title: Hand-assisted laparoscopic nephroureterectomy (HALNU): an assessment of the impact of obesity in 50 procedures.
abstract: OBJECTIVE
  The aims of this study was to review our experience with hand-assisted laparoscopic nephroureterectomy (HALNU) and to evaluate the impact of body-mass index (BMI) on outcomes.
  
  
  METHODS
  We retrospectively analyzed 50 HALNU patients. Twenty had body mass indices (BMIs) <25 (normal cohort), 18 had BMIs between 25 and 29.9 (overweight cohort), and 12 had BMIs >/=30 (obese cohort).
  
  
  RESULTS
  The cohorts had similar operative times: 349, 326, and 320 minutes, respectively. Most patients (38) underwent a total HAL distal ureterectomy, but 9 underwent an initial transurethral ureteral dissection (5 [25%], 2 [11%], and 2 [17%]). Five patients were converted to open and 1 had a planned open ureterectomy. The cystotomy was sutured closed in most but left open in 6 (3 [15%], 2 [11%], and 1 [8%]), and a stapled ureteral division was performed in 7 (3 [15%], 2 [11%], and 2 [17%]). Increased BMI was associated with delayed oral intake (P = 0.034). No significant cohort differences were observed for estimated blood loss (EBL), transfusion rate, complication rate, surgical margin status, distant metastases, or death rate. The obese cohort demonstrated trends toward increased hospitalization and bladder cancer recurrence (P = 0.083, P = 0.097). Patients with prior open surgery had longer hospitalizations (P = 0.024). Patients without prior surgery were more commonly alive with persistent disease (P = 0.027). EBL was greater for patients who had transurethral ureteral dissection (P = 0.030). Patients undergoing a stapled ureteral division had delayed oral intake, bowel function, and discharge (P = <0.001, P = 0.034, and P = 0.034).
  
  
  CONCLUSIONS
  HALNU is an effective surgical treatment for patients with BMIs as great as 45.
authors.affiliation: Department of Surgery, Medical College of Georgia, Augusta, Georgia, USA. jimbrown@mcg.edu
authors.forename: James A
authors.initials: JA
authors.lastname: Brown
authors.forename: Eric
authors.initials: E
authors.lastname: Chenven
authors.forename: Stephen W
authors.initials: SW
authors.lastname: Looney
authors.forename: Kelly M
authors.initials: KM
authors.lastname: Miller
authors.forename: Stephen E
authors.initials: SE
authors.lastname: Strup
authors.forename: Demetrius H
authors.initials: DH
authors.lastname: Bagley
authors.forename: Leonard G
authors.initials: LG
authors.lastname: Gomella
mesh_terms: D000368:Aged; D016063:Blood Loss, Surgical; D001803:Blood Transfusion; D015992:Body Mass Index; D002295:Carcinoma, Transitional Cell / Q000601:surgery; D053715:Cystotomy; D005260:Female; D006801:Humans; D007680:Kidney Neoplasms / Q000601:surgery; D010535:Laparoscopy; D008297:Male; D009362:Neoplasm Metastasis; D009364:Neoplasm Recurrence, Local; D009392:Nephrectomy / Q000379:methods* / Q000401:mortality; D009765:Obesity / Q000150:complications*; D011183:Postoperative Complications; D012189:Retrospective Studies; D016896:Treatment Outcome; D014513:Ureter / Q000601:surgery*; D014516:Ureteral Neoplasms / Q000601:surgery; D001749:Urinary Bladder Neoplasms / Q000601:surgery