to undertake more challenging procedures, including nephrectomies for inflamed, infected kidneys and live-donor nephrectomies. A step-by-step approach is presented for hand-assisted laparoscopic nephrectomy.     

Hand-assisted laparoscopic radical nephrectomy

Laparoscopic radical nephrectomy is the standard of care for the management of most renal cancers. The hand-assisted approach has bridged the gap between open nephrectomy and a pure laparoscopic approach. Hand-assisted laparoscopic nephrectomy allows tactile feedback, thus shortening the learning curve for some surgeons and allowing more experienced laparoscopists to perform more complex and challenging procedures.     

手助腹腔镜单纯性肾切除术的临床价值

目的 :探讨手助腹腔镜单纯性肾切除术的临床价值。方法 :采用手助腹腔镜行单纯性肾切除术 7例。结果 :7例手术均获成功 ,无术中和术后并发症发生。手术时间 85～ 30 0min ,平均 2 0 4min ;术中出血 30～2 0 0ml,平均 85ml;肾脏大小为 (14 .0cm× 8.5cm× 7.5cm)～ (2 4 .0cm× 2 0 .0cm× 10 .0cm) ;术后住院时间 6～15d。结论 :对于标准腹腔镜手术有难度的单纯性肾切除术 ,手助腹腔镜单纯性肾切除术 ,是一种可以选择的新的手术方式。     

Hand-assisted laparoscopic radical nephrectomy

Laparoscopic radical nephrectomy is the new standard of care for localized renal cancer. Hand assistance makes the procedure less daunting by providing tactile feedback. The authors consider the indications, contraindications, and technique for this operation, which provides the patient with the benefits of minimally invasive surgery while shortening the learning curve for the surgeon and allowing experienced laparoscopists to carry out more complex and challenging operations.     

Hand-assisted laparoscopic donor nephrectomy

Background: The hand-assisted approach to laparoscopic donor nephrectomy (LDN) might minimize the learning curve and shorten both the operation and the warm ischemia time. Our initial results from hand-assisted LDN are presented and compared with data from the literature. Methods: From January to September 2000, ten hand-assisted LDNs of the right kidney were performed. Results: The median operation time was 140 min (range, 120--400 min), and the warm ischemia time was 2.5 min (range, 1--4 min). There were no conversions. Postoperative morbidity included one urinary tract infection. All but one patient returned to a normal diet within 48 h. Opiates were needed a maximum of 48 h. One recipient experienced initial loss of graft function as a result of unknown causes. Conclusions: Even at the beginning of the learning curve, operation time and warm ischemia time are significantly reduced by the hand-assisted approach, as compared with conventional LDN. apd: 3 April 2001     

Hand-assisted laparoscopic partial nephrectomy

BACKGROUND AND PURPOSE: The indications for partial nephrectomy are expanding as newer and more complete data come forth. A partial nephrectomy has traditionally required a generous flank incision. We report our experience using hand-assisted laparoscopy (HAL) as a less-invasive approach to partial nephrectomies. PATIENTS AND METHODS: Between October 1999 and May 2000, we performed 11 HAL partial nephrectomies. The average age of the patients was 55.7 years, the average body mass index was 25.6, and the average ASA class was 2.2. The indications for partial nephrectomy were enhancing solid renal lesions (N = 9) and nonfunctioning renal moiety in a duplicated system (N = 2). In the majority of cases, access to the renal pedicle was obtained prior to the partial nephrectomy. However, in no case did the renal artery or vein require occlusion. Several excisional techniques were employed, but all relied heavily on the Harmonic Scalpel in conjunction with the argon beam coagulator. Different hemostatic agents were applied to the renal defect, including Surgicel, Avitene, and fibrin-soaked Gelfoam activated by thrombin. In several instances, pledget reinforced sutures were placed in the renal capsule to aid with hemostasis. RESULTS: The average operative time was 273 minutes, the estimated blood loss 319 mL, and the change in hematocrit 7.3 points. No patient required a transfusion, and there was one conversion to open. Postoperatively patients, required an average of 35.6 mg of morphine sulfate equivalent and 8.2 narcotic tablets, resumed oral intake in 1.7 days, and were discharged home in 3.3 days. There were no major complications and only two minor complications. Postoperatively, five lesions were found to be benign, four lesions were confirmed to be malignant, and two lesions were consistent with a nonfunctioning duplicated renal moiety. Specimen size averaged 180 cc, and the tumor diameter averaged 1.9 cm. There were no positive surgical margins. CONCLUSIONS: Hand-assisted laparoscopic partial nephrectomy is feasible and reproducible. The surgeon's hand in the operative field facilitates dissection, vascular control, hemostasis, and suturing. Further long-term and prospective studies are underway.     

Hand-assisted laparoscopic partial nephrectomy

The resurgence of nephron-sparing surgery for selected renal masses has fueled interest in minimally invasive approaches. Several authors have shown that laparoscopic partial nephrectomy is feasible if two goals are met: resection of the mass with negative margins and control of bleeding. The latter is a particular challenge, but numerous options are available. The authors describe the operative technique and the available results of hand-assisted laparoscopic partial nephrectomy.     

手辅助腹腔镜在亲属活体供肾切取中的应用25例报告

目的 探讨手辅助腹腔镜在亲属活体供肾切取中的应用.方法 回顾性分析25名亲属活体供肾者的资料.25名供者中,男性6名,女性19名,年龄(42±17)岁.23例为亲属血缘关系供肾,2例为夫妻间供肾.分析供者选择手辅助腹腔镜下取肾术的原因、供者的手术时间、供肾热缺血时间、术中出血量、肾脏及周围脏器损伤情况、术后恢复情况及移植肾功能恢复情况,评价手辅助腹腔镜下取肾术的临床应用效果.结果 对25名亲属供者应用手辅助腹腔镜下取肾术均获成功,无中转开放手术;24例取左肾,1例取右肾;手术时间(138±42)min,供肾热缺血时间为(145±22)s,术中出血量(53±32)m1;无供肾损伤,无切口相关并发症,仅有1例发生脾包膜撕裂;术后住院时间为(7.2±1.7)d,供者均满意.调查显示,供者选择手辅助腹腔镜下取肾术的主要原因是手术损伤小、切口对外观影响较小、心理负担轻.亲属活体供肾移植后,仅有1例受者发生移植肾功能恢复延迟,其余受者的血肌酐水平均在1周内下降至正常.结论 手辅助腹腔镜下取肾术综合了传统腹腔镜技术和开放性手术取肾的优点,微创,操作方便,供肾损伤机会少,切口对外观影响较小,供者易于接受.     

后腹腔镜下肾部分切除术治疗肾脏肿瘤

【摘要】 目的 探讨后腹腔镜下肾部分切除术的方法和临床应用价值。方法 选取2013年7月至2017年11月在本院收治37例肾脏肿瘤患者施行后腹腔镜下肾部分切除术,其中肾透明细胞癌T1a期23例,T1b期4例,肾错构瘤9例,T1a期肾嫌色细胞癌1例。术中充分游离肾脏和肿块表面脂肪,血管夹阻断肾动脉主干动脉,距肿块边缘正常组织0.5 cm处切除肿块,缝合创面并用Hem-o-lock固定减张。结果 36例成功施行腹腔镜下切除术,其中1例因行肾段动脉阻断未完全,出血较多中转开放手术,2例未行肾动脉阻断。手术时间65～225 min,平均95 min,术中出血量20～1000 mL,平均125 mL,肾动脉阻断时间10～35 min,平均24 min。1例术后2周继发出血,行介入栓塞治疗后出血停止。住院时间11～27 d,平均14.6 d,随访3～27个月,无远期并发症,肿瘤未见复发。结论 后腹腔镜下肾部分切除术治疗肾脏肿瘤创伤小,恢复快,效果显著,值得推广。     

活体供肾移植:手助腹腔镜供肾切除优于常规腹腔镜供肾切除

目的　比较活体供肾移植中手助腹腔镜供肾切除 (Hand -assistedlaparoscopicdonornephrectomy ,HALDN)和完全腹腔镜活体供肾切除 (Laparoscopicdonornephrectomy,LDN)以及对供肾者和接受肾移植者的影响。　方法　回顾总结 1996年 10月～ 2 0 0 1年 2月MountSinai医学中心所有LDN和HALDN的病例资料。 1996年 10月开始行LDN手术 ,1999年 6月转而行HALDN手术。　结果　与LDN组相比 ,HALDN组手术时间明显缩短 ( ( 2 11± 7)minvs ( 2 5 7± 5 )min ,P <0 0 5 ) ,术中出血量明显减少 ( ( 12 2± 17)mlvs ( 2 86± 33)ml,P <0 0 5 ) ,肾脏热缺血时间明显缩短 ( ( 10 6± 6 )svs ( 2 5 7± 8)s,P <0 0 5 ) ,术后淋巴漏和血栓形成发生率 ( 0 %vs 13 7% ( 16例 ) ;2 5 % ( 2例 )vs 6 8% ( 8例 ) ,P <0 0 5 )明显下降。　结论　在活体供肾移植中 ,HALDN似乎优于LDN ,但尚需要前瞻性对照研究予以进一步证实。     

Comparison of laparoscopic and open partial nephrectomy in clinical T1a renal tumors

PURPOSE: Partial nephrectomy has been established as a standard of care for T(1a) renal tumors. Laparoscopic partial nephrectomy (LPN) has been described as more difficult to perform than open partial nephrectomy (OPN). We compare our series of LPN and OPN. PATIENTS AND METHODS: From October 2002 to January 2006, 76 LPNs were performed for patients with clinical T(1a) tumors. These patients were matched with a cohort of patients who underwent OPN for solitary tumors of 4 cm or smaller in diameter. The cohorts were compared with regard to demographics, perioperative data, and outcomes. RESULTS: The patient populations were demographically similar. Although mean tumor size was smaller in the laparoscopic cohort (2.5 v 2.9 cm, P=0.002), the OPN cohort demonstrated shorter operative (193 v 225 min, P=0.004) and ischemia times (20.5 v 32.8 min). LPN was associated with less blood loss (212 v 385 mL, P<0.001) and shorter hospital stay (2.5 v 5.6 days, P<0.001), however. One positive margin occurred in each of the LPN and OPN cohorts. Intraoperative complications were similar, although LPN was associated with fewer postoperative complications. Of note, two LPN (2.6%) patients had emergent reoperation and complete nephrectomy because of postoperative hemorrhage. CONCLUSIONS: Despite increased operative and ischemia times, LPN patients demonstrated quicker recovery and fewer postoperative complications. Two patients in the LPN group, however, had emergent complete nephrectomy because of hemorrhage. We conclude that LPN is still an evolving alternative to OPN in patients with small renal tumors.     

Hand-assisted laparoscopic live donor nephrectomy

BACKGROUND: Hand-assisted laparoscopic donor nephrectomy (HLDN) may have advantages over laparoscopic donor nephrectomy, such as shorter learning curve, operation and warm ischaemia times. The aim of this study was to evaluate the feasibility and safety of HLDN. METHODS: Between January 2000 and October 2002, 50 consecutive HLDN procedures were performed through a low transverse abdominal incision, 23 right sided and 27 left sided. RESULTS: The median age of the donors was 44 years. No HLDN required conversion to an open procedure. The median operating time for HLDN was 153 min. The median warm ischaemia time was 3 (range 1.0-4.5) min and the median blood loss was 50 (range 20-500) ml in both left- and right-sided procedures. Eight patients suffered ten minor complications during their admission. The duration of hospital stay was 5 days for donors. Three recipients developed graft failure owing to acute rejection, renal vein thrombosis and ischaemic necrosis. CONCLUSION: Both left- and right-sided HLDN procedures were feasible and safe through a low transverse abdominal incision.