Retroperitoneal Laparoscopic Surgery Research Articles

PD-06.12: Experience of retroperitoneal laparoscopic surgery with 1560 cases at a single institution

Retroperitoneal approaches are widely used as laparoscopic procedures in management of urological disorders. We developed an easy technique for establishing retroperitoneal cavity and performing dissection during the operation.

Importance of Perioperative Processes of Care for Length of Hospital Stay after Laparoscopic Surgery

The technologic imperative has prompted the adoption of complex laparoscopic techniques by physicians with various degrees of skill. We sought to measure the impact of both case mix and physician practice (perioperative process/risk factors) on length of stay (LOS)-a common benchmark- after laparoscopic surgery. We identified 911 patients undergoing laparoscopic retroperitoneal surgery between 1996 and 2004, who comprise our study population. Patients remaining in the hospital >5 days-the 90th percentile for the sample-were classified as having a prolonged LOS. Adjusted models were developed to determine the independent association of case mix and process measures with a prolonged LOS. The likelihood ratio test was used to discern the improvement of fit of the process model compared with the case-mix model. Among factors related to case mix and structure of care, increasing age (odds ratio [OR] 1.1; 95% CI 1.0, 1.2), less surgeon experience (OR 6.1; 95% CI 2.1, 17.2), male gender (OR 2.1; 95% CI 1.2, 4.0), and American Society of Anesthesiologists score of 3 or 4 (OR 7.2; 95% CI 2.2, 23.3) were independently associated with a prolonged LOS. The need for a transfusion (OR 9.4; 95% CI 33.9, 23.2), the development of a postoperative complication (OR 4.6; 95% CI 2.2, 9.5), and longer operative time (OR 1.5; 95% CI 1.3, 1.8) explained additional variation in prolonged LOS outcomes when considering perioperative process/risk factors in the model. Perioperative factors significantly improved the fit of the model (chi (2) statistic 101.8; p < 0.0001). Significant variation in outcomes is explained by factors describing aspects of surgical expertise. Variability in the surgical skill set is likely greatest during the laparoscopic learning curve, which raises a quality-of-care concern during the initial implementation of the technique. Policies attempting to smooth the laparoscopic learning curve, such as mentoring and skill measurement prior to credentialing, could improve the quality of care.

Retroperitoneal Laparoscopic Surgery: Single Surgeon Experience

ObjectivesLaparoscopy has become an alternative procedure for various retroperitoneal conditions. It is not easy to learn, and special caution should be taken during its practice because of the presence of large vessels in the surgical field. We report here our 22-mo initial experience with retroperitoneal laparoscopic surgery. Material and methodsThe analysed period covers June 2004 to April 2006 (i.e., 22 mo) during which time 128 laparoscopic retroperitoneal surgical procedures were performed. Seventy-eight laparoscopic nephrectomies (43 radical, 16 simple, 14 nephroureterectomies, and 5 in living donors) were performed during this time period. Other types of retroperitoneal laparoscopic surgery were carried out in 50 cases: 10 pyeloplasties, 10 adrenalectomies, 10 partial nephrectomies, 9 retroperitoneal biopsies, 6 stone removals, and 5 cyst marsupialisations. ResultsMean hospital stay was 3.5 d (range: 2–9) for the laparoscopic nephrectomies and 3.3 d (range: 1–7) for the other retroperitoneal laparoscopic surgeries.The conversion rate to open surgery was 1.5% (2 of 128). ConclusionsLearning about renal laparoscopic surgery should be gradual and guided by common sense. The approach to retroperitoneal pathology is technically complex and dangerous because of the presence of the great vessels. The learning curve is long and the potential complications are severe.

Characterization and Management of Postoperative Hemorrhage Following Upper Retroperitoneal Laparoscopic Surgery

Surgical paradigms may change in the era of laparoscopic surgery. We evaluated a conservative nonsurgical approach to postoperative hemorrhage following laparoscopic upper retroperitoneal surgery as opposed to the more traditional strategy of reexploring the surgical site. In 911 laparoscopic procedures performed in 8 years we retrospectively identified risk factors and characterized treatment for postoperative hemorrhage. We considered postoperative hemorrhage to be present when postoperative transfusion was required that could not be accounted for by operative blood loss or another definable cause outside of the surgical field. Red blood cell transfusion was required after 53 procedures (5.8%), of which 34 (3.7%) were done for postoperative hemorrhage. Postoperative hemorrhage occurred only after nephrectomy in 3.3% of cases, after partial nephrectomy in 9.9% and after adrenalectomy in 5.4%. Multivariate analysis revealed a significant association of postoperative hemorrhage with patient age and American Society of Anesthesiologists score (preoperative factors), operative time and splenic injury (intraoperative factors), and gastrointestinal complications and prolonged hospitalization (postoperative factors). Postoperative hemorrhage increased mean hospitalization from 2.5 to 6.4 days. No significant differences in post-hospital recovery were associated with postoperative hemorrhage. Only 4 of the 34 patients (12%) required surgical management of postoperative hemorrhage. All other cases were conservatively managed. Outcome after surgical and conservative management did not differ except postoperative renal complications tended to be more common in the former cases (50% vs 7%). Most patients with hemorrhage following laparoscopic upper retroperitoneal surgery can be treated with conservative nonsurgical interventions.

Retroperitoneoscopic pyeloplasty: Using reconstructive methods based on intraoperative findings

Reconstructive laparoscopic procedures have been recognized as a less invasive treatment than conventional open procedures. However, although the laparoscopic pyeloplasty has also been accepted as useful, few findings have been reported relevant to the retroperitoneal approach. To elucidate its effectiveness and safety, laparoscopic surgery via the retroperitoneal approach was examined in our institution. Furthermore, the importance of laparoscopic observation for ureteropelvic junction and urine passage ureteropelvic junction without indwelling ureteral stent. Between July 1998 and December 2004, 13 men and 15 women underwent laparoscopic retroperitoneal surgery for ureteropelvic junction obstruction. The mean patient age was 33.6 years (range: 13-70 years). Methods of repair were determined by intraoperative findings for the relationship between the ureteropelvic junction and surrounding vessels. An indwelling ureteral stent was removed before initiating laparoscopic operation to observe the relationship between ureteropelvic junction and aberrant vessels more precisely. An aberrant renal vessel was found in 13 patients (46%). Dismembered pyeloplasty was carried out in 21 patients, Y-V plasty in five patients and Hellstrom technique in two patients. Ureteral transposition was not required in dismembered pyeloplasty cases. All patients achieved retroperitoneoscopic pyeloplasty without open conversion. The mean operative time was 272 min (range: 155-490 min). The mean estimated blood loss was 44 mL (range: 10-200 mL). No major complications were observed during the intraoperative period, but urinary tract infection occurred in two patients in the postoperative period. In all patients except one, obstruction was improved or resolved. Laparoscopic retroperitoneal surgery is not only able to repair ureteropelvic junction obstruction, but can also be done safety and less invasively. We believe that laparoscopic observation without indwelling stent will contribute to a more appropriate choice of pyeloplasty.

Obturator neuropathy after laparoscopic retroperitoneal surgery

The frequency of obturator nerve damage due to pelvic disease or gynecologic procedures is uncertain but thought to be rare. Gynecologic patients undergoing open lymphadenectomy or extensive retroperitoneal surgery along the sidewall in the obturator fossa are at increased risk of injury. The incidence, etiology and outcome of obturator nerve injury were evaluated retrospectively in 329 women who underwent laparoscopic retroperitoneal surgery in the gynecologic endoscopic service of Endoscopic Training Centre, Baby Friendly Hospital, Kladno, Czech Republic, between March 2000 and December 2005. Four cases of obturator neuropathy were identified (Table 1). Laparoscopic uterine

Outcome Analysis of Retroperitoneal Laparoscopic Heminephrectomy in Children

Retroperitoneal laparoscopic heminephrectomy is a relatively new, well tolerated, minimally invasive alternative to open surgery for children with a nonfunctioning moiety in a duplex kidney. We collected data to assess outcomes in our experience with this procedure. Data were retrospectively gathered on all patients operated on for retroperitoneal laparoscopic heminephrectomy at our institution between February 2001 and November 2004. Followup ultrasound was performed in all patients, and additional imaging was done only when clinically indicated. Retroperitoneal laparoscopic heminephrectomy was performed in 18 girls and 4 boys (18 upper and 5 lower pole moieties). Indications included ureterocele (12 patients), ectopic ureter (9) and vesicoureteral reflux (5). Mean age at surgery was 5 years (range 4 months to 18 years). Four patients required conversion to an open procedure due to inadequate exposure and were excluded from further review. Urine leaks developed postoperatively in 3 patients and were treated with Foley catheter drainage and/or stent placement. Two patients were noted to have large (more than 5 cm) asymptomatic retroperitoneal fluid collections on followup ultrasound. Functional loss of the remaining ipsilateral moiety was confirmed by DMSA scan in 2 children (ages 6 and 7 months). Doppler studies confirmed normal hilar blood flow in both cases. Clinical presentation for this subgroup included fever on postoperative day 3 in 1 patient and hypertension at 32 months postoperatively in 1. Mean followup was 33 months (range 3 to 56). Although retroperitoneal laparoscopic renal ablative surgery in children appears to be relatively safe and is associated with low morbidity, serious complications may occur with subtle or even late presentation.

Fluoroscopy-Assisted Retroperitoneal Laparoscopic Renal Surgery in Children

To investigate the use of C-arm fluoroscopy for locating small dysplastic renal lesions during retroperitoneal laparoscopic nephrectomy in children. From March 2003 to March 2005, two boys and four girls with a mean age of 5 years underwent retroperitoneal laparoscopic nephrectomy under C-arm fluoroscopic guidance. The indications for laparoscopic renal surgery were ectopic ureter with dysplastic kidney (N = 3), hypertensive nephropathy (N = 1), and dysplastic kidney secondary to reflux nephropathy (N = 2). All operations were completed with no necessity for conversion to open surgery. Small dysplastic kidneys were easily located using C-arm fluoroscopy, and retroperitoneal laparoscopic nephrectomy was then performed. One patient required open contralateral reimplantation after laparoscopic nephrectomy because of high-grade vesicoureteral reflux. The mean operative time was 139 minutes (range 71-210 minutes). Blood loss was minimal, and no transfusion was required. There were no intraoperative or postoperative complications other than a peritoneal injury in one patient, which caused no subsequent major problem. The mean postoperative hospital stay was 3.8 days, and all children returned to normal activity within 3 to 6 days. This is the first report to our knowledge of retroperitoneal laparoscopic renal surgery under C-arm fluoroscopic guidance. This approach allowed quick and easy location of small ectopic kidneys prior to retroperitoneal laparoscopic nephrectomy and was found to be very useful for the treatment of small dysplastic renal lesions in children.

Hemodynamic and Respiratory Effects of Pediatric Urological Retroperitoneal Laparoscopic Surgery: A Prospective Study

Our understanding of the effects of retroperitoneal CO(2) insufflation on cardiopulmonary variables in children remains limited. This study was designed to investigate prospectively the effect of CO(2) insufflation in a pediatric population undergoing retroperitoneal laparoscopic surgery. We prospectively evaluated a consecutive series of patients enrolled between July 2003 and August 2004. Anesthesia was administered following a standardized protocol. Data collection included respiratory rate, PAP, O(2) saturation, ETCO(2), HR, MAP, electrocardiogram and insufflation pressure. All variables were recorded before, during and after CO(2) insufflation at regular intervals of 1 to 2 minutes, with up to 23 measurements recorded for each period. A total of 18 participants were recruited. Mean +/- SD for age and weight were 79.4 +/- 53.2 months and 26.7 +/- 15.5 kg, respectively. Mean retroperitoneal CO(2) insufflation pressure was kept at 12 mm Hg. Significant differences (p <0.05) in average ETCO(2), PAP and MAP were noted after CO(2) insufflation compared to baseline (pre-pneumoretroperitoneum) values. HR and temperature did not change. At completion of the laparoscopic intervention physiological variables exhibited a trend to return to baseline values. This prospective study documents significant changes in systemic hemodynamic variables that seem to be directly associated with the insufflation of CO(2) during pediatric retroperitoneal laparoscopic surgery. This ongoing evaluation confirms the effect of laparoscopic urological surgery and CO(2) insufflation on cardiopulmonary function in children.

Complications of Retroperitoneal Laparoscopic Surgery

Purpose: Laparoscopic surgery is known to be safe and have low morbidity. Herein, all the complications of retroperitoneal laparoscopic procedures were evaluated. Materials and Methods: A total of 120 retroperitoneal laparoscopic surgeries were performed between January 2002 and December 2005. Every abnormal event was investigated retrospectively, and classified in detail according to the surgical steps and severity. Results: The complication ratio (total complications/total surgeries) was 0.38 (46/120). Open conversion was performed in 5 (4.2%). A transfusion was performed in 8 (6.7%) patients. 5 patients (4.2%) had neuromuscular problem related to position and 9 (7.5%) had access and insufflation related complications, including subcutaneous emphysema, abdominal wall hemorrhage, pneumothorax and pneumomediastinum. The intraoperative complications (5.8%) included peritoneal tearing, vascular injury and diaphragmatic injury. Postoperative complications occurred in 25 patients (20.8%), including pleural effusion, atelectasis/pulmonary infiltrate, wound dehiscence, paralytic ileus, retroperitoneal hematoma and urine leakage. 5 complications (4.2%) were classified as being major; main vascular injury (1.7%), urine leakage (1.7%) and diaphragmatic injury (0.8%). No serious complications, such as death, bowel injury, deep vein thrombosis, with pulmonary embolism, or gas embolism occurred. Other complications (41/46) were minor and managed conservatively, without any problem. Conclusions: The most common complications of retroperitoneal laparoscopic surgery seem to occur during the postoperative period, and are nonspecific to retroperitoneoscopy. Most complications are subclinical problems, which can be managed by conservative treatment. Retroperitoneal laparoscopic surgery is a safe procedure, with a low potential for complications. (Korean J Urol 2006;47:1294-1301) ꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏ

Suprarrenalectomía abierta y laparoscópica. Revisión de 10 años

AbstractWe present a 10 years open adrenalectomy review in our Service and the beginning of laparoscopic adrenalectomy in the last year as a part of the retroperitoneal laparoscopic program at the Hospital Universitario La Paz. The first laparoscopic adrenalectomy was done after 21 retroperitoneal laparoscopic surgeries. Our initial experience has been so good that we have reduced the contraindications for this technique and we have increased the number of laparoscopic surgery cases.

LONG‐TERM OUTCOME OF LAPAROSCOPIC SURGERY FOR COLORECTAL CANCERS

There are three types of laparoscopic surgery for colorectal disease, medial‐to‐lateral, lateral‐to‐medial and the retroperitoneal laparoscopic approach. The purpose of the present study is to evaluate the long‐term results of laparoscopic colectomy for colorectal cancer by the transabdominal and retroperitoneal laparoscopic approaches, to provide current status of clinical outcomes of laparoscopic surgery including acceptable ranges of complications, morbidity and survival rate. Many transabdominal operations have been reported the clinical outcomes either one surgical team or multiple center series in recent decades. However, only one journal reported retroperitoneal laparoscopic surgery, including data of 309 patients at Sakura National Hospital from June 1994 to March 2003. Ten cases (3.2%) were converted to open colectomy and nine of these were in the first 100 cases (1.9%) compared with only one within the other 209 patients (0.47%), this being within a reasonable range 0%−3.2%. There were no port site recurrences. Eight patients had lung and/or liver metastases and died of disease. The average survival time was 28.4 months. The 5‐year survival rates were 100%, 89.7%, 85.5% and 72.9% for stages I, II, IIIa and IIIb, respectively. In a literature review of journals for laparoscopic surgery for colorectal cancers, the conversion rate is variable from 0 to 17%, and the local recurrence rate is generally usually below 6.8%. The 5‐year survival rates are approximately 97‐89%, 88‐78% and 67‐59% for stages I, II and III, respectively.

Retroperitoneal laparoscopic nephron-sparing surgery for renal tumors: Report of 32 cases

Objectives To evaluate the feasibility and clinical efficacy of retroperitoneal laparoscopic nephron-sparing surgery for renal tumors. Methods Between June 2002 and February 2004, 11 cases of renal benign tumor and 21 cases of renal malignant tumor underwent enucleation of the tumor and wedge resection of the tumor through retroperitoneal laparoscopy, respectively. Tumor resection and hemostasis were mainly achieved by harmonic scalpel. Follow-up studies were performed with an evaluation using renal spiral computed tomography. Results All procedures were technically successful. The mean operating time was 70 minutes for enucleation and 96 minutes for wedge resection. The mean estimated blood loss was 35 mL for enucleation and 65.5 mL for wedge resection. The mean hospital stay after surgery was 6.5 days. No intraoperative complications occurred. The pathologic examination confirmed renal cell carcinoma in 21 patients and angiomyolipoma in 11. The pathologic stage was pT1a in the 21 patients with renal cell carcinoma. All resected tumor specimens had negative surgical margins for cancer. No local recurrence or trocar site metastasis was observed during a mean follow-up period of 13 months. Conclusions Our results indicate that retroperitoneal laparoscopic nephron-sparing surgery represents a feasible option for patients with localized renal tumors. This procedure could offer precise and complete tumor excision while minimizing morbidity, improving cosmesis, and shortening convalescence.

Cirugía retroperitoneal laparoscópica; experiencia de los 6 primeros meses del Hospital la Paz

We present the initial results of retroperitoneal laparoscopic surgery in the Hospital Universitario La Paz from july 2004 to december 2004. The program started after 2 years of pelvic laparoscopy surgery practice. The initial experience has been so good that we have reduced the contraindications for this technique and we have increased the number of laparoscopic surgery cases

Intraoperative pneumothrax during retroperitoneal laparoscopic surgery

Intraoperative pneumothrax during retroperitoneal laparoscopic surgery

Laparoscopic Nephron-Sparing Surgery: Preoperative Assessment with Three-Dimensional Computed Tomography

Objective: For retroperitoneal laparoscopic nephron-sparing surgery using a microwave tissue coagulator, it is helpful to know the relationship between the tumour, collecting system and vessels to prevent urinary leakage and vascular damage. We assessed the efficacy of multiplanar reformation and three-dimensional (3D) CT with the renal collecting system filled with contrast medium. Methods: Fifteen patients with small renal tumours of less than 3 cm in diameter underwent dynamic CT examination ten minutes after injection of contrast medium of 30 ml. Multiplanar reformation, volume-rendered and maximum intensity projection images were created for determining operative approaches and for planning the operation. Results: In all cases, the distance between the tumour and collecting system was measured on the multiplanar reformation. Accordingly, five cases were indicated for retroperitoneal laparoscopic nephron-sparing surgery using a microwave tissue coagulator. The remaining ten cases, due to the short distance (less than 10 mm), were not considered good candidates for this procedure. The relationship between the tumour, collecting system and vessels was well shown on the volume-rendered and maximum intensity projection images. Conclusions: Multiplanar reformation and 3D-CT are able to give us an understanding of the surrounding structures. They are helpful in defining the indications for retroperitoneal laparoscopic nephron-sparing surgery using a microwave tissue coagulator and preoperative planning of nephron-sparing surgery.

Justification of extraperitoneal laparoscopic access for surgery of the upper urinary tract.

Laparoscopic surgery was originally developed by gynecologists and general surgeons. Based on their experience, the first successful laparoscopic procedures in urology were performed transperitoneally. However, this novel technique transformed traditionally retroperitoneal procedures into transperitoneal procedures, giving free rein to distinct intraperitoneal complications. Retroperitoneal laparoscopy was a later development in urology. This approach has gained increasing popularity throughout the years and has challenged the transperitoneal laparoscopic route in many aspects. This review focuses on the advantages of retroperitoneal laparoscopic surgery of the upper urinary tract.

Mentored retroperitoneal laparoscopic renal surgery in children: a safe approach to learning.

To review the feasibility of introducing advanced retroperitoneal renal laparoscopic surgery (RRLS) to a paediatric urology division, using the mentorship-training model. Although the scope of practice in paediatric urology is currently adapting endoscopic surgery into daily practice, most paediatric urologists in North America have had no formal training in laparoscopic surgery. The study included four paediatric urologists with 3-25 years of practice; none had had any formal laparoscopic training or ever undertaken advanced RRLS. An experienced laparoscopic surgeon (the mentor) assisted the learning surgeons over a year. The initial phases of learning incorporated detailed lectures, visualization through videotapes and 'hands-on' demonstration by the expert in the technique of the standardized steps for each type of surgery. Over 10 months, ablative and reconstructive RRLS was undertaken jointly by the surgeons and the mentor. After this training the surgeons operated independently. To prevent lengthy operations, conversion to open surgery was planned if there was no significant progression after 2 h of laparoscopic surgery. Over the 10 months of mentorship, 36 RRLS procedures were undertaken in 31 patients (28 ablative and eight reconstructive). In all cases the mentored surgeons accomplished both retroperitoneal access and the creation of a working space within the cavity. The group was able to initiate ablative RRLS but the mentor undertook all the reconstructive procedures. After the mentorship period, over 10 months, 12 ablative procedures were undertaken independently, and five other attempts at RRLS failed. Although the mentored approach can successfully and safely initiate advanced RRLS in a paediatric urology division, assessing the laparoscopic practice pattern after mentorship in the same group of trainees is warranted. Ablative RRLS is easier to learn for the experienced surgeon, but reconstructive procedures, e.g. pyeloplasty, require a high degree of skill in laparoscopic technique, which may only be acquired through formal training focusing primarily on suturing techniques.

Vascular and Bowel Complications During Retroperitoneal Laparoscopic Surgery

Vascular and Bowel Complications During Retroperitoneal Laparoscopic Surgery

Vascular and Bowel Complications During Retroperitoneal Laparoscopic Surgery

We report on vascular and bowel complications during major retroperitoneal laparoscopic renal and adrenal surgery. A total of 404 patients underwent retroperitoneoscopy for various renal and adrenal pathology between July 1997 and February 2001. The occurrence of intraoperative vascular and bowel injuries, specific intraoperative circumstances, management techniques and outcomes were evaluated. There were 7 vascular injuries (1.7%) and 1 bowel injury (0.25%), which involved the right adrenal vein (2), left renal vein (2), right renal vein (1), right renal artery (1), inferior vena cava (1) and a superficial, small serosal injury to the duodenum (1). Of these 8 cases 5 (63%) had been treated prior with major open intra-abdominal surgery. Average blood loss for patients with vascular injuries was 1,186 cc (range 300 to 3,000). Of the 8 cases 1 was converted to open surgery and in another 2 cases the vascular injury was controlled through the extraction incision, which had already been created. Retroperitoneoscopic control and repair without open conversion were possible in each of the most recent 5 cases. Of the 404 cases open conversion has not been necessary for control of vascular or bowel complications in the most recent 200 cases, demonstrating the impact of the learning curve. During major renal and adrenal retroperitoneoscopic surgery our incidence of vascular and bowel injuries was 1.7% and 0.25%, respectively. With experience inadvertent vascular and bowel injuries can be efficaciously controlled retroperitoneoscopically despite the somewhat small operative field available.