Laparoscopic retroperitoneal renal cystectomy

First experience of laparoscopic kidney cyst resection by a single access method

We describe the first clinical experience of laparoscopic surgery for renal cyst by a single access. Advantages, disadvantages and prospects of this method are analized.

Laparoscopic adrenalectomy: comparison of outcomes between posterior retroperitoneoscopic and transperitoneal adrenalectomy with 10 years' experience

Background

Laparoscopic adrenalectomy is widely used for treating various adrenal tumors. Posterior retroperitoneoscopic adrenalectomy was introduced after transperitoneal laparoscopic adrenalectomy. The comparability and superiority of posterior retroperitoneoscopic adrenalectomy have been widely investigated. We aimed to compare the outcomes of posterior retroperitoneoscopic adrenalectomy and transperitoneal laparoscopic adrenalectomy using 10 years' data. The changes in outcomes over time were also analyzed.

Methods

This was a retrospective observational study. A total of 505 patients who underwent laparoscopic adrenalectomy between 2009 and 2018 were included. The patients were divided into two groups: transperitoneal (n=114) and retroperitoneal (n=391) groups. Patients who underwent posterior retroperitoneoscopic adrenalectomy were further classified into sub-groups (sub-group 1: 2009-2012; sub-group 2: 2013-2015; and sub-group 3: 2016-2018) based on time periods. Clinicopathological factors and postoperative outcomes were retrospectively reviewed and analyzed.

Results

The retroperitoneal group showed significantly shorter operation time, diet initiation time, and hospital stay compared to the transperitoneal group (P=0.000, 0.000 and 0.000, respectively). Analgesics were used less frequently in the retroperitoneal group than in the transperitoneal group (P=0.048). In the retroperitoneal group, the time to postoperative diet initiation shortened over time (P=0.000).

Conclusions

Posterior retroperitoneoscopic adrenalectomy is a favorable surgical method that results in patient outcomes that are comparable to those of conventional transperitoneal laparoscopic adrenalectomy, without compromising patient safety.

Laparoscopic transperitoneal and retroperitoneal adrenalectomy: a 20-year, single-institution experience with an analysis of the learning curve and tumor size [lap transper and retroper adrenalectomy]

BACKGROUND

The superiority of laparoscopic transperitoneal (TP) versus retroperitoneal (RP) adrenalectomy is an ongoing debate.

METHODS

Data from 163 patients (TP: n = 135; RP: n = 28) undergoing minimally invasive adrenalectomy were analyzed. Both operative [intraoperative blood loss, previous abdominal surgery, conversion rate, operative time and tumor size] and perioperative [BMI (body mass index), ASA (American Society of Anesthesiologists) score, time of hospitalization, time of oral intake, histology and postoperative complications] parameters were compared. Both the learning curve (LC) and tumor size were analyzed.

RESULTS

We found significant differences in the mean operative time (p = 0.019) and rate of previous abdominal surgery (p = 0.038) in favor of TP. Significantly larger tumors were removed with TP (p = 0.018). Conversion rates showed no significant difference (p = 0.257). Also, no significant differences were noted for time of hospitalization, intraoperative blood loss and postoperative complications. In terms of the LC, we saw significant differences in previous abdominal surgery (p = 0.015), conversion rate (p = 0.011) and operative time (p = 0.023) in favor of TP. Large (LT) and extra-large tumors (ELT) were involved in 47 lesions (LT: 40 vs. ELT: 7), with a mean tumor size of 71.85 and 141.57 mm, respectively. Mean intraoperative blood loss was 64.47 ml vs. 71.85 ml, time of hospitalization was 5.10 vs. 4.57 days and mean operative time was 76.52 vs. 79.28 min for LT and ELT, respectively.

CONCLUSION

A shorter operative time and lower conversion rate in favor of TP were noted during the learning curve. TP proved to be more effective in the removal of large-, extra-large and malignant lesions. The RP approach was feasible for smaller, benign lesions, with a more prolonged learning curve.

Posterior retroperitoneoscopic adrenalectomy-Case series

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Posterior retroperitoneoscopic (PR) technique has advantages over transperitoneal approach.

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Many surgeons keep using laparoscopy because they are more confident when working in the wider peritoneal space.

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Posterior retroperitoneoscopy is feasible and safe, and avoids bowel injury.

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PR adrenalectomy has a small learning curve.

Introduction

Posterior retroperitoneoscopic adrenalectomy has advantages over transperitoneal technique. However many surgeons prefer the transperitoneal technique because they get a familiar and wider working space.

Material and methods

A retrospective analysis of the first 10 patients submitted to posterior retroperitoneoscopic adrenalectomy was conducted. Data collected included: diagnosis, size, operation time, blood loss, conversion rate, morbidity and mortality, in-hospital length of stay. Compare our outcomes with worldwide bigger series, and take conclusions on the feasibility of the technique was the objective.

Results

We included 2 pheochromocytomas, 1 giant cystic pheochromocytoma, 4 Conn’s, 2 Cushing’s, 1 non-functioning tumor with 4 cm. Mean operation time was 46,7 min for lesions ranging from 1,8 to 14 cm. Blood loss was negligible. One patient (10%) was converted to laparotomy because of a past clinical history of dorsal and lumbar trauma. No morbidity and no mortality. Mean hospital length of stay was 2,2 days.

Discussion

Mean operation time found in bigger series published in worldwide literature is 40–105,6 min. Complication rate reported ranges from 0 to 14,4%. No mortality has been ever reported. Blood loss reported in other series is 10–50 ml. The data found in our study matches other studies data. Since the same surgeon who had never performed the technique before operated all patients, makes us believe the technique is safe and feasible.

Conclusion

Posterior retroperitoneoscopic adrenalectomy has a small learning curve. It is technically safe and feasible. More patients will be collected to validate these results.

Transperitoneal versus retroperitoneal laparoscopic nephroureterectomy in the management of upper urinary tract urothelial carcinoma: a matched-pair comparison based on perioperative outcomes

BACKGROUND

Radical nephroureterectomy is considered as the gold standard for the surgical treatment of upper urinary tract urothelial carcinoma (UTUC). Laparoscopic radical nephroureterectomy (LNU) can be performed via the transperitoneal (TLNU) or retroperitoneal (RLNU) approach, and each one has its own advantages and limitations. Our study was conducted to describe the difference between TLNU and RLNU by comparing the perioperative outcomes.

METHODS

From January 2009 to October 2014, 68 patients underwent TLNU or RLNU at our center were retrospectively collected and 1:1 matched for age, body mass index and tumor side. Baseline characteristics and perioperative outcomes were evaluated and compared, respectively.

RESULTS

There were no significant differences between the TLNU and RLNU group in terms of baseline characteristics, operating time, estimated blood loss, visual analogue pain scale, cosmetic results, intraoperative and postoperative complication rate. Compared to TLNU approach, RLNU was associated with a quicker time to first oral intake (2.9 vs 2.0 days, p = 0.02) and hospital discharge (6.7 vs 5.6 days, p = 0.02).

CONCLUSION

Both transperitoneal and retroperitoneal laparoscopic approaches are safe and effective methods for treatment of UTUC. Retroperitoneal approach has the advantage in terms of quicker bowel recovery and shorter hospital discharge.

Is larger tumor size a contraindication to retroperitoneal laparoscopic adrenalectomy?

PURPOSE

To evaluate the surgical feasibility of retroperitoneal laparoscopic adrenalectomy for tumors exceeding 5 cm.

METHODS

A retrospective review was carried out on all adrenalectomies performed between 2002 and 2011. All surgical procedures were performed or supervised by one of two experienced laparoscopic surgeons. A total of 133 patients who underwent retroperitoneal laparoscopic adrenalectomy were divided according to tumor size: group I (n = 57) had tumors <5 cm and group II (n = 76) had tumors ≥5 cm. The operative outcomes included surgical time, change in hemoglobin level, estimated blood loss, necessity for blood transfusion, time to ambulation, hospitalization duration, postoperative complications according to the Clavien-Dindo classification, and the rate of conversion to open surgery.

RESULTS

The estimated blood loss (271.75 ± 232.98 mL vs. 367.24 ± 275.11 mL; p = 0.037), time to ambulation (1.60 ± 0.49 days vs. 1.89 ± 0.31 days; p = 0.001), and postoperative hospitalization (7.88 ± 3.08 days vs. 9.264 ± 3.10 days; p = 0.012) were significantly higher in group II. The operation time and hemoglobin level change were not statistically different between groups. Blood transfusions were performed in 3 patients from group I and 6 patients from group II (5.3 vs. 7.9 %; p = 0.449). No patients experienced conversion to open surgery.

CONCLUSIONS

Retroperitoneal laparoscopic adrenalectomy can be used in patients with tumors larger than 5 cm.

A comparative study of the transperitoneal and posterior retroperitoneal approaches for laparoscopic adrenalectomy for adrenal tumors

BACKGROUND

Laparoscopic adrenalectomy is considered the gold standard for the surgical treatment of small adrenal tumors. However, several approach routes, such as the transperitoneal (TP), lateral retroperitoneal, and the posterior retroperitoneal (PR) approaches are being used based on surgeon's preference. The PR approach has several benefits compared with the others. Recently, the authors used the PR approach to treat several adrenal tumors and here describe the methods used in detail and the preliminary results obtained.

METHODS

From January 2009 to July 2010, 58 patients underwent adrenalectomy. Open adrenalectomy and robotic adrenalectomy were performed in 5 and 10 patients. Also, 43 patients underwent laparoscopic adrenalectomy, and the TP and PR approaches were used in 26 and 17 patients, respectively. Clinicopathologic data and surgical outcomes were evaluated and compared retrospectively.

RESULTS

There were no significant differences between the TP and PR groups in terms of age, sex, BMI, lesion side, volume of blood loss, or tumor size (3.86 ± 3.83 in TP approach, 2.64 ± 1.61 in PR approach). Mean operative time and average oral intake time using the PR approach were shorter than for the TP approach. Less analgesia use was required in patients who underwent PR approach.

CONCLUSIONS

This study shows that posterior retroperitoneoscopic adrenalectomy is a safe procedure and the operative time is comparable to transperitoneoscopic adrenalectomy. The use of the PR approach for small adrenal tumor can provide very favorable surgical outcomes compared with the TP approach.

'Stepped procedure' in laparoscopic cyst decortication during the learning period of laparoscopic surgery: Detailed evaluation of initial experiences

BACKGROUND

We evaluated the importance and efficacy of 'stepped procedure' in laparoscopic cyst decortication as an initial experience in it.

MATERIALS AND METHODS

A 36 renal cyst cases were included. The stepped retroperitonoscopic cyst excision divided into three groups. First step, doing the incisions to place the ports and expanding the retroperitoneal space with balloon distension, second step, placement of trocars and reach to the cyst, third step, aspiration and decortication of the cyst. The difficulty of the sessions was measured with the Visual Analog Scale (VAS) scoring system. Score was determined according to the difficulty of the surgical step ranging from '0' to '10', '0', too easy, '10' too difficult'. The durations were measured. One-way ANOVA test was used for statistical analysis.

RESULTS

The mean age was 52.0 (20-75) years. The mean operation time was 52.0 min. The mean duration of the first step was 12.5, second, 26.0 and third, 22.5 min. The mean VAS of first step, 3.2, second, 6.0 and third, 3.6 There were only significant differences in duration time and VAS score for second step among the surgeons (P<0.05).

CONCLUSIONS

Laparoscopic cyst decortication may provide gaining experience to approach the kidney laparoscopically. The side, size and localization of cysts were not found associated with the difficulty of the method.

Laparoscopic adrenalectomy: Comparison of lateral transperitoneal and lateral retroperitoneal approaches

Laparoscopic adrenalectomy has become the method of choice of removal of most of adrenal lesions. This study investigated and compared the results of 2 different approaches of laparoscopic adrenalectomy, through retrospective review of 40 patients. Within this study period between 1995 and 2004, there were 20 lateral retroperitoneal and 20 lateral transperitoneal laparoscopic adrenalectomies performed. There was no significant difference in demographic variables between the 2 groups. Operative time, days to diet and ambulation, hospital stay, rate of conversion and complication did not differ significantly between the 2 approaches. No recurrence was detected upon mean follow-up period of 15.9 months. Learning curves showed gradual decrease in operation time in both approaches, reflecting maturation of techniques. In conclusion, both lateral transperitoneal and lateral retroperitoneal laparoscopic adrenalectomy are safe and effective. There is no difference in outcome between 2 approaches.

Laparoscopic Adrenalectomy: A Single-Center Experience of 43 Cases

PURPOSE

To evaluate the surgical feasibility of laparoscopic adrenalectomy and what laparoscopy offers for the surgeon and the patient.

PATIENTS AND METHODS

From March 1996 to June 2004, 43 transperitoneal laparoscopic adrenalectomies were performed for various pathological states. Functioning adrenal masses and solid masses>5 cm were the most common indications. The mean size of the masses on abdominal CT was 6.8 cm in the largest diameter. All patients were assessed regarding the operative time, blood loss, complications, and conversion to open surgery. The postoperative course was reported with special attention to the complications and hospital stay.

RESULTS

The mean operative time was 125 minutes with a mean blood loss of 60 mL. Intraoperative complications occurred in 3 cases (6.9%), necessitating conversion to open surgery in 2 to control bleeding from the avulsed right adrenal vein. A third case of conversion was elective because of difficult dissection of a large left pheochromocytoma from the renal hilum, so there was a 6.9% rate of conversion to open surgery. All patients showed early ambulation, early start of eating, and a short hospital stay (mean 2.6 days).

CONCLUSION

Laparoscopic adrenalectomy is surgically feasible and can be applied for different adrenal pathologies. The procedure can be performed with a reasonable operative time, minimal blood loss, and an acceptable rate of complications. Laparoscopic adrenalectomy provides excellent postoperative recovery and convalescence with a short hospital stay.

Retroperitoneoscopic Deroofing of a Giant Renal Cyst in a Solitary Functioning Hydronephrotic Kidney With a 3-port Technique

To explore the safety and feasibility of performing retroperitoneoscopic renal cystectomy in a case of massive giant renal cyst in a solitary hydronephrotic renal unit. We have described the retroperitoneal three-trocar technique. The role of laparoscopic renal cyst ablation in giant symptomatic renal cysts and non-polycystic kidney disease has been discussed. The patient was successfully managed by retroperitoneoscopic deroofing using a three-port technique. The operating room time was 90 minutes and her hospital stay lasted 54 hours. The fluid cytology and cyst histology were negative for tumor. Complete resolution of the cyst was noted on a follow-up ultrasound done after 2 months. Currently at 9-month follow up, the patient is ultrasonographically free of any cyst recurrence or hydronephrosis. The retroperitoneal approach is feasible for marsupializing giant symptomatic renal cysts and appears to be safe for solitary symptomatic renal units too. It shortens the overall operating time and avoids the complications and demerits of transperitoneal access.

Percutaneous resection of renal cysts

Symptomatic renal cysts can be managed endoscopically via retrograde ureterorenoscopy, antegrade percutaneous nephroscopy, or laparoscopy. Although all three methods are minimally invasive and effective, the retrograde approach is limited by the size and location of the cyst. Laparoscopy is also effective but is associated with multiple port sites, extensive dissection, and technical difficulty. We utilize percutaneous trans-parenchymal endocystolysis as a first-line therapy. The technique is described in detail.

Laparoscopic cyst marsupialization in patients with autosomal dominant polycystic kidney disease

PURPOSE

Autosomal dominant polycystic kidney disease is characterized by progressively enlarging renal cysts associated with hypertension, renal failure, pain, hematuria and infection. We explored the role of laparoscopic cyst marsupialization for managing cyst related problems.

MATERIALS AND METHODS

In 4 male and 11 female adults with autosomal dominant polycystic kidney disease who had preserved renal function laparoscopic cyst marsupialization was done for pain unilaterally and bilaterally in 9 and 6, respectively. An average of 204 cysts per kidney (range 11 to 635) were decorticated or drained.

RESULTS

Average operative time was 5.5 hours. Patients were discharged from the hospital after an average of 3.2 days. At a mean followup of 2.2 years (range 0.5 to 5) pain was decreased an average of 62% (range 30% to 90%) in 11 cases (73%). One patient had no improvement and 1 had subsequent worsening of pain postoperatively. Two patients with initial improvement had pain recurrence 4 and 36 months postoperatively, respectively. Hypertension resolved in 1 patient (7%), improved in 20% and did not change in 40%. In 33% of the cases hypertension worsened, requiring additional antihypertensive medication. Renal function remained stable in 13 patients (87%), improved in 1 (6.5%) and worsened in 1 (6.5%). Overall patients who underwent a bilateral procedure had better long-term pain relief and more improvement in hypertension.

CONCLUSIONS

Laparoscopic cyst marsupialization may effectively decrease cyst associated pain. In some cases hypertension may be improved. Renal function remained stable in all except 1 patient. At a mean followup of 2.2 years the benefits of aggressive laparoscopic cyst decortication appear to be relatively long lasting when bilateral decortication is indicated. The benefits of unilateral cyst decortication are less predictable and of shorter duration.

Laparoscopic management of renal cystic disease

Laparoscopic management of renal cystic disease is a highly effective, safe, and minimally invasive alternative to open surgery and antegrade or retrograde endoscopic procedures. Simple renal cysts can be accessed either transperitoneally or retroperitoneally. Almost all studies of the laparoscopic approach have demonstrated great satisfaction in terms of efficacy, minimal complications, operative time, minimal blood loss, hospital stay, recuperation, and cosmesis over other methods of treating renal cysts. Laparoscopic unroofing of peripelvic cysts is more challenging owing to their proximity to hilar vessels and the collecting system. Such surgery should be considered an advanced laparoscopic procedure. Access may be achieved either transperitoneally or retroperitoneoscopically. The basic principle of adequate exposure is essential for effective treatment. If the cyst is not completely excised, the surgeon must fulgurate the edge and tack perirenal fat in the residual cyst cavity to prevent recurrence and facilitate drainage. Laparoscopic evaluation of complex cysts seems to be sound. The results are promising, and follow-up does not show any increase in peritoneal seeding, tract recurrence, or distant metastases in the small number of neoplasms diagnosed at laparoscopy. Nevertheless, more studies are required with long-term follow-up. Bosniak type IV renal cysts or malignancy in renal cysts can be managed by laparoscopic radical nephrectomy with either access. Laparoscopic cyst marsupialization in patients with ADPKD is the latest emerging indication for laparoscopy in renal cystic disease. This procedure not only effectively reduces pain in some patients but also improves hypertension and stabilizes renal function, delaying renal replacement therapy. Long-term follow-up and further evaluation are needed.

Renal cystic disease. Laparoscopic management

Laparoscopy offers a safe and efficacious means of ablating symptomatic simple renal cysts while conferring the usual benefits of shorter hospital stay, quicker convalescence, and reduced postoperative pain, although no direct comparison with open surgery has been performed. For indeterminate, complex renal cysts, laparoscopic exploration may spare the patient a morbid open operation to assess a cystic lesion of indeterminant risk. Although laparoscopic removal of kidneys with ADPKD remains a technically challenging exercise, centers of laparoscopic expertise have demonstrated the safety and feasibility of the procedure, thereby expanding the benefits of laparoscopic surgery to patients traditionally relegated to open surgical management.

Laparoscopy in urology

Mention of all of the procedures in urology that have been attempted, or are being done, laparoscopically is beyond the scope of this article. The laparoscopic procedures outlined in this article are gaining increasing support as surgeons attempt to redefine gold standard minimally invasive therapies in the new millennium. Additional procedures, such as laparoscopic retroperitoneal lymph node dissections for low-stage, nonseminomatous germ cell testicular cancers and laparoscopic renal cryoablation of small renal cancers, are soon to be added to this list. As laparoscopic instrumentation and equipment continue to improve, it will become possible to explore even more procedures laparoscopically. Advances in imaging techniques, lasers, miniaturized robotics, and other areas may further define what is meant by the term minimal access surgery in the decades to follow.

The role of retroperitoneoscopy in the management of renal and adrenal pathology

OBJECTIVES

To describe the technique, findings and results of retroperitoneoscopic ablation of recalcitrant renal, giant adrenal and complex peripelvic cysts, and nephrectomy for nonfunctioning congenital anomalous kidneys.

PATIENTS AND METHODS

Nine patients (six men and three women, mean age 56 years, range 44-68, five with renal, two with adrenal and two with peripelvic cysts, diameter 6-14 cm) were treated by retroperitoneoscopic cyst ablation using three 10-mm ports. Six further patients (two male and four female, mean age 24 years, range 13-38) underwent retroperitoneoscopic nephrectomy using three or four ports for anomalous nonfunctioning kidneys; three patients had a pelvic kidney, two a horseshoe kidney and one an iliac kidney. Isthmusectomy was also performed in the patients with horseshoe kidneys.

RESULTS

Retroperitoneoscopic cyst ablation was successful in all nine patients; the mean (range) operative duration was 69 (50-85) min in patients with simple renal and adrenal cysts, and 185 (160-210) min in patients with peripelvic cysts. The mean (range) blood loss was 130 (50-200) mL and hospital stay 2.33 (2-4) days. At the last follow-up, 15-39 months after the procedure, all patients were asymptomatic and satisfied with the outcome, with no recurrence of cysts. Retroperitoneoscopic nephrectomy with isthmusectomy (when applicable) was successful in the six patients with anomalous kidneys, with a mean (range) operative duration of 105 (85-120) min; the mean (range) blood loss was 116 (75-150) mL and the analgesic requirement 208 (150-250) mg of diclofenac sodium. The hospital stay was 2-3 days and the delay before return to preoperative activity 7-14 days.

CONCLUSIONS

Retroperitoneoscopic cyst ablation is a safe and effective method to treat symptomatic cysts of the upper urinary tract which are refractory to other forms of management. Dissection is difficult in patients with peripelvic cysts. Retroperitoneoscopic nephrectomy for anomalous kidneys is a challenging procedure because of the abnormal location, anomalous vessels and presence of an isthmus. With advances in laparoscopy and increasing experience, open surgery for such conditions is likely to become obsolete.

Three approaches for laparoscopic unroofing of simple and complicated renal cysts

We report 2 cases of simple renal cysts which were marsupialized with 2 laparoscopic approaches involving either transperitoneal, with reflection of the colon medially or dissection through the mesocolon, and a case of a multilocular renal cyst which was treated by the retroperitoneal approach. Although laparoscopic unroofing of a renal cyst is a safe and effective alternative to open surgical techniques, the transperitoneal approach should only be used for simple renal cysts. The retroperitoneal approach for complicated renal cysts may be indicated if preoperative examinations exclude the possibility of malignancy.

Laparoscopy for adult polycystic kidney disease: a promising alternative

The purpose of this study was to evaluate the efficacy of laparoscopy in managing patients with abdominal symptoms from autosomal dominant polycystic kidney disease (ADPKD). From April 1993 to July 1995, four patients with ADPKD underwent seven laparoscopic procedures: five cyst decortications were performed in two patients using a laparoscopic ultrasound unit and two laparoscopic nephrectomies were performed in two patients with end-stage renal failure. The mean operative time was 207 minutes for laparoscopic cyst decortication and 272 minutes for laparoscopic nephrectomy. The two nephrectomy specimens were 2,200 g and 1,750 g, respectively. The mean intraoperative blood loss was 85 mL. The patients resumed their oral intake within 10 hours after laparoscopic cyst decortication and within 16 hours after laparoscopic nephrectomy. The mean amount of parenteral analgesics required postoperatively was 12 mg morphine sulfate for cyst decortication and 30 mg morphine sulfate for nephrectomy. The mean hospital stay was 3 days for cyst decortication and 3.5 days for nephrectomy. The patients returned to their usual activities after an average of 2 weeks. Based on pain analog scales, all the patients have shown marked reduction in their symptoms (average, 90%) during an average follow-up period of 6.6 months. Laparoscopic cyst decortication and nephrectomy are effective minimally invasive treatment options for patients with adult polycystic kidney disease who are experiencing abdominal symptoms due to marked renal enlargement. We believe that by using a laparoscopic ultrasound unit, most renal cysts may be safely removed, and if need be, even "giant" kidneys can be removed laparoscopically. To the best of our knowledge, the two nephrectomy specimens in this study represent the largest kidneys removed laparoscopically to date and the first laparoscopic nephrectomies in ADPKD patients.

Initial experience with retroperitoneoscopic nephroureterectomy: use of a double-balloon technique

OBJECTIVES

To report the initial experience with retroperitoneoscopic nephroureterectomy for symptomatic, end-stage vesicoureteral reflux.

METHODS

Two patients underwent a nephroureterectomy by a four-port retroperitoneal laparoscopic approach. In 1 patient, a double-balloon technique was used to dissect the pelvic extraperitoneal space and gain access to the juxtavesical ureter. In the second patient, the distal ureter was mobilized with routine laparoscopic dissection techniques.

RESULTS

Operative time was 6 and 5.5 hours, respectively, and mean hospital stay was 4 days. Mean patient follow-up is 17.5 months.

CONCLUSIONS

The technique of retroperitoneoscopic nephroureterectomy is in evolution; until now, a major concern has been the inadequate access to the distal ureter through a completely retroperitoneoscopic approach. Described herein is a double-balloon technique that significantly facilitates dissection of the juxtavesical ureter during a retroperitoneal laparoscopic nephroureterectomy.

Direct needle insufflation for pneumoretroperitoneum: anatomic confirmation and clinical experience

OBJECTIVES

The feasibility and safety of direct needle insufflation to create pneumoretroperitoneum was assessed by an imaging study and clinical experience.

METHODS

A total of 10 patients without previous retroperitoneal surgery or diseases received computed tomography scans of the retroperitoneum 2 cm above the iliac crest. Distances between quadratus lumborum and colon (Q-C distance) were measured in the supine and lateral positions. Changes of Q-C distance were calculated when the patient was changed from the supine to the lateral position. Operative charts on 38 retroperitoneoscopic procedures were collected prospectively to assess complications related to direct needle insufflation, which was performed by inserting a 14 G Veress needle blindly along the posterior axillary line 2 cm above the iliac crest.

RESULTS

Q-C distance increased from 8.7 to 27.3 mm (left side) and 4.6 to 18.1 mm (right side) when the patient was changed from the supine to the lateral position, both P values < 0.05. An average distance of 23 mm between colon and quadratus lumborum was found when patients were lying laterally. The misplacement of a Veress needle was encountered in 1 patient, in which a prefascia insufflation resulted in conversion of the endoscopic procedure. Needle puncture caused no visceral or great vessel injury.

CONCLUSIONS

Significant anterior movement of the colon was found when patients were changed from the supine to the lateral position. It provided a window for inserting the Veress needle blindly into the retroperitoneum. The high success rate (97%) and low complication rate of direct needle insufflation were found in actual clinical applications. We considered needle insufflation a safe and effective method of establishing a pneumoretroperitoneum for any retroperitoneoscopic procedure.

Laparoscopic retroperitoneal partial nephrectomy

To our knowledge we report the initial case of laparoscopic partial nephrectomy performed completely via the retroperitoneal approach. The retroperitoneal space was developed by inflating a balloon. Renal parenchymal hemostasis was obtained by a newly designed double loop apparatus and the argon beam coagulator. Convalescence was rapid and no complications have been noted during a followup of 7 months.