BJU International (1999), 83, 504–505

P O I NT OF TE C HN I QU E

Hand-assisted laparoscopic nephroureterectomyF.X. KEELEY, N.K. SHARMA* and D.A. TOLLEYScottish Lithotriptor Centre, Western General Hospital, Edinburgh and *Royal Oldham Hospital, Oldham NHS Trust, Oldham, UK

the lithotomy position and the left ureteric orifice resectedIndications

until the ureter was completely detached from the trigoneand detrusor. A 22 F Foley catheter was inserted. TheThe laparoscopic approach has been used to perform a

wide variety of urological procedures, but laparoscopic patient was then placed in an oblique flank position with10° of backward tilt. The Intromit incision template wasnephrectomy has remained outside routine urological

practice because of the long experience and training placed over the tip of the 12th rib and the skin sitemarked clearly. A 12-mm trocar was inserted underrequired, and prohibitive operative duration.

Laparoscopic nephroureterectomy has even longer direct vision into the peritoneum via an incision at thelevel of the umbilicus and the lateral edge of the rectusreported operative duration [1]. We have used a specially

designed port, the Intromit (Medtech, Dublin, Eire, sheath; a pneumoperitoneum was created. A 5-mm portwas placed subcostally in the anterior axillary line; aFig. 1), which allows the surgeon or assistant to place

a hand in the abdomen while reliably maintaining a 12-mm port was placed at the level of the iliac fossa inthe anterior axillary line. The colon was reflected topneumoperitoneum. We believe that the use of this

device compensates for the lack of tactile sensation and create space in the flank and the ureter identified andclipped.thus reduces the diBculty and length of this procedure.

A 7-cm incision was made at the previously markedsite and the Intromit placed. An assistant placed their

Methodhand in the abdomen through the device and helpeddissect out the hilum by retracting the kidney and fat.A 49-year-old moderately obese woman presented with

gross, painless haematuria; IVU showed a 3-cm filling Once the renal vein was identified, the assistant retractedit with a finger while the surgeon clipped the renaldefect in the left renal pelvis and urinary cytology was

positive for TCC. Cystoscopy was unremarkable and artery. The renal vein was then divided using anEndoGIA stapler (Autosuture Inc, USA). The kidney wasshe was referred for possible laparoscopic nephro-

ureterectomy. quickly freed from surrounding structures. The ureterwas then dissected down into the pelvis while theAfter inducing anaesthesia, the patient was placed inassistant applied gentle retraction on the kidney. Theureter and kidney were removed intact via the sameincision.

The total operative duration was 110 min and theestimated blood loss minimal. Pneumoperitoneum wasmaintained throughout the procedure. The assistant hadto remove the hand every 10–15 min because of painfrom venous occlusion at the level of the cuC. The patientrequired no postoperative narcotics and was discharged5 days after surgery; she returned to her normal activitiesin 3 weeks.

Advantages and disadvantages

Since 1993, we have performed 26 transperitoneallaparoscopic nephroureterectomies; here we describe ourFig. 1. Hand-assisted division of the renal vein. Note that theinitial experience with hand-assisted laparoscopicassistant’s fingers (large arrows) are retracting the kidney,

providing excellent exposure of the renal vein (small arrow). nephroureterectomy using the Intromit. The advantages

504 © 1999 BJU International

POINT OF TECHNIQUE 505

of this technique are improved retraction, dissection and The skills required for laparoscopic nephrectomyinclude endo-coordination, endoperception and endo-tactile feedback, especially during management of the

renal vessels. The kidney and ureter were removed dexterity. These can be acquired by most urologists, buton occasion the lack of tactile feedback can restrict orintact, a principle we believe is important when per-

forming laparoscopic surgery for cancer. This manoeuvre slow successful laparoscopic procedures. The use of ahand in the abdomen to provide enhanced surgical ‘feel’also saves time needed for entrapment and morcellation.

Reducing the operative duration is imperative for laparo- may help urologists reduce the time needed for learningand may lead to wider acceptance of laparoscopy. Thescopic nephrectomy and nephroureterectomy to become

more widely accepted. The present hand-assisted laparo- Intromit may also be useful for the experienced laparo-scopic surgeon in complex laparoscopic procedures orscopic nephroureterectomy lasted 110 min; this is over

5 h shorter than the average operative time in the largest those requiring intact removal of the organ, such astumour nephrectomy, nephroureterectomy, or donorreported series [1] and is 46 min shorter than the mean

operative time in our earlier series [2]. One time-saving nephrectomy.step is the resection of the ureteric orifice followed byantegrade laparoscopic ureterectomy, as described byRassweiler et al. [3]. References

The design of the Intromit oCers several advantages 1 McDougall EM, Clayman RC, Elashry O. Laparoscopicover the Pneumo sleeve, the use of which has recently nephroureterectomy for upper tract transitional cell cancer:been reported [4]. First, the Intromit can be placed on The Washington University experience. J Urol 1995; 154:

975–80the abdominal wall quickly; second, the pneumoperi-2 Keeley FX, Tolley DA. Complications of laparoscopic nephrec-toneum is not compromised; and finally, the template is

tomy. J Endourol 1997; 11: S163 abstract P11–7significantly smaller, so that additional laparoscopic ports3 Rassweiler J, Henkel T, Petempa D et al. The technique ofcan be placed nearer to the usual positions.

transperitoneal laparoscopic nephrectomy, adrenalectomyAttention to technical details is essential. Other investi-and nephroureterectomy Eur Urol 1993; 23: 425–31gators have reported placing the device through a mid-

4 Nakada SY, Moon TD, Gist M, Mahvi D. Use of the Pneumoline incision so that the surgeon can use the

sleeve as an adjunct in laparoscopic nephrectomy. Urologynondominant hand [4,5]. We found that using the 1997; 49: 612–3assistant’s hand, rather than the surgeon’s, allows for 5 Gorey TF, Bonadio F. Hand-assisted laparoscopic surgery.more eBcient dissection. Placement of the Intromit is Sem Laparosc Surg 1997; 4: 102–9better delayed until enough room in the flank has beencreated by reflecting the colon; otherwise, the inner cuCof the Intromit would occupy too much space and Authorsobscure the laparoscopic view. Further, the assistant

F.X. Keeley Jr, MD, Endourology Fellow.must remove their hand from the wound at regular N.K. Sharma, MS, FRCS(Urol), Consultant Urologist.intervals because of pain from venous occlusion. Finally, D.A. Tolley, MBBS, FRCS, Consultant Urologist.this device requires suBcient skin surrounding the Correspondence: Mr D.A. Tolley, Scottish Lithotriptor Centre,incision for an adequate seal; this aspect makes the Western General Hospital, Crewe Road, Edinburgh EH4 2XU,

UK.Intromit most useful in obese patients.

© 1999 BJU International 83, 504–505