LAPAROSCOPIC NEPHROURETERECTOMY FOR UPPER TRACT TRANSITIONAL CELL CANCER 979

the laparoscopy patients resumed oral intake more rapidly and required less parenteral analgesics. In addition, the hos- pital stay and convalescence for the laparoscopic nephroure- terectomy patients were significantly shorter, they returned to work or usual activities in less than half the time (2.8 versus 6 weeks) and they completely recovered 5 times more rapidly (6 weeks versus 7.4 months) than the open surgical patients.

CONCLUSIONS

Based on our experience, we believe that laparoscopic nephroureterectomy is a feasible treatment option for pa- tients with upper tract transitional cell carcinoma. The effi- cacy of this procedure appears to be equal to that of open nephroureterectomy. The 2 major drawbacks to the approach are the longer operative time and the need for significant laparoscopic experience on the part of the surgeon. However, the benefits of the less invasive surgical approach are less postoperative discomfort, a rapid return to normal activities and a brief convalescence.

REFERENCES

1. Nocks, B. N., Heney, N. M., Daly, J. J., Perrone, T. A, Griffin, P. P. and Prout, G. R., Jr.: Transitional cell carcinoma of renal pelvis. Urology, 19 472, 1982.

2. Wagle, D. G., More, R. H. and Murphy, G. P.: Primary carcinoma of the renal pelvis. Cancer, 33: 1642, 1974.

3, Cummings, K. B.: Nephroureterectomy: rationale in the man- agement of transitional cell carcinoma of the upper urinary tract. Urol. Clin. N. Amer., 7: 569, 1980.

4. Clayman, R. V. and Kavoussi, L. R.: Endosurgical techniques for the diagnosis and treatment of noncalculous disease of the ureter and kidney. In: Campbell's Urology, 6th ed. Edited by P. C. Walsh, A. B. Retik, T. A. Stamey and E. D. Vaughan, Jr. Philadelphia: W. B. Saunders Co., pp. 2231-2303, 1992.

5. Kerbl, K, Clayman, R. V., McDougall, E. M., Urban, D. A., Gill, I. and Kavoussi, L. R.: Lapamscopic nephroureterectomy: eval- uation of first clinical series. Eur. Urol., 2% 431, 1993.

6. Clayman, R. V., Kavoussi, L. R., McDougall, E. M., Soper, N. J., Figenshau, R. S., Chandhoke, P. S. and Albala, D. M.: Lapa- roscopic nephrectomy: a review of 16 cae.es. Surg. Laparoscopy Endoscopy, 2 29, 1992.

7. Rassweiler, J., Potempa, D. M., Henkel, T. O., Guenther, M., Tschada, R. and Alken, P.: The technical aspects of transpen- toneal laparoscopic nephrectomy (TLN), adrenalectomy (TLA) and nephroureterectomy. J. Endourol., 6: S58,1992.

8. Stockdale, A. D. and Pocock, T. J.: Abdominal wall metastasis following laparoscopy: a case report. Eur. J. Surg. Oncol., 11: 373,1985.

9. Clayman, R. V., Kavoussi, L. R., Figenshau, R. S., Chandhoke, P. S. and Albala, D. M.: L a v p i c nephroureterectomy: initial clinical case report. J. Lapamendosoopic Surg., 1: 343,1991.

10. Dobronte, Z., Wittmann, T. and Karacsony, G.: Rapid develop ment of malignant metastases in the abdominal wall after laparoscopy. Endoscopy, 1 0 127, 1978.

11. Urban, D. A., Kerbl, K, McDougall, E. M., Stone, A. M., Fadden, P. T. and Clayman, R. V.: Organ entrapment and renal mor- cellation: permeability studies. J. Urol., 150: 1792, 1993.

12. Gleeson, N. C., Nicosia, S. V., Mark, J. E., Hoffman, M. S . and Cavanagh, D.: Abdominal wall metastases from ovarian can- cer aRer laparoscopy. Amer. J. Obst. Gynec., 169 522,1993.

13. Figenshau, R. S., Albala, D. M., Clayman, R. V., Kavoussi, L. R., Chandhoke, P. S. and Stone, A. M.: Laparoscopic nephroure- terectomy: initial laboratory experience. Min. Invasive Ther., 1: 93, 1991.

14. Williams, D. F.: Titanium as a metal for implantation. Part 1: physical properties. J. Med. Eng. Technol., 1: 195, 1977.

15. Williams, D. F.: Titanium as a metal for implantation. Part 2: biological and clinical applications. Biomed. Eng., 1: 266,1977.

16. Kakizoe, T., Matsumoto, K, Nishio, Y. and Kishi, K.: Analysis of 90 step-sectioned cystmtomized specimens of bladder cancer. J. Urol., 131: 467, 1984.

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EDITORIAL COMMENT

One of the justifiable criticisms of using laparoscopy as treatment n patients with urological malignancies is the paucity of data dem- nutrating equivalent efficacy when compared with traditional open iurgery. The authors should be commended for keeping continued :lose surveillance of their patients and contrasting the outcome with I contemporary group undergoing open nephmureterectomy. These lata add to the pool of evidence that using careful technique in select patients will result in intermediate tumor-free status comparable to that for open surgery. This can be accomplished with additional patient benefits, including less postoperative pain, more rapid con- valescence and minimal scarring. Continued followup will be neces- sary to verify long-term efficacy.

While giving hope to the future role of laparoscopy in urology, this article raises several significant concerns. In the hands of a highly experienced group, the operative time remained lengthy. Because the most expensive cost in the perioperative period is operating room time, laparoscopy is the most expensive option.' Unfortunately, cost is taking a greater role in directing patient care and the various payors will have to decide if the personal patient benefits can justify the added cost to health care.

The long operative time also emphasizes the fact that this procedure is not easy and does not give hope to the average umlogid practice in which there are fewer opportunities to gain tecbnid expertise. If a urologist truly believes in this procedure should he or she attempt laparoscopic nephrouretemcbmy or refer it to a specialty center? A p d u r e does not help the general patient population if it can only be performed by a few physicians with "magic hands."

The solution to these concerns hopefully will come with improved technology and more effective methods of postgraduate training. For example, a new laparoscopic suturing device has decreased the o p erative time for laparoscopic pyeloplasty from 6.2 hours in our 6rst 5 patients to 2.8 hours in the last 5.2 Further developments wi l l be necessary to gain similar time saving with other urological laparo- scopic procedures, such as nephrouretereetomy. Urologists inter- ested in laparoscopy should continue to update their information on the latest techniques and gain hands-on experience through reputa- ble courses. When undertaking a challenging procedure, urologists with limited training should use the assistance of more experienced colleagues. Potentially more effective and convenient methods to enhance postgraduate training are being evaluated using %elemen- toring" systems.3

Louis R. Kavoussi Bmdy Urological Institute Johns Hopkins Medical Institutions Baltimore, Maryland

1. Winfield, H. N., Troxel, S. A., Rasbid, T. M., Lund, G. 0. and Donovan, J. F.: Laparumpic urologic surgery-the 6nancial realities. J. Endouml., 8: S92, 1994.

2. Adams, J. B., Moore, R. M., Partin, A. W. and Kavoussi, L. R.: New laparoscopic suturing device: initial clinical experience. Unpublished data.

3. Kavoussi, L. R., Moore, R. G., Partin. A. W., Bender, J. S., Zenilman, M. E. and Satava, R. M.: Telerobotic assisted lapa- rompic surgery: initial laboratory and clinical experience. Urology, 44: 15,1994.

REPLY BY AUTHORS

Laparoscopic urology remains in its infancy, having been introduced into adult urology only 5 years ago. Already with respect to myriad open procedures the laparoscopic approach has proved to be as efficacious with less morbidity and a shorter convalescence than its incisional counterpart. The area in which laparoscopy still suffers is with regard to costs. The largest component driving the cost issue is that of oper- ating mom time. Decrease in operative time must await further surgeon experience as well as the development of new technologies allowing for more efficient tissue dissection. In regard to laparoscopic nephrectomy/nephroureterectomy, several advances have already been made, such as lateral insfiation, elimination of ureteral catheterization and in our experience newer forms of dissection, such as pneumodis- section.' Indeed, in comparing our earliest experience with

980 WAROSCOPIC NEPHROURETERECTOMY FOR UPPER TRACT TRANSITIONAL CELL CANCER

nephroureterectomy with our most recent data operative times have decreased by 2 to 3 hours.

Nevertheless, it must be stressed that our experience with laparoscopic nephroureterectomy, while the most extensive reported from a single institution to date, only comprises 10 patients. As such, comparing our initial experience with laparoscopic nephroureterectomy to a contemporary group of individuals undergoing standard incisional nephroureterec- tomy in the hands of fully trained, board certified, urological oncologists is certain to result in significant time biases against the laparoscopic approach. However, even in these few initial patients the benefits of laparoscopy from the standpoint of achieving equivalent efficacy with less morbid- ity and convalescence are readily apparent.

In regard to cost-effectiveness, we believe that the learning curve for laparoscopic nephroureterectomy will likely con- tinue for more than 50 cases. Indeed, in general surgery even for the simplest of procedures, such as laparoscopic cholecys- tectomy, the learning curve is reportedly 30 to 50 cases before operative times become stable at a lower level.’

In addition, it is important for the urologist to realize that cost data can be misleading. Indeed, the operating room cost at our hospital averages almost $30 per minute and, if a procedure is 1 to 2 hours longer than its open counterpart, a hospital stay decrease of even 5 to 7 days would still not be sufficient to render the procedure cost-effective. However, in Europe the cost of a surgical procedure to the insurer is not limited to that of the hospital stay but includes convales- cence. Certainly if one subtracts from the hospital costs the financial benefits to a comPany or society of having a worker

tients undergoing laparoscopic nephroureterectomy the pro- cedure would have become financially as well as medically attractive. A paradigm shift of this nature is long overdue in the ever prosperous arena of health care management.

In the meantime we believe that it is extremely important for urological surgeons to become facile with laparoscopic techniques. We do not believe that this technology should remain in a specialty center. Rather, there should be an individual in each major urological group who is a skilled laparoscopic surgeon. Any group of 5 should supply 1 urolo- gist in the group with an experience of more than 50 to 70 cases yearly, which would be sufficient to allow that individ- ual to become and remain facile in laparoscopy. To be certain, if our specialty views laparoscopy as a “magic hands” proce- dure, rather than disappearing because there are so few urological magicians the technology and expertise will more than likely be transferred to other nonurological surgical disciplines. Indeed, in some areas of the country this is al- ready happening. Minimally invasive surgery is here to stay, and we may as well get on with the business of learning these less invasive techniques before the business is no longer at hand.

1. Pearle, M. S., Nakada, S. Y., McDougall, E. M., Monk, T. G., Clayman, R. V., F’ingleton, E. and Fbemer, F. D.: Laparoscopic pneumodissedion: initial clinical experience. Urology, in press.

2. Cagir, B., Rangraj, M., Maffuci, L. and Herz, B. L.: The learning curve for laparoscopic cholecystectomy. J. Laparoendo. Surg., 4 419, 1994. return to full employment 4 weeks eariy, in halfof our pa-