Comparison of hand assisted and standard laparoscopic radical nephroureterectomy for the management of localized transitional cell carcinoma

Purpose: Hand assisted laparoscopy affords the surgeon tactile sensation and blunt dissection, which are currently limited using the standard laparoscopic technique. Therefore, we compared standard and hand assisted laparoscopic radical nephroureterectomy for localized upper tract transitional cell carcinoma. Materials and Methods: The medical records of 27 patients who underwent standard (11) or hand assisted (16) laparoscopic radical nephroureterectomy between April 1998 and January 2001 were retrospectively reviewed. The parameters of efficacy, efficiency, safety and convalescence were compared. Results: Mean patient age was 64 and 66 years (p = 0.72) in the standard and hand assisted groups, and the mean American Society of Anesthesiologists score was 2.5 and 2.7 (p = 0.64), respectively. All standard and 15 of the 16 hand assisted (94%) procedures were successfully completed via laparoscopy. Total operative time was more than 1 hour shorter for hand assisted than for laparoscopic radical nephroureterectomy (4.9 versus 6.1 hours, p = 0.055). Mean estimated blood loss was similar in the standard and hand assisted groups (190 and 201 ml., p = 0.78). In each group 1 patient required blood transfusion. Mean specimen weight was significantly higher in hand assisted cases (576 versus 335 gm., p = 0.036). Mean time to oral intake was similar in patients who underwent standard and hand assisted laparoscopic radical nephroureterectomy (13 and 20 hours, respectively, p = 0.45). The mean analgesic requirement was also similar (29 and 33 mg. morphine sulfate, respectively, p = 0.83). Mean hospital stay in uncomplicated cases was similar for standard and hand assisted surgery (2.9 and 2.5 days, respectively). Overall hospital stay in the 2 cohorts was also similar (3.3 and 4.5 days, respectively, p = 0.59). Four patients per group experienced postoperative complications. There were no deaths in the standard group but 1 patient (6%) in the hand assisted group died postoperatively. Mean time to partial and complete convalescence in the standard and hand assisted groups was 2.4 and 5.2, and 3.5 and 8.0 weeks, while mean followup was 27.4 and 9.6 months, respectively. Conclusions: Compared with standard laparoscopy hand assisted laparoscopy decreases operative time without significantly altering short-term parameters of convalescence. However, long-term convalescence after hand assisted laparoscopic radical nephroureterectomy is 1 to 3 weeks longer (p = 0.27). Longer followup in the hand assisted cohort is necessary to determine whether there are any differences in the 2 methods in regard to cancer control.