Retroperitoneal Approach Research Articles

Does indirect decompression by oblique lateral interbody fusion produce similar clinical and radiological outcomes to direct decompression by open transforaminal lumbar interbody fusion.

Open transforaminal lumbar interbody fusion (O-TLIF) remains the most popular and widely practiced lumbar fusion method even today, providing direct decompression. Oblique lateral interbody fusion (OLIF) is a novel retroperitoneal approach that allows placement of a large interbody cage which provides an indirect neural decompression, and screws can be placed minimal invasively or through the Wiltse OLIF (W-OLIF) approach. We aim to find out the short-term efficacy of W-OLIF to O-TLIF in terms of radiological and clinical outcomes in patients of lumbar degenerative diseases. Fifty-two patients were divided equally into two groups (group O-TLIF and group W-OLIF). Several parameters were measured, such as the spinal cord cross-sectional area (SC-CSA), foraminal cross-sectional area (F-CSA), disc height (DH), foraminal height (FH), Schizas grade for stenosis, and Meyerding's grading for olisthesis. Functional scores were measured using the visual analog scale (VAS) for low back pain (LBP) and lower limbs, Oswestry Disability Index. All parameters were repeat measured at 3 months follow-up. Statistical analysis was done using SPSS software. Both groups were similar in composition preoperatively. There was significant improvement in all clinical and radiological parameters post-surgery in either group. However, at 3 months, The DH, FH, FSA, and VAS (LBP) were better in the W-OLIF group than in O-TLIF. Procedure-related complications were seen in both groups (15% in the O-TLIF group and 19% in the W-TLIF group), but only one patient in O-TLIF required revision due to cage migration. Similar improvement occurs in most of the clinical and radiological parameters in the W-OLIF group compared to the O-TLIF group. Few radiological parameters such as the DH, FH, and F-CSA and the VAS (LBP) correction are superior in the W-OLIF group in the short-term follow-up. We conclude that indirect decompression by W-OLIF provides equivalent, if not better, results than the traditional O-TLIF lumbar fusion.

Safety and efficacy of laparoscopic transperitoneal versus retroperitoneal resection for benign retroperitoneal tumors: a retrospective cohort study.

Benign retroperitoneal tumors (BRTs) are clinically rare solid tumors. This study aimed to compare the safety and efficacy of laparoscopic transperitoneal versus retroperitoneal resection for BRTs. The clinical data of 43 patients who had pathologically confirmed BRTs and underwent laparoscopic resection in a single center from January 2019 to May 2022 were retrospectively analyzed. Patients were divided into two groups according to the surgical methods: the Transperitoneal approach group (n = 24) and the Retroperitoneal approach group (n = 19). The clinical characteristics and perioperative data between the two groups were compared. The baseline data and surgical variables were analyzed to determine the impact of different surgical approaches on the treatment outcomes of BRTs. No significant difference was observed between the two groups in gender, age, body mass index, the American Society of Anesthesiologists score, presence of underlying diseases, tumor size, tumor position, operation duration, intraoperativehemorrhage, postoperative hospital stay, intestinalfunctionrecoverytime, and postoperative complication rate. The conversion rate from laparoscopic to open surgery was significantly lower in the Transperitoneal approach group than in the Retroperitoneal approach group (1/24vs.5/19, χ2 = 4.333,P = 0.037). Tumor size was an independent influencing factor for the effect of surgery (odds ratio = 1.869, 95% confidence interval = 1.135-3.078,P = 0.014) and had a larger efficacy on the retroperitoneal group (odds ratio = 3.740, 95% confidence interval = 1.044-13.394,P = 0.043). The laparoscopic transperitoneal approach has the inherent advantages of anatomical hierarchies and surgical space, providing a better optical perspective of the targeted mass and improved bleeding control. This approach may have better efficacy than the retroperitoneal approach, especially in cases of a large tumor or when the tumor is located near important blood vessels.

The role of the multidisciplinary team in surgical management of intractable tubo-ovarian abscess as a late sequelae of challenging Crohn's disease in the modern era: A case report and review of current literature.

Chronic, severe Crohn's disease in a young female patient can result in surgical complexity. The rarity of the presentation of intractable pelvic abscesses within this etiology with additional considerations given to fertility concerns and hence requirement for input from a multi-disciplinary team makes this a vital case in building a consensus for evidence-based surgical management. A 29-year-old nulliparous woman was referred to our tertiary centre for surgical management of Crohn's disease with known tubo-ovarian abscess and abdominoperineal and abdominal wall sinuses. Her previous surgical history included 4 midline laparotomies, subtotal colectomy and proctectomy with stoma formation. The patient underwent egg collection to preserve fertility. This was followed by midline laparotomy and abdominoperineal resection, which involved a retrograde radical modified hysterectomy using the Hudson technique, alongside excision of the perineal sinus, with reconstruction of the perineal defect using an internal pudendal artery perforator gluteal fold flap, and in addition to excision and drainage of the abdominal wall abscess. Involvement was sought from gynecological oncology, colorectal, urology, plastics, stoma, fertility, microbiology, and gastroenterology teams, which enabled successful preservation of end organ function and improvement in patient psychological well-being. This case is a paradigm of surgical challenge, requiring expert gynecological oncology techniques including a retroperitoneal approach, nerve and vessel sparing considerations alongside colorectal and urological procedures. Moreover, we believe that our blueprint for effective multi-disciplinary practice will inform the future management of gynecological surgery. Therefore this report aims to contribute towards the optimum management of the gynecological sequelae of Crohn's disease.

Retroperitoneal Nephrometry Scoring System (RETRO) for Minimal-Invasive Partial Nephrectomy.

To propose a standardized scoring system of renal tumors suitable for partial nephrectomy based on mini-invasiveness and retroperitoneal approach. One-hundred and five patients in retroperitoneal group were prospectively enrolled from January 2017 to December 2018. Perioperative characteristics of all patients were collected: age, gender, BMI, preoperative blood test and imaging results, operation time (the time period starts from the skin incision to the final skin closure), estimated blood lost, clamping time, complications within 30 days, American Society of Anesthesiologists (ASA) score, pathology. An algorithm was extracted, and it was used to predict the risk of complications. Symptoms, ASA score and RETRO score were significantly correlated to postoperative complications, excluding tumor size, ischemia time and operation time. Adjusted RETRO points were an independent factor to predict complication rate (p = 0.006). Limitation was that it did not analyze the relationship between the RETRO score and the long-term outcomes. The RETRO score simplifies the risk evaluation of partial nephrectomy for patients with renal tumor, especially benefits those surgeries performed under robot-assisted laparoscope via retroperitoneal approach. The new RETRO score system that we developed is a selection criterion to perform surgery via different approaches, and an accurate system to evaluate the complexity during partial nephrectomy.

Anterior lumbar interbody fusion (ALIF): a review of the procedure and associated complications

Degenerative disc disease and facet joint disease involving the lumbar spine are common in the aging population and are the most frequent causes of disability. Surgical interbody fusion of degenerative levels is the most common management technique. This is an effective treatment option to stabilize the spine and reduce mechanical pain and provides indirect decompression of the neural elements while restoring lordosis and correcting the deformity. Depending on the direction of the approach to the vertebral column, various techniques have been described. Anterior lumbar interbody fusion (ALIF) offers clear and wide visualization of the disc allowing the use of large interbody grafts, which provide a significant biomechanical advantage over other types of fusion. The transperitoneal approach is a much older technique and it is not commonly performed unless in isolated cases with extensive retroperitoneal scaring following multiple abdominal surgeries. The transperitoneal approach has been associated with higher rates of bowel injury, ileus, and retrograde ejaculation, and is limited at the L5–S1 segment, hence many spine surgeons favor a retroperitoneal approach. The major setback of ALIF is the need for great vessel mobilization. This manipulation of the vessels may lead to deep vein thrombosis and a direct vascular injury. This makes vascular anatomy studies in the preoperative stage invaluable in avoiding vascular injury. Other complications include possible injury to intraperitoneal and retroperitoneal organs, especially in patients with previous surgery and adhesions. Manipulation of the intestines causes postoperative ileus which lasts a few days. Sexual dysfunction in form of retrograde ejaculation is another complication seen in patients following ALIF and this has been attributed to injury to the superior hypogastric sympathetic nerves in the lower lumbar region.This article reviews the ALIF procedure i. e., transperitoneal and retroperitoneal approaches, and the associated intraoperative, early, and late complications.

Intraoperative Complications of the Anterior Retroperitoneal Approach to the Lumbosacral Spine in the Supine Position: A Proposal for an Algorithm to Predict the Degree of Difficulty of the Surgical Procedure

The main concern in anterior exposure of the lumbosacral spine is the risk of vascular injury during mobilization and retraction of the blood vessels. Preoperative planning is considered essential to reducing the incidence of vascular injury, although no consensus has been reached on the preferred methodology for such planning. This is a retrospective study, including all patients operated on by a single surgeon, who received anterior lumbar-spine surgery in the supine position as a primary procedure before undergoing an anterior lumbar interbody fusion (ALIF) or an artificial disc replacement (ADR). The aim of this study was to list the intraoperative complications observed. We included 156 patients (87 women; mean age, 48 years) who met the inclusion criteria. The overall complication rate was 6.4% (10/156). The most frequent complications were an incidental peritoneal opening (seven patients, 4.4%); two left–iliac-vein injuries (1.28%) that were sutured; and one dural tear during a decompression maneuver of the canal. No neurological, arterial, or ureteral injury or retrograde ejaculation was reported. The use of a sound protocol that includes planning, assessment of approach difficulty, and step-by-step surgical technique can reduce the rate of vascular injury in anterior lumbosacral-spine surgery.

Induction of Lumbar Disc Degeneration in Rabbits Through a Transabdominal Approach.

Lower back pain is an extremely common medical issue in populations worldwide. One of the main contributors to lower back pain is intervertebral disc (IVD) degeneration. An ideal animal model of IVD degeneration is essential to study the pathophysiology of lower back pain and investigate potential therapeutic strategies. Rabbit models are reliable, economical, and easily established animal models. The retroperitoneal approach has been widely used to induce IVD degeneration in rabbit models. However, there are reported complications associated with this technique, such as the avulsion of segmental arteries and nerve root injury. In this paper, we aim to show a surgical protocol using needle puncture to establish rabbit lumbar disc degeneration via a transabdominal approach. Consequently, radiological checks and histological analyses indicated that lumbar disc degeneration was successfully established in rabbits. This surgical protocol presents the precise location of target discs and high reproducibility of IVD degeneration models with fewer complications.

Technique and outcomes of robotic-assisted retroperitoneal radical nephrectomy.

Robotic retroperitoneal partial nephrectomy (rRPN) has numerous advantages over transperitoneal surgery, including direct access to the renal hilum and posterior tumors, and avoidance of the peritoneal cavity in patients with a hostile abdomen. Although the use of the retroperitoneal approach has increased over the last decade, there is little literature on robotic retroperitoneal radical nephrectomy (rRRN), which has similar benefits over the transperitoneal approach. The aim of this study was to describe our technique for robotic retroperitoneal nephrectomy (rRN) and assess its feasibility and outcomes at a high-volume center. A retrospective review of patients who underwent some form of rRN [rRRN, robotic retroperitoneal simple nephrectomy (rRSN), or robotic retroperitoneal nephroureterectomy (rRNU)] at a single institution between 2013 and 2023. Patient characteristics, operative data, and postoperative complication rates were assessed. The technique for rRN was detailed. A total of 13 renal units in 12 patients were included for analysis (7 rRRN, 5 rRSN, 1 rRNU). Median patient age was 64.0 years, and median body mass index (BMI) was 36.0 kg/m2. Indications for retroperitoneal surgery were prior abdominal surgery in all patients, including three with bowel diversions, super morbid central obesity in two patients, and a large ventral hernia in one patient. Median operative time was 213 minutes and median estimated blood loss (EBL) was 85 cc. Median postoperative length of stay (LOS) was 3 days, and only one patient experienced a Clavien-Dindo grade ≥3 complication within 90 days of surgery. The retroperitoneal approach for robotic-assisted nephrectomy is feasible and associated with similar outcomes as the transperitoneal approach. This approach may prove beneficial in select patients with significant prior abdominal surgery including those who are morbidly obese.

Minimally invasive recipient procedure in kidney transplantation.

There are several procedural variations for kidney transplant donors, including open, laparoscopic, hand-assisted, and robotic methods, with either an intra- abdominal or retroperitoneal approach. Conversely, fewer options are available for the recipient procedure. We introduce a method that involves a small incision, with the goal of being less invasive for recipients. Our current method was introduced in April 2022. As of July 2023, we have completed 27 cases. We analyzed several factors in these 27 cases, including the size of the incision, rewarming time, anastomosis time, graft function, analgesic use, and complications. The average incision size was 73 mm. The time taken for anastomosis was 24. 1 minutes, while the rewarming time averaged 43.1 minutes. There were no instances of primary nonfunction. One case necessitated postoperative dialysis three times due to heart failure. Following stent removal, one patient developed grade 1 hydronephrosis. There was one instance of bleeding from the drain insertion site. Another case involved a clamp injury to the external iliac artery, which necessitated stent insertion on the fourth postoperative day. Compared to procedures performed using conventional methods, the use of analgesics was less in these cases. Our minimally invasive technique, which involves a small incision, is a feasible alternative that could potentially be less invasive than traditional methods.

Retroperitoneal Single-Port Robot-Assisted Nephroureterectomy with Bladder Cuff Excision: Initial Experience and Description of the Technique.

With the introduction of the single-port (SP) robot, surgery that was difficult to attempt is becoming possible. Nephroureterectomy (NUx) for upper tract urothelial carcinoma also seems to be able to attempt a retroperitoneal (RP) approach. to investigate the feasibility of SP robotic RP NUx with bladder cuff excision. we sequentially analyzed 20 patients who underwent SP robot NUx from January 2021 to December 2022. all patients were diagnosed with upper tract urothelial carcinoma (UTUC) and were operated upon by a single expert using the da Vinci SP platform (Intuitive Surgical, Sunnyvale, CA, USA) with retroperitoneal approach. A total of 20 patients underwent SP robotic NUx with bladder cuff excision. The mean age of patients was 69.45 ± 8.68 years, and the mean body mass index (BMI) was 25.37 ± 3.00 kg/m2. The mean tumor size was 2.42 ± 1.03 cm on a CT scan, with right-sided tumors in eight patients (40%) and left-sided tumors in 12 patients (60%). The median console time was 106 min and 40 s, and the expected blood loss was 122.50 ± 75.18 mL. Final pathology showed that all of the patients were diagnosed as having urothelial carcinoma; one patient was classified as Ta (5.00%), three patients were classified as T1 (15.00%), seven patients were classified as T2 (35.00%), eight patients were classified as T3 (40.00%), and one patient was classified as T4 (5.00%). None of these 20 patients showed any complications based on the Clavien-Dindo scale. SP robotic NUx using a retroperitoneal approach provides feasible perioperative and postoperative outcomes for UTUC.

Open Aortic Reconstruction Configurations for Retroperitoneal Approach to Aortic Aneurysms: Aorto-Femoral Reconstruction is a Negative Predictor of Long-Term Outcomes

Open Aortic Reconstruction Configurations for Retroperitoneal Approach to Aortic Aneurysms: Aorto-Femoral Reconstruction is a Negative Predictor of Long-Term Outcomes

A bidirectional cohort study to compare the outcomes of transperitoneal and retroperitoneal approaches in subjects undergoing laparoscopic live donor nephrectomy

Abstract Background Laparoscopic transperitoneal donor nephrectomy (LDN) is currently the standard procedure for renal donation from living donors. Only a handful of clinical studies have compared the outcomes of retroperitoneoscopic donor nephrectomy (RLDN) and LDN. More robust data and systematic comparative analyses of the outcomes and complications of these 2 techniques are needed. This study aimed to elucidate the noninferiority of RLDN to LDN. Materials and methods All live renal donors who underwent either RLDN or LDN at our institution during the period of January 2015 to March 2021 were considered subjects, excluding those who refused to participate in the study. This was a bidirectional cohort study. Demographic and clinical data were collected and analyzed using standard statistical methods. Statistical significance was set at p < 0.05. Results Our study included 89 subjects: 40 in the LDN group and 49 in the RLDN group. The RLDN group had significantly shorter warm ischemia time (2.85 vs. 6.04 minutes), a lower fall in hemoglobin on postoperative day (POD)-1 (1.73 vs. 2.24 g/dL), lower estimated blood loss (601.93 vs. 797.27 mL), and lower pain on POD-1 (0.78 vs. 1.28). The improvement in recipient’s estimated glomerular filtration rate on POD-30 was significantly higher in the RLDN group (79.98 vs. 63.73 mL/min/1.73 m2). There was a significantly higher fall in estimated glomerular filtration rate of donor after nephrectomy in RLDN group on POD-30 (35.53 vs. 30.60 mL/min/1.73 m2). However, there were no significant differences in other parameters. Conclusions Our study, conducted in India, showed that the majority of RLDN outcomes were better than those of LDN. Hence, RLDN is clearly non-inferior to the gold standard LDN. A well-designed randomized controlled study is required to elucidate the statistical superiority of one approach over another.

Which surgical approach is more favorable for pheochromocytoma of different sizes (< 6 cm vs. ≥ 6 cm)? A single retrospective center experience

BackgroundTo compare the surgical effects of lateral transperitoneal approach (LTA) and posterior retroperitoneal approach (PRA) for pheochromocytoma of different sizes.MethodsData on patients with pheochromocytoma from 2014 to 2023 were collected from our hospital. According to different surgical approaches and tumor size, all patients were divided into four groups: tumor size < 6 cm for LTA and PRA and tumor size ≥ 6 cm for LTA and PRA. We compared these two surgical methods for pheochromocytoma of different sizes.ResultsA total of 118 patients with pheochromocytoma underwent successful laparoscopic surgery, including PRA group (n = 80) and LTA group (n = 38). In tumor size < 6 cm, the outcomes were no significant difference in LTA and PRA. In tumor size ≥ 6 cm, there was a significant difference in operation time (214.7 ± 18.9 vs. 154.3 ± 8.2, P = 0.007) and intraoperative blood loss (616.4 ± 181.3 vs. 201.4 ± 45.8, P = 0.037) between LTA and PRA.ConclusionLTA and PRA were performed safely with similar operative outcomes in patients with pheochromocytoma size < 6 cm. While both LTA and PRA were executed with a commendable safety profile and comparable operative results in patients afflicted by pheochromocytomas < 6 cm, the PRA technique distinctly showcased advantages when addressing large-scale pheochromocytomas (≥ 6 cm). Notably, this manifested in reduced operative time, diminished intraoperative blood loss, decreased hospitalization expenses, and a paucity of procedural complications.

Impact of Visceral Fat Area on Intraoperative Complexity and Surgical Approach Decision for Robot-Assisted Partial Nephrectomy: A Comparative Analysis with BMI.

BACKGROUND Optimizing surgical approaches for robot-assisted partial nephrectomy (RAPN) is vital for better patient outcomes. This retrospective study aimed to examine how visceral fat area (VFA) and body mass index (BMI) correlate with intraoperative complexities, thereby guiding the selection of surgical techniques for RAPN. MATERIAL AND METHODS The study analyzed the medical records of 213 Chinese patients diagnosed with a range of benign and malignant renal neoplasms and treated with RAPN in 2020. Visceral fat area was quantified using computed tomography (CT) scans taken at the umbilical level. Various perioperative indicators, such as demographic details, clinicopathological parameters, operation time, estimated blood loss (EBL), warm ischemic time (WIT), and intraoperative complications, were assessed. RESULTS For the retroperitoneal approach, patients with either visceral obesity or general obesity had longer operation times (P<0.001 and P=0.004) and had a tendency for higher EBL (P=0.003 and P=0.001) compared to non-obese patients. In the transperitoneal approach, those with visceral obesity had significantly longer operation times (P=0.008) than their non-viscerally obese counterparts; however, general obesity showed no impact on operation time (P=0.251). Estimated blood loss was higher for patients with visceral obesity (P=0.004), but no significant difference was noted among those with general obesity (P=0.980). CONCLUSIONS VFA appears to offer predictive advantages over BMI in assessing intraoperative complexities for transperitoneal RAPN. When used in conjunction with BMI, it could serve as a valuable tool in selecting the most appropriate surgical approach for RAPN.

Application of the single-port robotic platform during radical nephroureterectomy for upper tract urothelial carcinoma: feasibility of the single-port robot in the multi-quadrant setting.

Urothelial carcinoma of the upper tract (UTUC) is a malignancy that accounts for 5-10% of all urothelial carcinomas. Radical surgery is the primary treatment option due to the high rate of invasive stages at the time of diagnosis. Nephroureterectomy (NU) with bladder cuff excision is the current standard of care. While laparoscopic NU has been established since 1991, many centres still perform open surgery due to the complexity of laparoscopic instrumentation and the steep learning curve for excising the bladder cuff. With the increasing adoption of the multi-port (MP) robotic surgery, NU has increasingly been performed using this platform. The use of MP robotic systems for NU has been challenged by the need for patient repositioning and/or redocking of the robot, which can consume valuable operative time. The transition from the daVinci Si to the daVinci Xi system has seen a noticeable reduction in redocking and patient repositioning. However, owing to the multi-quadrant nature of the surgery in question, the use of multiple ports and external instrument clashing are still persistent problems. Moreover, there is a growing interest in utilizing a retroperitoneal approach for robot-assisted NU due to its potential benefits such as improved control of hilar structures, reduction of blood loss, shorter operative time and hospital stay, reduced complications and decreased postoperative discomfort. The application of the daVinci single-port (SP) robotic platform during radical NU for UTUC is feasible and has the potential to improve the current surgical approach. Indeed, the use of a SP platform may solve the problem of patient repositioning and redocking of the robot, improve superficial aesthetic outcome and minimize external instrument clashing. While maintaining an optimal oncological control, the retroperitoneal approach, which has been difficult to replicate and adopt using the MP approach, may become standard practice. However, more studies are needed to confirm the benefit of this approach and ultimately determine the impact of the daVinci SP on the management of UTUC.

Retroperitoneal approach for robot-assisted partial nephrectomy: still underused despite the supporting evidence.

Retroperitoneal approach for robot-assisted partial nephrectomy: still underused despite the supporting evidence.

992 Pioneering Robot-Assisted Spine Surgery in the United Kingdom

Abstract Aim The placement of a large interbody implant allows for a larger fusion area. Retroperitoneal approaches, like anterior, antero-lateral, and lateral fusion, facilitate the placement of these implants. At the same time, robot-navigation facilitate complex, minimally invasive spine surgery for posterior screw fixation. This is a single-surgeon, single-centre report on the experience of the first procedures ever performed for navigated robot-assisted spine surgery in the United Kingdom. Method Between October 2019 and May 2021, we identified 34 consecutive patients who underwent robot-assisted spine surgery. The demographic, intra-operative, and peri-operative data were reviewed. Results Of the 34 patients, 65 levels were treated in total (204 screws). 21 patients (60%) underwent single-level fixation, 14 of them (67%) were treated at the L5/S1 level, 3 at L3/L4, 3 at L4/L5 and 1 at L2/L3 level, 13 patients (40%) underwent multi-level fixation, with 4 of them treated for adult scoliosis. Eight patients underwent a supine ALALIF approach and one a lateral decubitus AL-ALIF, 7 had a pure ALIF approach, 8 patients underwent combined XLIF and AL-ALIF approach in a lateral decubitus, 6 underwent pure XLIF approach, 1 patient had previous TLIF surgery, and 3 patients underwent single position lateral surgery (lateral decubitus fusion and posterior screw fixation). Conclusions Minimally invasive spine surgery using robot-assisted navigation yields an improved level of accuracy, decreased radiation exposure, minimal muscle disruption, decreased blood loss, shorter operating theatre time, length of stay, and lower complication rates. Further follow-up of the patients treated will help compare the clinical outcomes with other techniques.

Development of novel tracers for sentinel node identification in cervical cancer.

Indocyanine green (ICG) with near-infrared (NIR) fluorescence imaging is used for lymphatic mapping. However, binding of ICG to blood proteins like serum albumin can shorten its retention time in sentinel lymph nodes (SLNs). Here, we investigated the efficacy and safety of a new fluorescence tracer comprising phytate and liposome (LP)-encapsulated ICG. Coadministration of phytate with LP containing phosphatidic acid promotes chelation mediated by Ca2+ in bodily fluids to enhance SLN retention. Uniformly sized LPs (100 nm) encapsulating ICG under conditions that minimized fluorescence self-quenching during storage were produced. We analyzed the behavior of the new tracer (ICG-phytate-LP) and control tracers (ICG and ICG-LP) in the lymphatic flow of mice in terms of lymph node retention time. We also tested lymphatic flow and safety in pigs that have a more human-like lymphatic system. LPs encapsulating stabilized ICG were successfully prepared. Mixing LP with phytate in the presence of Ca2+ increased both the particle size and negative surface charge. In mice, ICG-phytate-LP had the best lymph node retention, with a fluorescence intensity ratio that increased over 6 h and then decreased slowly over the next 24 h. In pigs, administration of ICG and ICG-phytate-LP resulted in no death or weight loss. There were no obvious differences between blood test results for the ICG and ICG-phytate-LP groups, and the overall safety was good. ICG-phytate-LP may be a useful new tracer for gynecological cancers that require time for lymph node identification due to a retroperitoneal approach.

A comparison of perioperative outcomes of transperitoneal versus retroperitoneal robot-assisted partial nephrectomy: a systematic review.

RAPN can be carried out via a transperitoneal or retroperitoneal approach. The choice between the two approaches is open to debate and usually based on surgeon preference. The perioperative outcomes of transperitoneal robot-assisted partial nephrectomy versus retroperitoneal robot-assisted partial nephrectomy were compared. A systematic review of the literature was performed up to May 2020, using PubMed, Cochrane, Scopus and Ovid databases. Articles were selected according to a search strategy based on PRISMA criteria. Only studies comparing TRAPN with RRAPN were eligible for inclusion.Eleven studies were included in the quantitative synthesis. Baseline demographics (age, BMI, ASA, tumour size, and RENAL nephrometry score), intraoperative data (operative time, estimated blood loss, and warm ischaemia time) and postoperative outcomes (major complications according to Clavien-Dindo, length of hospital stay (LOS) and positive surgical margin rate) were recorded. A total of 3139 patients were included (2052 TRAPN vs. 1087 RRAPN).There was no significant difference in demographic variables (age, BMI), tumour size (p = 0.06) nor the nephrometry score (p = 0.20) between the two groups.Operative time(p = 0.02), estimated blood loss (p < 0.00001) and LOS (p < 0.00001) were significantly lower in the RRAPN group. No differences were found in major postoperative complications (Clavien-Dindo > 3; p = 0.37), warm ischaemia time (p = 0.37) or positive surgical margins (p = 0.13). Future researchers must attempt to achieve adequately powered, expertise based, multi-surgeon and multi-centric studies comparing TRAPN and RRAPN. RRAPN gives similar outcomes to TRAPN. RRAPN is associated with reduced operative time and LOS. Ideally, surgeons should be familiar and competent in both RAPN approaches and adopt a risk-stratified and patient-centred individualised approach, dependent on the tumour and patient characteristics. RAPN is feasible via two approaches. The retroperitoneal approach seems to be associated with a shorter operation time and hospital stay.

Pre-gerotal fat patch-A novel alternative to haemostatic agents during partial nephrectomy.

This study aimed to determine if using a pre-gerotal fat patch at open partial nephrectomy (PN) as a haemostatic bolster is a viable alternative to using synthetic haemostatic agents. Human Research Ethics Committee approval was obtained for audit of a prospectively kept database from July 2012 to July 2021, which followed outcomes of patients who received a low-tension pre-gerotal fat patch renorrhaphy at open PN. Patient demographics, intraoperative measures, histological outcomes and post-operative complications were analysed. Using a retroperitoneal approach, the peritoneum was mobilised and a vascularised pedicle of pre-gerotal fat was rotated in the direction of the kidney. Routine definition of the hilum, clamping of the hilar vessels and dissection of mass followed. After watertight closure and haemostasis, the harvested pre-gerotal fat patch was placed over the defect and secured using low-tension renorrhaphy. Two-layer closure of the abdominal wall with placement of a drain was routine. A total of 55 patients underwent open PN. Mean age was 60.4 (35-77) years. There were 38 men and 17 women, and 32 right and 23 left PNs. Mean mass size was 31.9 mm (10-95 mm) and collecting system was breached in 36.5% of cases. One patient (1.9%) suffered a Clavien-Dindo IIIb complication requiring return to theatre and transfusion due to a bleed from an intercostal artery. There were no renal bed bleeds, urine leaks or urine fistulas detected. Mean intraoperative blood loss was 355 mL (50-1500 mL) and mean post-operative creatinine increased by 10.7 μmol/L (51-172 μmol/L). Mean follow up was 40.2 (4-109) months. Utilisation of an anatomical pre-gerotal fat patch to provide pressure at the renorrhaphy site during open PN is an effective technique to assist with surgical haemostasis. This simple technique avoids the costs of haemostatic agents, whilst adding minimal operating time to procedures.