Retroperitoneoscopic or Transperitoneal Approach for Neurogenic and Adrenal Tumors in Children? A Comparison on the Way to Enhanced Recovery in Pediatric Surgical Oncology

BACKGROUND

Minimally invasive surgery is increasingly utilized for resection of neurogenic tumors in children. The minimally invasive retroperitoneoscopic approach was recently reported in children, but transperitoneal laparoscopy still remains the most common technique. The aim of this study is to compare a novel single-port retroperitoneoscopy (SPR) approach for pediatric neurogenic tumor resection with transperitoneal laparoscopic (TPL).

METHODS

Patients undergoing minimally invasive resection of abdominal neurogenic tumors over 5 years at a single institution (from 2018 to 2022) were retrospectively reviewed. Tumor volume, stage, presence of image-defined risk factors (IDRFs), neoadjuvant chemotherapy, operative time, estimated blood loss (EBL), length of stay (LOS), complications, oral morphine equivalents per kilogram (OME/Kg), and time to chemotherapy were assessed and compared with SPR and TPL approaches.

RESULTS

Eighteen and fifteen patients underwent TPL and SPR, respectively. No significant differences were found between the TPL and SPR approaches in terms of tumor characteristics and IDRFs. Patients who underwent SPR had a significantly faster recovery (p = 0.008) and less postoperative opioid use compared to those in TPL (p = 0.02), thus allowing an enhanced recovery after surgery (ERAS) protocol application. TPL and SPR approaches were performed in presence of IDRFs, respectively in 2 (11%) and 4 patients (27%), with a IDRFs-related conversion in one TPL procedure. Both approaches had one < Grade 3 Clavien Dindo complication, but not requiring further surgery.

DISCUSSION

SPR approach can be considered as a safe and feasible minimally invasive approach for the resection of pediatric primary adrenal and neurogenic tumors. The retroperitoneoscopic approach performed using a single port technique represents a promising new frontier of ERAS application in pediatric surgical oncology.

CONCLUSION

SPR is a viable surgical alternative in selected neurogenic abdominal tumors with limited IDRFs, thus allowing for the application of ERAS protocols in these patients.

LEVEL OF EVIDENCE

Level III.

Robot-Assisted Retroperitoneoscopic Diamond Bypass Pyeloplasty

AIM

Robot (da Vinci Si; Intuitive Surgical, Sunnyvale, CA) assisted retroperitoneoscopic diamond bypass pyeloplasty (R-RDBP) performed for ureteropelvic junction (UPJ) obstruction (n = 5) is presented.

METHODS

Patients were placed affected side up and the retroperitoneal space accessed conventionally using 3-4 trocars. The diamond-shaped anastomosis involved incising the lowest part of the renal pelvis 12-15 mm transversely and the ureter distal to the obstruction 10-12 mm longitudinally. The first two sutures were placed retroperitoneoscopically; one from the mid-caudal line of the renal pelvis to the apex of the ureteric incision (the apex of the diamond) and the other from the corner of the incision in the renal pelvis to halfway along the ureteric incision. Trocars were replaced and the robot system docked. The first robot suture was placed between these two sutures, and the anastomosis completed by suturing from posterior to ventral applying minimal tension to keep the anastomosis close to the renal pelvis. All sutures were interrupted absorbable 5-0 monofilament.

RESULTS

Mean age at R-RDBP was 4.3 (range: 1-14) years old. Height/weight were average. Preoperative Society for Fetal Urology (SFU) grading was 4.0 in all cases. All repairs were primary and progressed smoothly without perioperative complications; 3/5 had improved appetite postoperatively. Mean SFU grades 1-3 months postoperatively were 2.8, 2.2, and 1.6, respectively. Diuretic renography that was obstructive in all cases preoperatively was normal in four and delayed in one case, postoperatively.

CONCLUSION

R-RDBP prevented rotation/kinking of the ureter, enhanced precision of suturing, and maximized the diameter at the anastomosis, facilitating smooth urine flow.

LEVEL OF EVIDENCE

LEVEL IV.

Minimally invasive techniques in benign and malignant adrenal tumors

Minimally invasive adrenalectomy has become the main treatment modality for most adrenal lesions. Both laparoscopic transabdominal and retroperitoneoscopic approaches are safe and feasible options, each with respective advantages, including better surgical outcomes, fewer complications, and faster recovery over open adrenalectomy. While open surgery remains a valid modality in treatment of adrenocortical cancer in the presence of some findings such as invasion, robotic platforms, and minimally invasive surgery have gained popularity as technology continues to evolve. Organ preservation during adrenalectomy is feasible in some conditions to prevent adrenal insufficiency. Ablative technologies are increasingly utilized in benign and malignant tumors, including the adrenal gland, with various outcomes. A multidisciplinary team, an experienced surgeon, and a high-volume center are recommended for any surgical approaches and management of adrenal lesions. This review article evaluated recent findings and current evidence on minimally invasive adrenalectomy.

Predicting surgical outcome in posterior retroperitoneoscopic adrenalectomy with the aid of a preoperative nomogram

BACKGROUND

Posterior retroperitoneoscopic adrenalectomy (PRA) has several advantages over transperitoneal laparoscopic adrenalectomy (TLA) regarding operative time, blood loss, postoperative pain, and recovery. However, it can be a technically challenging procedure. To improve patient selection for PRA, we developed a preoperative nomogram to predict operative time.

METHODS

All consecutive patients with tumors of ≤ 7 cm and a body mass index (BMI) of < 35 kg/m2 undergoing unilateral PRA between February 2011 and March 2020 were included in the study. The primary outcome was operative time as surrogate endpoint for surgical complexity. Using ten patient variables, an optimal prediction model was created, with a best subsets regression analysis to find the best one-variable up to the best seven-variable model.

RESULTS

In total 215 patients were included, with a mean age of 52 years and mean tumor size of 2.4 cm. After best subsets regression analysis, a four-variable nomogram was selected and calibrated. This model included sex, pheochromocytoma, BMI, and perinephric fat, which were all individually significant predictors. This model showed an ideal balance between predictive power and applicability, with an R2 of 38.6.

CONCLUSIONS

A four-variable nomogram was developed to predict operative time in PRA, which can aid the surgeon to preoperatively identify suitable patients for PRA. If the nomogram predicts longer operative time and therefore a more complex operation, TLA should be considered as an alternative approach since it provides a larger working space. Also, the nomogram can be used for training purposes to select patients with favorable characteristics when learning this surgical approach.

The place of retroperitoneoscopic hemi-nephroureterectomy for duplex kidney in children; risk of damage to the remnant moiety and strategies to reduce the risk

OBJECTIVE

To analyse the outcomes of retroperitoneoscopic upper and lower moiety hemi-nephroureterectomy (HNU) and to assess the different variables that may have an impact on outcome; remnant moiety damage, morbidity and the need for secondary surgery.

METHODS

Prospectively recorded data of retroperitoneoscopic HNU's performed by a single surgeon from 2005 to 2018 were analysed. Patients were split into 2 groups according to moiety affected (UMHNU and LMHNU). Clinical presentation, underlying pathology, remnant moiety DRF on renal scintigraphy, and need for further surgery were recorded. Detailed operation notes were studied regards to renal vasculature, degree of dilatation, inflammatory changes and operative difficulties encountered. Renal loss was defined as remnant moiety DRF <10% post-operatively. Change in DRF was assessed regards to the moiety, pathology and age at surgery (<1 year, 1-2 years and ≥2 years). UMHNU group was further sub-divided into 3 subgroups: ureteroceles, ectopic ureters and 'other' pathology. Statistical analysis was performed using Fishers Exact test; findings were considered statistically significant at p < 0.05.

RESULTS

78 operations met the inclusion criteria on 75 patients (3 bilateral). There were no conversions to open, and 67% were performed as day-case procedures (53/78 patients). In 91.2% (71/78) patients the procedure was definitive in resolving pathology and symptoms. 7 patients needed further procedures after HNU, 5 for ureterocele/ureteric stump. Overall, there was remnant moiety renal loss in 5.1% (4/78) patients, all with UM surgery (3 ectopic ureters and 1 ureterocele). All 4 operations were recorded prospectively as 'difficult operations' due to grossly dilated UM ureter/pelvis measuring >2 cm in diameter. 2 patients had a thinned out lower moiety (LM) sitting on top of the UM renal pelvis like a pancake with all vessels stretched over this dilated pelvis/ureter causing difficulty in accurate identification. There was intra-operative concern about some damage to LM vessels in 3 patients. Age <1year was also related to increased renal loss (2/8 patients <1 year, 1/25 patients 1-2 years, 1/45 patients ≥2 years of age P = 0.005).

CONCLUSION

Retroperitoneoscopic LMHNU is a safe and definitive procedure with rapid recovery and minimal scarring. UMHNU has higher rates of remnant moiety loss due to more complex renal pathology, but remains a safe, successful operation on the majority of patients. Renal damage was also related to age <1year (p = 0.005) and re-operation risk after UMHNU correlated to the presence of ureterocele (p = 0.003).

The future of "Retro" robotic partial nephrectomy

Partial nephrectomy (PN) is the gold standard treatment for appropriately selected renal masses. Recent surgical advancements and adoption of the robotic technique has led to greater adoption of nephron-sparing surgery. Robotic PN was initially described via the transperitoneal (TP) approach, however, retroperitoneal (RP) access is possible and in some cases more desirable. In the RP approach, the kidney is accessed from its posterior surface and the intraperitoneal space is avoided. The RP approach to PN has the benefit of avoiding intraperitoneal viscera and colonic mobilization in patients with extensive prior abdominal surgery. The technique also eliminates the need for renal unit rotation in patients with posterior tumors and affords access to masses directly posterior to the renal hilum. The RP and TP approach to PN have shown similar oncologic and perioperative outcomes. Several recent studies have reported shorter operative times and lengths of stay (LOS) with comparable warm ischemia times for the RP approach when compared to transperitoneal PN (tPN). Given the indispensable deliverables of this approach in select patients, robotic retroperitoneal PN (rPN) should be in the armamentarium of a versatile urologic kidney surgeon. This review describes the current state of rPN and compares the indications and outcomes of the TP and RP approaches.

Single-site retroperitoneoscopy in pediatric metastatic lymphadenopathy

BACKGROUND

Retroperitoneoscopic surgery (RS) is increasingly used for the diagnosis, staging, and treatment of solid tumors, but rarely in pediatric surgical oncology for retroperitoneal lymph node dissection (RPLND). Herein, we use single-site RS for RPLND in children and compare the perioperative outcomes with those for the transperitoneal laparoscopic approach (TPLA).

METHODS

A single institution retrospective chart review was performed for patients undergoing single-site RS and TPLA (January 2018 till June 2019). We compared patient demographics, diagnoses, operative times, complications, postoperative analgesia, and length of hospital stay between both groups.

RESULTS

Eight patients (median age of 16.5 years) undergoing single-site RS for RPLND and five patients (median age 17 years) undergoing TPLA RPLND were compared. Groups were comparable in age, median operative duration (232 vs 234 min, p = 0.77), and complications (1 vs 1, p = 0.72). Median postoperative hospital stay and total morphine equivalent doses used postoperatively were significantly lower in the RS group, (0.5 vs 2 days, [p = 0.03] and 0.1 vs 0.4 mg/kg [p = 0.01], respectively). Eight patients underwent ipsilateral modified template RPLND for paratesticular RMS (six single-site RS and two TPLA) and lymph node metastases were found in 50% of these patients. The rest were resections of metastatic lesions for germ cell tumor and neuroblastoma (two single-site RS and three TPLA).

CONCLUSIONS

Single-site RS is a safe and feasible technique in carefully selected pediatric surgical oncology patients. RS provides an excellent view of the retroperitoneum, requires less postoperative analgesia, and is associated with faster recovery.

LEVEL OF EVIDENCE RATING

IV.

Retroperitoneoscopic Standard or Hand-Assisted Versus Laparoscopic Standard or Hand-Assisted Donor Nephrectomy: A Systematic Review and the First Network Meta-Analysis

BACKGROUND

At the present four minimally invasive procedures namely retroperitoneoscopic (RPDN), laparoscopic (LPDN), hand-assisted retroperitoneoscopic (HARDN) and hand-assisted laparoscopic donor nephrectomy (HALDN) are used to perform donor nephrectomies. The current evidence based on retrospective studies and on pairwise only meta-analyses is inconclusive. Up to authors' best knowledge there is no so far network meta-analysis to compare all the above-mentioned procedures. Therefore, a network meta-analysis was conducted to compare the feasibility, safety and reproducibility of the four donor nephrectomies procedures.

METHODS

Google Scholar, EMBASE, PubMed, and Cochrane library were used for a systematic literature search. Both updated pairwise and network meta-analyses were performed.

RESULTS

Compared to LPDN there was evidence of significantly more right kidneys retrieved with RPDN; nonsignificant differences demonstrated both with HALDN and HARDN compared to LPDN. There was evidence that the operative time was significantly shorter by 77 min in RPDN compared to LPDN; on the other hand, HARDN and HALDN did not demonstrate significant differences when compared to LPDN.

CONCLUSIONS

The present study demonstrates that each approach can be applied safely in adequately selected patients. Moreover, retroperitoneoscopic is reliable, safe and easily reproducible alternative of LPDN for both left and right kidneys.

Influence of fellowship educational experience on practice patterns for adrenalectomy: A survey of recent AAES fellowship graduates

BACKGROUND

Current practice patterns for adrenalectomy among endocrine surgeons is a limited area of study. Here we survey relatively junior endocrine surgeons regarding educational experiences in adrenalectomy and correlate these with current practice.

METHODS

An electronic survey was sent to recent AAES-accredited fellowships graduates (2014-2019), querying adrenalectomy volume and approaches during fellowship and current practice patterns.

RESULTS

Most graduates (63.2%) performed >20 adrenalectomies in fellowship. Exposure was greatest to open (94.1%) and laparoscopic transabdominal (92.6%) adrenalectomy, followed by retroperitoneoscopic (86.7%). The majority (73.5%) of respondents stated their current practice patterns are the same as their exposure during training. Preoperative diagnosis, side of lesion, and patient comorbidities were all ranked as significant predictors affecting choice of approach (p < 0.001).

CONCLUSION

The large majority of AAES fellowship graduates receive high-volume adrenalectomy experience in several approaches. The technique to which a trainee was exposed to most frequently was the greatest predictor for preferential approach in current practice.

Use of endoscopic tissue morcellator in removing retroperitoneal fat in retroperitoneoscopic radical nephrectomy

Background

Evaluate the safety and effectiveness of using an endoscopic tissue morcellator (ETM) to remove the retroperitoneal fat during retroperitoneoscopic radical nephrectomy (RRN).

Methods

The use of ETM in the removal of retroperitoneal fat was retrospectively analyzed in patients who underwent RRN for localized renal cancer in our hospital from January 2010 to January 2018. We accrued the appropriate patients and divided them into two groups. The first group included patients of RRN where ETM was used to remove the retroperitoneal fat, while the second group was comprised of patients of RRN where ETM was not performed, which served as the control group. Each group was further divided into two subgroups, including obese patients (BMI ≥ 28) and patients suffering from high-volume renal cancer (Stage T2a). The differences between the two groups as well as their subgroups were analyzed and statistically compared.

Results

All 222 nephrectomies were completed under retroperitoneoscopy, ETM was used in 105 of these 222 patients. Among them, 31 cases were of obese patients, and 26 cases were of high-volume renal cancer patients. The other 117 patients had undergone RRN without the use of ETM. Among them, 36 cases were of obese patients, and 28 cases were of high-volume renal cancer patients. The differences in age, BMI, tumor position, and tumor size between the two groups were not statistically significant, P > 0.05. Both the surgical time and the blood loss for the ETM group were significantly lower than the control group, p < 0.05. In the subgroup analysis, the obese patients and patients with high tumor volume also showed a significantly lower surgical time and less blood loss, p < 0.05. The postoperative hospitalization time, the total survival rate, and the disease-free survival rate were not statistically significant, p > 0.05.

Conclusions

The use of ETM in removing the retroperitoneal fat during the RRN can potentially reduce the surgical time and lessen the blood loss. This technique is especially advantageous for obese and large-volume tumor patients.

Feasibility and safety profile of posterior retroperitoneoscopic adrenalectomy in high-risk patients - A retrospective analysis

OBJECTIVES

Posterior retroperitoneoscopic adrenalectomy (PRA) is used for removal of benign adrenal lesions. Though literature shows low complication rate in this procedure, there is no consensus about safety profile of PRA in high-risk patients. This study aimed to determine the feasibility and safety profile of PRA in high-risk patients.

METHODS

This retrospective study recruited all patients who underwent PRA for benign adrenal lesions in the study center. Patients with an American Society of Anesthesiologists (ASA) score of ≥3, on anticoagulant therapy or a body mass index (BMI) over 30 were classified as high-risk patients. We analyzed patients' demographics, comorbidities, perioperative mean arterial pressure and operative time, postoperative complications and tumor characteristics. Mortality and morbidity rates and length of hospital stay of the high-risk and low-risk groups were compared. The chi-square and t tests were used to determine relationships between categorical variables between groups.

RESULTS

Forty two PRA procedures were done on 21 men and 21 women; mean age of 50 years in low and 62 years in high risk groups. Twenty six (61.9%) patients had high-risk profile. We recorded 4 (9.5%) intra- and postoperative complications, while one (2.3%) PRA was converted to open due to intra-operative hemorrhage. Mean operative time of 86.45 and 108.19 min (p = 0.204), and postop hospital stay of 4.44 and 6.65 (p = 0.25) days were recorded for low and high risk groups, respectively. Intraoperative arterial pressure of ≥170 mmHg was noted for 6 low and 11 high risk patients (p = 885).

CONCLUSION

Our results indicate that PRA for benign adrenal lesions is safe and feasible in patients with a high-risk profile without a risk of increased peri- and postoperative complications.

Surgical Approaches to the Adrenal Gland

Adrenalectomy can be performed open, endoscopically or robotically, utilizing a transabdominal or retroperitoneal approach. This chapter describes the relevant anatomy, various approaches and surgical techniques, pre-operative work-up and optimization, and post-operative management of patients undergoing an adrenalectomy.

Retroperitoneoscopic lower pole heminephrectomy

INTRODUCTION

Retroperitoneoscopic heminephrectomy is a challenging procedure but with advantages over open and transperitoneal laparoscopic approaches. Lower pole heminephrectomy is less commonly undertaken compared with the upper pole.s OBJECTIVE: This VideoBank article aims to aid the surgeon in reducing the associated risks by demonstrating key steps including patient positioning, access and demonstrating key critical views.

MATERIALS AND METHODS

This is a video article with audio commentary of a pediatric patient undergoing a retroperitoneoscopic lower pole heminephrectomy.

CONCLUSION

Lower pole heminephrectomy can be safely undertaken via a retroperitoneoscopic approach.

Minimally Invasive Surgery for Primary and Metastatic Adrenal Malignancy

Since the first description of laparoscopic adrenalectomy (LA) for pheochromocytoma and Cushing syndrome in 1992, the utilization of and indications for a minimally invasive approach to the adrenal gland have vastly expanded. Although minimally invasive adrenalectomy has been established as the preferred approach for patients with benign tumors of the adrenal gland, minimally invasive adrenalectomy for cancer remains controversial. In this article, the authors review the indications for minimally invasive adrenalectomy for adrenal nodules suspicious for, or established to represent, a primary malignancy or a site of metastatic cancer.

Resection of a thoracoabdominal ganglioneuroma via a retroperitoneal minimally invasive approach

A 10-year-old girl presented to her pediatrician with a history of cough and fever. A chest radiograph revealed a paraspinal mass. On cross-sectional imaging, the mass traversed the diaphragm, extending from T9 to L1 spinal levels with involvement of the T10–12 neural foramen. Vanillylmandelic and homovanillic acid levels were normal. On review of historical radiographs, the mass had increased in size. Thus, surgical resection was recommended for diagnosis and treatment.

The patient was placed in left lateral decubitus position. The retroperitoneal space was accessed inferior to the twelfth rib. One 12 mm and two 5 mm ports were used. Development of the retroperitoneal space was achieved with both blunt dissection and a vessel-sealing device. The diaphragm was incised to resect the thoracic component of the mass. The tumor was adherent at the neural foramen and was resected flush with the spine. The diaphragm repaired primarily. She was discharged home on post-operative day four without complication. Pathology demonstrated a ganglioneuroma. The patient was well at her follow-up, and imaging one year postoperatively was without recurrence. No additional treatment was required.

A laparoscopic retroperitoneal approach allows for a safe, minimally invasive resection of a thoracoabdominal mass without violation of the abdominal cavity.

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.

Transition from laparoscopic to retroperitoneoscopic approach for live donor nephrectomy

BACKGROUND

Laparoscopic donor nephrectomy has become the standard of care due to multiple benefits. Currently, there are various techniques employed with two different approaches: transperitoneal (TLDN) or retroperitoneoscopic (RLDN) approach. There is a lack of data to determine which technique is superior, although the RLDN offers an anatomical advantage by avoidance of manipulation of the intraperitoneal organs. The aims of this study were to explore the merits of RLDN to TLDN and assess the learning curve of transition from TLDN to RLDN.

METHODS

From January 2010 to February 2017, 106 live donor nephrectomies were performed: 56 by TLDN and 50 by RLDN. Data on patient demographics, perioperative parameters, analgesic consumption, pain scores, and kidney graft function were collected and analysed. Data were compared with a Student's t test or Mann-Whitney test. A CUSUM analysis was performed to investigate the learning curve.

RESULTS

All live donor nephrectomies were successful with no conversion to open surgery. There was no blood transfusion, readmission, or mortality. No postoperative complications were graded over Clavien II. Kidney function was comparable in both groups. The follow-up period ranged from 3 to 78 months.

CONCLUSION

Retroperitoneoscopic live donor nephrectomy is a safe approach with comparable results to TLDN. RLDN has an anatomical advantage as it avoids manipulating the intraperitoneal organs and retains a virgin abdomen and hence translates to a lower perioperative complication risk.

Optimal Management of a Synchronous Diagnosis of Phaeochromocytoma and Colorectal Neoplasia

The incidence rates of phaeochromocytoma and colorectal cancer (CRC) are approximately 1 and 65 per 100,000 per year, respectively. Simultaneous presentation of these conditions is rare and poses unique management challenges. We report on treatment strategies and clinical outcomes in a series of patients with colorectal neoplasia and phaeochromocytoma. Demographic and clinical details of four patients over a 4-year period were reviewed. The median (range) age at first presentation was 66 (52-70) years. Phaeochromocytoma (2.5-12.5 cm) was confirmed on biochemistry after incidental detection of an adrenal mass on CT scan-three had CT for staging of CRC and one had CT scan for weight loss. Adrenalectomy (three retroperitoneoscopic and one open procedure) was first performed after maximally tolerated alpha blockade; no significant complications were observed. Normalisation of biochemistry was confirmed and the patients then underwent colorectal surgery-laparoscopic right hemicolectomy, open right hemicolectomy (with further extensive surgery) for locally advanced cancer, laparoscopic low anterior resection and open high anterior resection. One respiratory infection and a seroma were the post-operative complications seen. In patients with a simultaneous diagnosis of phaeochromocytoma and CRC, surgical interventions should be staged. Adrenalectomy should first be performed to avoid haemodynamic instability during colorectal resection. A retroperitoneoscopic approach to the adrenal in patients with ipsilateral colonic tumours avoids transgressing the planes for colorectal resection. The synchronous diagnosis of these two rare conditions and the reported stimulatory effect of catecholamines on colorectal epithelia raise the possibility of an increased incidence of colorectal neoplasia in patients with phaeochromocytoma.

Outcome of laparoscopic upper pole heminephroureterectomy in children: A two-centre experience

OBJECTIVE

To report our multicentre experience and outcomes with laparoscopic transperitoneal and retroperitoneal upper pole heminephroureterectomy (HNU) in children with renal duplex systems and impaired upper pole.

PATIENTS AND METHODS

Laparoscopic HNU was performed in 22 children (15 girls, seven boys) with a mean age of 5.9 years. A retroperitoneal approach was used in 17 patients and a transperitoneal approach in the remaining five, between 2005 and 2010. Urinary tract infection was the initial presenting symptom in all children except for one with urinary retention caused by a large ureterocele. Voiding cystourethrography and renal scintigraphy revealed dual collecting systems on the right side in 11 and on the left in 11 cases. The upper pole collecting system was non-functioning in all cases. Postoperative ultrasonography was done at 1 and 3 months, with renal scintigraphy at 3 months, to check the remaining function of the lower moiety.

RESULTS

Overall, the mean operation time was 152 min (144 min for retroperitoneal and 160 min for transperitoneal). Blood loss was 10-50 mL and there were no intraoperative complications. The mean (SD) hospitalisation and postoperative follow-up were 3.5 (1.25) days and 22 (9.83) months, respectively. Postoperative recovery was uneventful and at the 3-month follow-up renal scintigraphy revealed no parenchymal loss of the remaining renal moiety.

CONCLUSION

Laparoscopic HNU in children can be performed via transperitoneal or retroperitoneal approach, both with low morbidity and with the typical benefits of laparoscopic surgery.

Clinical analysis of retroperitoneoscopic nephroureterectomy for renal tuberculosis

OBJECTIVES

To explore the feasibility and safety of retroperitoneoscopic nephroureterectomy for kidney tuberculosis.

METHODS

Forty-eight retroperitoneoscopic nephroureterectomies and thirty-five nephroureterectomies for kidney tuberculosis procedures were performed from June 2008 to December 2014. The patients consisted of 53 males and 30 females with a mean age of 36 years (range: 26-51 years). The patients' data were reviewed and analyzed.

RESULTS

The retroperitoneoscopic nephroureterectomy procedures were completed successfully in 48 cases with no conversions to open surgery. The mean operating time was 170 minutes (range: 121-258 minutes), the mean blood loss was 110 ml (range: 70-250 ml), and the mean hospital stay was 5.70 days (range: 5-14 days); these were all much less than nephroureterectomy procedures (P < 0.05). A total of five minor complications (10.4%) occurred, injury to the peritoneum was observed in three patients, and infection at the incision site was observed in two patients, there were no obvious difference between the two surgical methods (P > 0.05). Seventy-five patients were followed up, and the average follow-up time was 12.5 months (range: 6-20 months). All the patients recovered without any lesions remaining.

CONCLUSIONS

The results of this study indicate that retroperitoneoscopic nephroureterectomy is a feasible, safe, effective, and less invasive treatment modality for treating renal tuberculosis.

Management of suspected adrenal metastases at 2 academic medical centers

BACKGROUND

The optimal management of suspected adrenal metastases remains controversial.

METHODS

This is a retrospective bi-institutional review of 37 patients who underwent adrenalectomy for suspected adrenal metastasis between 2001 and 2014.

RESULTS

Three (8%) patients had benign adenomas on final pathology. At a median follow-up of 21 months, 7 (32%) patients were alive with no evidence of disease and 7 (32%) were alive with recurrent disease. Recurrence-free survival (RFS) was 8 months; decreased RFS was associated with positive margins and size ≥6 cm. Overall survival (OS) was 29 months; decreased OS was associated with capsular disruption. There were no differences in RFS or OS by surgical approach.

CONCLUSIONS

The favorable OS supports adrenalectomy in select patients with suspected adrenal metastases. Minimally invasive adrenalectomy is safe and effective, but the surgical approach should be based on the ability to achieve a margin-negative resection with avoidance of capsular disruption.

Single incision prone retroperitoneoscopic paediatric nephrectomy

OBJECTIVE

We have previously reported our early experience (2 patients) of single-incision nephrectomy via the retroperitoneal prone route using an advanced access platform (GelPOINT Mini). Here, we review our series to date and also present a detailed video demonstrating the technique.

METHOD

In the prone position, a single transverse incision was made at the midpoint on a line along the lateral border of erector spinae bounded by the lower border of the 12th rib and iliac crest. Posterior abdominal muscles were split and the deep lumbodorsal fascia incised. The Alexis retractor was positioned and the Gel-Seal cap with low-profile sleeves locked in place. Hilar vessels were divided by endoclip application or harmonic scalpel. The kidney was retrieved directly or via an endobag. The Alexis retractor was removed and wound closed with absorbable sutures.

RESULTS

Between July 2013 and March 2015, we have used this approach to perform 10 nephrectomies in nine patients (4 male and 5 female). The median age at nephrectomy was 10.9 years (range 2.7-15.9 years). The median kidney length was 7.5 cm (range 3.7-11.5 cm). No complications occurred and none converted to open procedure.

CONCLUSION

Single incision retroperitoneal nephrectomy is feasible, safe, and provides excellent cosmesis.

Retroperitoneoscopic left upper moiety heminephroureterectomy for dribbling incontinence

A 7-year-old girl underwent a prone, retroperitoneoscopic left upper moiety heminephroureterectomy for a non-functioning upper moiety associated with a dilated, ectopic ureter. The dilated ureter was noted prenatally, but postnatal investigations failed to demonstrate the duplex system. The child remained asymptomatic until she represented at 6 years of age, with dribbling of urine. She went on to have an ultrasound scan, dimercaptosuccinic acid and magnetic resonance urogram, which identified a grossly-dilated fluid-filled structure in proximity of the left kidney, but failed to demonstrate the small non-functioning left upper moiety. A computed tomography urogram was more helpful in establishing the diagnosis. Retroperitoneoscopy via three 5-mm ports allowed clear visualisation of both the left duplex ureters, as well as the small non-functioning upper moiety, which had been challenging on the pre-operative imaging. The procedure is described in the accompanying video. The child was discharged home the following day and has been completely well and dry at 6 months' follow-up.

Retroperitoneoscopic live donor nephrectomy: 7 cases

Laparoscopic living donor nephrectomy causes less pain, shorter hospital stays and a quicker return to daily activities. Because of potential bowel injuries and risk of intestinal obstruction secondary to adhesions later on, the retroperitoneoscopic donor nephrectomy (RDN) technique has been developed. The first 7 RDN cases carried out at our organ transplantation unit between December 2006 and May 2007 were retrospectively examined. The male/female ratio of the patients was 4/3. Left nephrectomy was performed in all cases. In two patients, the conventional method was performed because of an adhesion in the hilar area in one patient and because of technical difficulty after entering the peritoneum in another patient. Serious complications such as massive hemorrhage and intestinal injury were not observed. None of the patients required blood transfusion. The mean operative time was 161 minutes, with the exception of 2 patients who required conversion to other methods. Mean warm ischemia duration was 125 seconds. Oral feeding began the first postoperative day. The mean inpatient stay was 3.5 days. The mean recipient creatinine levels 24 hours and 1 month post-procedure were 3.78 mg/dl and 1.04 mg/dl, respectively. RDN is technically more difficult and has a steeper learning curve compared to transperitoneal donor nephrectomy. As our RDN cases increase, we will obtain more representative data on complications.