CONCLUSIONS

Hand assisted laparoscopy has enabled us to perform anextremely technical and demanding surgery in little longerthen normal time with a good result. In the future, additionalcases will further decrease the operative time. We believethat we have brought a minimally invasive radical procedureinto the armamentarium of the practicing urologist. Thisprocedure can be performed in urological practices and is notstrictly relegated to a few academic centers. This advancemay allow more patients to enjoy the benefits of laparoscopyfor complex urological procedures with a rapid return tonormal activities.

REFERENCES

1. Tschada, R. K., Rassweiler, J. J., Schmeller, N. and Theodorakis,J.: Laparoscopic tumor-nephrectomy–the German experi-ences. J Urol, suppl., 153: 479A, abstract 1003, 1995

2. Winfield, H. N., Chen, R. N. and Donovan, J. F.: Laparoscopictrick of the trade: how to overcome lack of tactile feedback.J Endourol, 10: S189, 1996

3. Nakada, S. Y., Moon, T. D., Gist, M. and Mahui, D.: Use of thepneumo sleeve as an adjunct in laparoscopic nephrectomy.Urology, 49: 612, 1997

4. Gill, I. S., Fergany, A., Klein, E. A., Kaouk, J. H., Sung, G. T.,Meraney, A. M. et al: Laparoscopic radical cystoprostatectomywith ileal conduit performed completely intracorporeally: theinitial 2 cases. Urology, 56: 26, 2000

5. O’Reilly, M. J., Saye, W. B., Mullins, S. G., Pinto, S. E. andFalkner, P. T.: Technique of hand-assisted laparoscopic sur-gery. J Laparoendosc Surg, 6: 239, 1996

6. Wolf, J. S., Jr., Moon, T. D. and Nakada, S. Y.: Hand assistedlaparoscopic nephrectomy: comparison to standard laparo-scopic nephrectomy. J Urol, 160: 22, 1998

7. Vara-Thorbeck, C. and Sanchez-de-Badajoz, E.: Laparoscopicileal-loop conduit. Surg Endosc, 8: 114, 1994

8. Sanchez de Badajoz, E., Gallego Perales, J. L., Reche Rosado,A. R., Gutierrez de la Cruz, J. M. and Jimenez Garrida, A.:Laparoscopic cystectomy and ileal conduit: a case report.J Endourol, 9: 59, 1995

EDITORIAL COMMENT

Since the initial report of laparoscopic nephrectomy by Clayman etal,1 the transition to laparoscopy has been hindered by a lack of

training cases and the steep learning curve of renal and pelviclaparoscopy. Traditionally, laparoscopic innovation has been spear-headed by a few academic centers of excellence. Hand access hasempowered more urologists to attempt complex laparoscopic proce-dures with confidence (reference 3 in article). This initial report ofhand assisted cystoprostatectomy and diversion further amplifies itsadvantages its in urology.

The authors should be congratulated for reporting an innovativeuse of hand access. However, the concept of laparoscopic cystectomyand urinary diversion is not new. In fact, Gill et al published a logicalseries of animal studies and clinical series using standard laparo-scopic techniques.2–4 What is impressive about the technique ofPeterson et al is the simplicity of the extracorporeal suturing, sim-plicity of intact specimen removal, and shortened convalescence (2weeks to driving, 4 weeks to complete recovery). There also may besome benefit in maintaining the hand access device in the woundduring the extracorporeal portion of the operation to lower the risk ofwound infection and complications. Of particular note, all surgicalmargins were negative in a procedure, which took only “a little”longer than the standard open approach.

Peterson et al are correct in stating that laparoscopic innovationshould not be relegated to the academic centers alone. There iscertainly room for more innovators in urological laparoscopy, andreports such as this add to the body of literature that urologists needto maintain control of minimally invasive urological procedures.However, readers must remember that this is a case report. Issuessuch as body habitus, delayed complications and long-term cancerfollowup, can only be addressed by the test of time and the perfor-mance of more cases. A responsibility of innovators is that of accu-rate reporting of clinical outcomes. We anxiously await their initialclinical series.

Stephen Y. NakadaDepartment of SurgeryThe University of Wisconsin Medical SchoolMadison, Wisconsin

1. Clayman, R. V., Kavoussi, L. R., Soper, N. J. et al: Laparoscopicnephrectomy: initial case report. J Urol, 146: 278, 1991

2. Gill, I. S., Fergany, A., Klein, E. A. et al: Laparoscopic radicalcystoprostatectomy with ileal conduit performed completelyintracorporeally: the initial 2 cases. Urology, 56: 26, 2000

3. Fergany, A. F., Gill, I. S., Kaouk, J. H. et al: Laparoscopicintracorporeally constructed ileal conduit after porcine cys-toprostatectomy. J Urol, 166: 285, 2001

4. Fergany, A. F., Novick, A. C. and Gill, I. S.: Laparoscopic urinarydivision. World J Urol, 18: 345, 2000

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