UROLOGICAL SURVEY
Caruso RP, Phillips CK, Kau E, Taneja SS, Stifelman MD
Department of Urology, New York University School of Medicine, New York, New York
J Urol. 2006; 176: 36-39
PURPOSE: Advances in laparoscopy have made laparoscopic partial nephrectomy a technically feasible procedure but it remains challenging to even experienced laparoscopists. We hypothesized that robotic assisted laparoscopic partial nephrectomy may make this procedure more efficacious than the standard laparoscopic approach.
MATERIALS AND METHODS: Ten patients with a mean age of 58 years and mean tumor size of 2.0 cm underwent robotic assisted laparoscopic partial nephrectomy and another 10 with a mean age of 61 years and mean tumor size of 2.18 cm underwent laparoscopic partial nephrectomy, as performed by a team of 2 surgeons (MS and ST) between May 2002 and January 2004. Demographic data, intraoperative parameters and postoperative data were compared between the 2 groups.
RESULTS: There were no significant differences in patient demographics between the 2 groups. Intraoperative data and postoperative outcomes were statistically similar. In the 10 patients who underwent robotic assisted laparoscopic partial nephrectomy there were 2 intraoperative complications. There was 1 conversion in the laparoscopic partial nephrectomy group.
CONCLUSIONS: Robotic assisted laparoscopic partial nephrectomy is a safe and feasible procedure in patients with small exophytic masses. The robotic approach to laparoscopic partial nephrectomy does not offer any clinical advantage over conventional laparoscopic nephrectomy.
Editorial Comment
Advances in laparoscopy allowed surgeons to perform complex reconstructive and ablative surgical procedures. Laparoscopic partial nephrectomy is the best example to depict these innovations where accuracy, speed and surgeon's expertise must work in concert. Robotic surgery may bring some advantages to the novice laparoscopists when performing laparoscopic radical prostatectomies but for nephron-sparing nephrectomies does not appear to help. Although the authors acknowledge the need of randomization of larger number of patients for clinical validation, this study is a pioneer comparing laparoscopic partial nephrectomy (LPN) versus robotic assisted laparoscopic partial nephrectomy (RALPN). Interestingly, the authors believe that the distance between the surgeon and the sterile surgical field may have decreased the threshold to convert the RALPN to a hand assisted or open procedure. Other potential disadvantages of the robotic system are cost, training, equipment malfunction and setup time. Additionally, while LPN can safely be performed with a primary surgeon and an assistant, RALPN is a procedure that must be done with 2 experienced surgeons. In conclusion, RALPN is not ready for primetime yet.
Dr. Fernando J. Kim
Chief of Urology, Denver Health Med Ctr
Assistant Professor, Univ Colorado Health Sci Ctr
Denver, Colorado, USA
Comparison of laparoscopic partial nephrectomy a nd laparoscopic hand pain during hand assisted laparoscopic nephrectomy - an ischemic event?
Ost MC, VanderBrink BA, Rastinehad AR, Smith AD, Lee BR
From the Department of Urology, North Shore-Long Island Jewish Medical Center, New Hyde Park, New York, USA
J Urol. 2006; 176: 149-54
PURPOSE: The etiology of hand discomfort during hand assisted laparoscopic nephrectomy may be ischemic in nature. We determined if pneumoperitoneal pressure sustained to the hand during hand assisted laparoscopic nephrectomy poses an occupational risk, contributing to local hand hypoxia and resultant extremity pain.
MATERIALS AND METHODS: A total of 442 measurements of hand oxygen saturation were made during hand assisted laparoscopic nephrectomy. A Nellcor(r) OxiMax(tm) Max-1(r) oxygen sensor was attached to the left index finger of each surgeon and hand assisted laparoscopic nephrectomy was performed using a LapDisc(r) at 15 mm Hg pneumoperitoneal pressures. Local hand oximetry readings and a numerical pain distress scale (range 0 to 10) were recorded every 2 minutes. To control for motion artifact oximetry readings were taken during hand motion and at rest. The Student t test was used to compare differences in local hand oxygen saturation and hand pain in and between study groups.
RESULTS: A history of hand pain during hand assisted laparoscopic nephrectomy was significantly associated with local hypoxia during operative motion and at rest (p= 0.023 and 0.012, respectively), even with an adequate fascial incision and standard pneumoperitoneal pressures. During hand assisted laparoscopic nephrectomy hand pain was most significantly associated with local hypoxia after 24 minutes (p 0.0002), when local oxygen saturation was 56% to 88%.
CONCLUSIONS: A cohort of urologists is predisposed to ischemic hand pain during hand assisted laparoscopic nephrectomy. The etiology of this pain may be hypoxic in nature, attributable to pneumoperitoneal pressure decreasing perfusion and causing venous congestion or regional local ischemia. Circumferential antebrachial constriction from the LapDisc(r) does not seem to be a significant contributing factor in the presence of an adequate fascial incision. Hand pain secondary to ischemia is most significant after 24 minutes at 15 mm Hg. Future studies in more subjects are called for to validate these findings to elucidate which surgeons are predisposed to this potential occupational hazard and what perioperative measures can be taken to avoid hand pain during hand assisted laparoscopic nephrectomy.
Editorial Comment
Hand assisted procedures allowed less experienced laparoscopic surgeons to offer a less invasive approach to their patients with results comparable to purely laparoscopic surgery; i.e.; radical nephrectomy. Unfortunately, the causes of hand numbness and/or pain have never been completely elucidated, i.e. fascial length and compression, pneumoperitoneum, etc.
Interestingly, this paper demonstrated that after 24 minutes of pneumoperitoneum (15 mm of Hg) the surgeon's hand would suffer hypoxia that may trigger symptoms of discomfort and pain. For surgeons that would occasionally perform this type of surgery may not suffer the effects of local hypoxia but for those who would routinely perform hand-assisted procedures that would last more than 24 minutes should be aware of this occupational risk and take precautions to prevent from chronic problems.
Dr. Fernando J. Kim
Chief of Urology, Denver Health Med Ctr
Assistant Professor, Univ Colorado Health Sci Ctr
Denver, Colorado, USA
Endourology & laparoscopy
Publication Dates
-
Publication in this collection
16 Aug 2006 -
Date of issue
June 2006
