Transperitoneal Route Research Articles

Percutaneous cholecystostomy in acute cholecystitis – Narrative review article

Percutaneous cholecystostomy is often performed to treat high-risk patients with acute cholecystitis who are not suitable for cholecystectomy. It is performed by the interventional radiologist and can be performed through the transhepatic or transperitoneal route (direct gallbladder puncture, without passing through the liver). Percutaneous cholecystostomy is used as a bridging procedure to stabilize high-risk patients with acute cholecystitis. We prepared this narrative review article to describe the indications for performing this procedure and the consequences of its performance and to compare it with emergency cholecystectomy.

Image-guided percutaneous cholecystostomy: challenging the norms.

Image-guided percutaneous cholecystostomy (IGPC) is a widely recognized and regularly employed procedure in numerous institutions, serving as an indispensable cornerstone in the management of patients with acute cholecystitis. The most up-to-date literature has found that the transperitoneal route is at least as safe as the transhepatic route and that both the trocar and Seldinger techniques are equally safe and effective. The above novel insights may offer reassurance and alleviate concerns among operators performing IGPC by dispelling the fixation on previously established beliefs and thus providing flexibility, which lightens the load on the operator. Future studies could further investigate these findings and shed light on potential disparities in the safety and efficacy profiles associated with the subcostal and intercostal approaches, different drainage catheter sizes, and/or the impact of operator experience on complication rates.

Robot-assisted partial nephrectomy using the novel Hugo™ RAS system: Feasibility, setting and perioperative outcomes of the first off-clamp series.

Hugo Robot-Assisted Surgery (RAS) System has been conceived with enhanced modularity but its role for nephron-sparing surgery setting still remains poorly explored. We aimed to describe our experience in robot-assisted partial nephrectomy (RAPN) with a three-arms setting for the first off-clamp series using the new Hugo RAS System. Patients were placed on an extended flank position at the margin of the surgical bed with a slightly flexion (45°). The first 11 mm robotic trocar (camera port) was placed along the pararectal line 14 ± 2 cm far from the umbilicus. The pneumoperitoneum was then induced through the AirSeal system (SurgiQuest, Milford, Connecticut, USA©). Two more 8 mm operative robotic ports were placed under direct vision, either 8 ± 1 cm far from optic's port. Two 12 mm laparoscopic ports for bed-assistant were placed between robotic ports. Monopolar curved shears, fenestrated grasper, and large needle driver were used in a three-instruments configuration. Off-clamp RAPN was successfully performed in seven patients with cT1 renal masses using a trans-peritoneal route. Median port placement and docking time was 6 min (IQR, 4-8 min). Hemostasis was achieved through renorraphy using a single transfix stitch with sliding clips technique. There was no need for additional ports placement. No intraoperative complications occurred, no clashing of robotic instruments or between the robotic arms was observed. No technical failures of the system occurred. Median console time was 83 min (IQR, 68-115 min). Median estimated blood loss were 200 ml (IQR, 50-400 ml). All patients were discharged between post-operative day 2 and 3, without the need of hospital readmission. No complications were recorded within the first 30 post-operative days. We performed the first series of off-clamp RAPN using the novel HUGO RAS System. This novel robotic platform showed an easy-friendly docking system, providing excellent perioperative outcomes with a simple three-arms configuration.

Retroperitoneoscopic Ureterolithotomy for the Management of Proximal Ureteric Stones: Initial Clinical Experience

Objective: Laparoscopic ureterolithotomy provides results equivalent to open ureterolithotomy for proximal ureteric stones, can be performed transperitoneally and retroperitoneally. The study aims to assess the efficacy of retroperitoneoscopic ureterolithotomy for managing proximal ureteral stones. Patients and Methods: It was a retrospective study carried out in the period from March 2018 to November 2021. 14 patients with proximal ureteric stones 16–26 mm (20.07± 02.8), all located above the upper border of the sacroiliac joint. Eleven (78.57%) patients underwent retroperitoneoscopy as a primary procedure, one (07.14%) had a history of failed ESWL, and two patients (14.28%) failed retrograde ureteroscopy. Retroperitoneoscopic ureterolithotomy was performed by lumbar approach with initial access conducted by open technique and creation of space by digital and homemade balloon dissection and secured 10 mm Hasson trocar at the primary port site, and 0° telescope advanced. Two 5-mm trocars were placed under visualization forming a triangle. The stone was removed from the primary port site while visualizing retrieval through the 5 mm. port using a fine 30° Cystoscope. Ureterotomy closure was performed by intracorporeal interrupted sutures of 4-0 polyglactin over 5 fr double-J stent, and a drain was left in the retroperitoneum. Results: Retroperitoneoscopic ureterolithotomy was accomplished in 11 out of 14 cases (78.58%). Three (21.42%) were converted to open surgery (2) and transperitoneal ureterolithotomy (1). The reason for open conversion was the failure to locate the ureter due to severe adhesion in 1 case, technical problems during dissection in 1 case, and another access problem, injury to the peritoneum, which was converted to the transperitoneal route. In 11 successful cases, the mean operative time was 126.5 ± 23.81 (90-170) min. There was no requirement for transfusions. There were no major perioperative and post-operative complications were observed. According to the modified Clavien classification, 07(63.63%) patients were reported to be grade I, whereas 04(36.36%) patients were reported to be grade II. One patient was managed with a course of antibiotics due to post-operative fever. Two patients who developed subcutaneous emphysema and superficial wound infection were treated conservatively. One urinary leakage was subsided by urethral re-catheterization. The drain was removed at 03.81 ±01.25(03-07) days. The mean hospital stay was 04.09 ± 01.13 (03-07) days. Conclusion: Retroperitoneoscopic ureterolithotomy has acceptable overall complication rates. It is an effective, low-morbidity alternative for the treatment of proximal ureter stones. Bangladesh J. Urol. 2022; 25(2): 84-92

End Sigmoid Colostomy Reconstruction Using Purse-string Subcutaneous Suture via Extraperitoneal Route at the Site of a Previous Transperitoneal Loop Stoma.

We previously experienced two cases of end sigmoid colostomy reconstruction via the extraperitoneal route at the same site as the transperitoneal loop stoma. For an anterior rectus fascia, the transperitoneal route used closed intraperitoneal interrupted sutures and continuous sutures with barbed sutures. A new extraperitoneal route was established through the sutured anterior rectus sheath. Before reconstructing the end stoma, a subcutaneous purse-string with monofilament absorbable sutures tied to create an approximately 2.5 cm diameter was used. There were no early complications associated with the stoma. One year after surgery, a parastomal hernia was not defined. Using the presented technique, two cases were successfully recreated extraperitoneally at the same site's end stoma.

Hugo RAS Robot-Assisted Partial Nephrectomy for High-Nephrometry Score Complex Renal Mass: Case Report and Surgical Technique

Hugo™ robot-assisted surgery (RAS) system has been conceived with enhanced modularity cart features and an independent arm-cart docking, nonetheless its role for nephron-sparing surgery has not been defined yet. From October 2022, 15, consecutive patients underwent off-clamp robot-assisted partial nephrectomy (RAPN) for T1 tumors. We are a solely off-clamp partial nephrectomy (PN) center, consequently the T2 RAPN was carried out clampless. Furthermore, we acquired experience and familiarity with Hugo RAS, thanks to an initial series of 15 robotic radical prostatectomies. We report the first RAPN with the new Hugo RAS system for a large highly complex right posterior hilar renal mass (8 cm, cT2) in a 63-year-old man with a BMI of 35.3 kg/m2. The choice to perform RAPN for high-nephrometry score renal mass without hilar clamping was because of the technique we usually perform at our center as we have never done on-clamp procedures. The purpose was to assess the feasibility and the modularity of Hugo RAS independent arm-cart docking even in complex posterior hilar renal tumor, and to explore its role in the setting of off-clamp RAPN. Preoperative hemoglobin, serum creatinine, and estimated glomerular filtration rate were 15.5 g/dL, 0.92 mg/dL, and 115.1 mL/min per 1.73 m2, respectively. The patient was placed on an extended flank position. A modified three-arm configuration was used by a conventional transperitoneal route. Port placement and docking time required 5 minutes. Complete kidney mobilization, identification of arterial branches feeding the tumor, and straightforward approach to the renal mass represented standard key steps of our off-clamp RAPN technique. Tumor enucleation was achieved developing an anatomical cleavage plane. Intraoperative bleeding was controlled with double suction, a slight increase of the pneumoperitoneum to 20 mm Hg, monopolar energy, and renorraphy with a 2/0 Monocryl single-running suture using a sliding-clip technique. No intraoperative complications occurred. No additional port placement was necessary. Console time was 110 minutes, estimated blood loss were ~500 mL. Patient was discharged on postoperative day 3 after bladder catheter and abdominal drain removal, with hemoglobin, serum creatinine, and eGFR of 11.8 g/dL (∆Hb 3.7 g/dL), 0.94 mg/dL, and 112.6 mL/min per 1.73 m2, respectively. Histologic evaluation revealed a chromophobe renal cell carcinoma. Considering the intra- and perioperative outcomes, the lack of complications, and the fast docking, this robotic platform seems to be an user-friendly technology. Currently, the small series considered as the granularity of data regarding the application of Hugo RAS in the RAPN setting hinder to assess that this novel platform is comparable with conventional robotic systems. Further studies with a larger cohort are needed to establish the noninferiority of this platform, but preliminary results seem encouraging. The authors declare no conflict of interest and any commercial associations during the past 3 years. No funding was received for this article. Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. Institutional Review Board Statement: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Source of Work: This study was carried out at Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy. Runtime of video: 4 mins 45 secs

STUDY OF POSTOPERATIVE ANALGESIA AFTER CAESAREAN SECTION WITH SURGICAL TRANSVERSUS ABDOMINUS PLANE BLOCK

Background: Transversus abdominis plane block has become an established modality of providing postoperative analgesia with added benets of improved analgesia and decreased opioid consumption. One of the possible alternatives in postoperative pain treatment after abdominal surgery is the landmark-approach transversus abdominis plane block (TAP block). A hundred patients w Method: ho fullled inclusion criteria are included in study after obtaining informed written consent. Surgical TSP block is administered by transperitoneal route before closure of peritoneum with 0.25% bupivacain (dose adjusted according to weight of patient). No postoperative analgesia given for both groups. Postoperative pain is assessed by blind observer and visual analogue score (VAS) observed every hour till 24 hour of post-operative period. Rescue analgesia time monitored if analgesia given. We observed that in case group majority of the patients belongs Results: to 25-29 years age group (24; 48%) whereas in control group majority of the patients belonged to 19-24 years age group (23;46%). The mean gestational age in case group was 38.33±1.15 weeks while in control group it was 38.26±1.32 weeks. We observed no signicant difference in the gestational age of both the groups. We observed that postoperative VAS score signicantly less in the case group than control group. We found that case group require signicantly less rescue analgesia as compared to control group. We found no signicant difference in the ambulation time of both the group

Long term experience of robotic retroperitoneal partial nephrectomy as the default approach in the management of renal masses: should the paradigm shift?

Although retroperitoneal surgery has demonstrated a better quality of recovery compared to transperitoneal routes, Retroperitoneal Robot Assisted Partial Nephrectomy (RRAPN) remains proportionally infrequent. As the boundaries of what is achievable robotically continue to be pushed, we present our experience at a high-volume tertiary referral centre that specialises in retroperitoneal surgery, exploring its feasibility as standard of care in the management of small renal masses. A prospective database of 784 RAPNs (2009-2020) was reviewed and 721 RRAPNs (92%) were performed at our centre. In our practice, we utilise a four-port approach to RRAPN. Patient, tumour and operative characteristics were assessed and both oncological outcomes and trifecta and pentafecta achievements were determined. Pentafecta was defined as achieving trifecta (negative surgical margin, no post-operative complications and WIT of < 25min) plus over 90% estimated GFR preservation and no CKD stage upgrading at 1year. Multivariate analysis was conducted to predict peri-operative factors which may prevent achieving a trifecta/pentafecta outcome. From 784 cases, 112 RAPNs were performed for imperative reasons, whilst the remainder were elective. Mean BMI ± s.d amongst our cohort was 28.6 ± 5.7. Mean tumour size was 3.1cm (range 0.8-10.5cm) and 47% of cases were stratified as intermediate/high risk using R.E.N.A.L nephrometry scoring. Forty-six patients had lesions in a hilar location, and 31% were anterior. Median blood loss was 30mls, with an open conversion rate of 1% and transfusion rate of 1.6%. Median warm ischaemic time (WIT) was 21min, positive surgical margins were found in 4% and our post-operative Clavien 3/ > complication rate was 2.6%. We had a 1-day median length of stay with a 30day readmission rate of 2%. Of 631 patients (80%) with a definitive histological diagnosis of cancer, 23% had T1b/ > disease. Over a mean 15month follow-up period (range 1-125months), 2% of patients developed recurrences and our cohort demonstrated a 99% 5year cancer specific survival. Trifecta was achieved in 67% of cases and pentafecta in 47%. Age (p = 0.05), operative time (p = 0.008), pT1b tumours (p = 0.03), R.E.N.A.L score and blood loss (p = 0.001) were found to statistically significantly influence achievement of trifecta. Pentafecta achievement was influenced by R.E.N.A.L score (p = 0.008), operative time (p = 0.001) and blood loss (p = 0.001). We demonstrate the retroperitoneal approach in RAPN is feasible and safe irrespective of lesion location and complexity. In the hands of high-volume centres that are skilled in the retroperitoneal approach the benefits of retroperitoneal surgery can be extended even to challenging cohorts of patients without compromising their oncological or functional outcomes.

Robot-assisted simple prostatectomy for prostates greater than 100 g

Efforts are ongoing to treat severe benign prostatic hyperplasia as traditional endoscopic treatment options are often difficult to perform and associated with significant complications. This manuscript highlights our initial experience of robot-assisted simple prostatectomy [RASP] with minimum a year follow-up. We also compared our outcomes with published literature. After an Institution Review Board approval, we gathered data of 50 cases of RASP between Jan 2014 and May 2021. Patients with prostate volume > 100cc [calculated from magnetic resonance imaging (MRI)] and prostate biopsy confirmed benign prostate were candidates for RASP. Patients underwent RASP via transperitoneal route either by suprapubic or trans-vesical approach. Preoperative demographics, peri-operative parameters and post-operative parameters such as hospital stay, catheter removal, urinary continence and uroflow were recorded in standard database and presented as descriptive statistics. Patients presented with a baseline median International Prostate Symptom Score (IPSS) of 23 (inter-quartile range (IQR) 21,25) and a median PSA of 7.7ng/ml (IQR 6.4,8.7). Median preoperative prostate volume was 167ml (IQR, 136,198ml). Median console time was 118min, and median estimated blood loss was 148ml (IQR 130, 167ml). None of our cohort needed intraoperative transfusion, conversion to open surgery or developed any complications. Median time to Foley removal was 10days (IQR 8,12). Significant drop in the IPSS score and improvement in Qmax was noted over the period of follow-up. RASP is associated with considerable improvements in urinary symptoms. However, comparative studies with endoscopic treatment options of large prostatic adenomas are warranted and ideally include cost analysis of different procedures.

Urological laparoscopic procedures and results performed by a single urologist in a secondary state hospital

Amaç: İkinci basamak devlet hastanesinde tek ürolog tarafından gerçekleştirilen ürolojik laparoskopik operasyonların sonuçlarını irdelemek.Gereç ve Yöntem: Ocak 2018 – Ocak 2021 yılları arasında Şanlıurfa Eğitim ve Araştırma Hastanesi’nde ürolojik laparoskopik cerrahi geçiren 30 hastanın verileri retrospektif olarak incelendi. Operasyon tipi, ameliyat süreleri, taraf, dren süreleri, hastanede kalış süreleri ve komplikasyonları not edildi. Bulgular: Tüm hastalara transperitoneal yolla laparoskopi yapıldı. On beş hastaya laparoskopik nefrektomi, 4 hastaya dismembred piyeloplasti, 8 hastaya üreterolitotomi, 3 hastaya ise kist eksizyonu uygulandı. Ortalama hasta yaşı 40,43 + 16,72 (14-76) saptandı. Erkek/kadın oranı 13/17 olmak üzere %43,3 erkek ve %56,7 kadın saptandı. Operasyon sürelerine bakıldığında nefrektomi 173,26 (120-240) dk. piyeloplasti 240 ± (210-270) dk. üreterolitotomi 110,75 (75-180) dk. kist eksizyonu 112,66 (100-138) dk. saptandı. Tüm hastaların drenaj miktarları eser miktarda (&amp;lt;50ml) idi. Dren çekilme süresi nefrektomi 2,26 (1-4) gün, piyeloplasti 3,5 (2-4) gün, üreterolitotomi 2,62 (2-4) gün, kist eksizyonu 1 (1) gün saptandı. Hastanede kalış süresi nefrektomi 3,46 (2-7) gün, piyeloplasti 4.5 (3-5) gün, üreterolitotomi 3.5 (2-7) gün, kist eksizyou 1,67 (1-2) gün saptandı. Toplam 30 vakanın 3’ünde (%10) açık prosedüre geçildi. Sadece internal iliak ven yaralanması olan bir hastaya 2 ünite kan transfüzyonu yapıldı. Komplikasyonlar Clavien-Dindo sınıflamasına göre değerlendirildiğinde internal iliak ven yaralanması sonrası açık onarım yapılan hasta Clavien-Dindo grade 3b, post-operatif atelektazi gelişen 3 hasta ise Clavien-Dindo grade 1 olarak kaydedildi. Sonuç: Laparoskopik operasyonlar ülkemizde üniversite hastaneleri ve eğitim klinikleri başta olmak üzere birçok merkezde açık operasyonların yerini almaktadır. Cerrahın yeteneğine ve tecrübesine göre değişkenlik göstermekle birlikte laparoskopik operasyonlar uzun öğrenme eğrisi gerektirmektedir. Günümüzde laparoskopik vakaların artışına sekonder asistanların deneyimlerinde de artış söz konusu olmaktadır. Laparoskopik operasyonlar; laparoskopi eğitimi almış ve deneyimleme fırsatı olmuş ürologlar tarafından uygun hasta seçimi ve doğru planlama ile ikinci basamak hastanelerde güvenle yapılabilir.

Laparoscopic extraperitoneal colostomy has a lower risk of parastomal hernia and bowel obstruction than transperitoneal colostomy.

Several studies indicate that an extraperitoneal colostomy can prevent the development of a parastomal hernia (PSH) as compared to a transperitoneal colostomy. However, the clinical value of laparoscopic extraperitoneal colostomy, and its influence on bowel obstruction and PSH remain unclear. The present study aimed to clarify the impact of laparoscopic extraperitoneal colostomy on the development of a PSH and bowel obstruction. This study included 327 consecutive patients who underwent laparoscopic abdominoperineal resection or Hartmann's procedure between January 2013 and December 2019 after fulfilling selection criteria. The incidence of a PSH (Clavien-Dindo classification ≥ grade I) and bowel obstruction (≥ grade IIIa) in the transperitoneal and extraperitoneal route groups were analyzed using univariate and multivariate analysis. The patients were classified into transperitoneal (n = 222) and extraperitoneal (n = 105) route groups. The patient characteristics, except for body mass index and operative time, were comparable between the groups. A PSH and bowel obstruction occurred more frequently in the transperitoneal than in the extraperitoneal route group (17.1% vs. 1.9% and 15.3% vs. 6.7%, respectively; p < 0.01 and p = 0.03, respectively). The multivariate analysis showed that age ≥ 70years, body mass index ≥ 22.4kg/m2, and a transperitoneal route were independent risk factors for the development of a PSH, and a transperitoneal route was an independent risk factor for bowel obstruction. The transperitoneal route was identified as a risk factor for the development of both a PSH and bowel obstruction after laparoscopic abdominoperineal resection or Hartmann's procedure.

Retroperitoneal versus transperitoneal percutaneous catheter drainage of necrotic pancreatic collections: a comparative analysis.

To compare the success rate, clinical outcomes, and complications of retroperitoneal (RP) versus transperitoneal (TP) percutaneous catheter drainage(PCD) of the necrotic pancreatic fluid collections. This retrospective study comprised consecutive patients with acute pancreatitis who underwent PCD of lesser sac collections amenable to drainage via both TP and RP routes. The patients were divided into two groups based on the route of drainage (group I, RP, and group II, TP). The technical success, clinical success, complications, and clinical outcomes were compared between the groups. Subgroup analysis was performed based on the timing of drainage (acute necrotic collections, ANC vs. walled-off necrosis, WON) and organ failure (OF). Seventy-nine patients [mean age, 38.7 ± 12.3years, 54 males] were included in the study. Group I and II comprised 22 (27.8%) and 57 (72.2%) patients, respectively. The procedures were technically successful in all the patients. There was no significant difference in the complication rate between the two groups. The clinical success was higher in group II (75.4%) as compared to group I (54.5%). However, the difference was not statistically significant (p = 0.070). There was no significant difference in the hospital stay (p = 0.298), intensive care unit stay (p = 0.401), need for surgical necrosectomy (p = 0.243), and mortality (p = 0.112) between the two groups. The outcomes in patients with OF and ANC were not affected by the route of PCD. Clinical success rate was significantly higher in WON undergoing TP drainage (p = 0.009). Both RP and TP routes of PCD are safe and effective. Clinical success rate was significantly higher in WON undergoing TP drainage.

Comparison of the extraperitoneal and transperitoneal routes for permanent colostomy: a meta-analysis with RCTs and systematic review

AimTo assess the efficacy of extraperitoneal colostomy (EPC) in preventing stoma-related complications.BackgroundTransperitoneal colostomy (TPC) is a widely used surgical approach. However, TPCs have been reported to have increased risks of stoma-related complications, such as parastomal hernias, stomal retraction, and stomal prolapse. The purpose of EPC is to reduce these complications. However, there is still a lack of evidence-based studies.Materials and methodsMEDLINE, EMBASE, Web of Science, Scopus, MOOSE, PubMed, Google Scholar, Baidu Scholar, and the Cochrane Library were searched to conduct a systematic review and meta-analysis with RCTs. The meta-analysis was performed with RevMan 5.4 software.ResultsThis study included 5 eligible RCTs. Compared with the TPC group, the EPC group had lower incidence rates of parastomal hernias (RR, 0.14; 95% CI, 0.04–0.52, P = 0.003, I2 = 0%) and stomatal prolapse (RR, 0.27; 95% CI, 0.08–0.95, P = 0.04, I2 = 0%), but a higher rate of defecation sensation (RR, 3.51; 95% CI, 2.47–5.0, P < 0.00001, I2 = 37%). No statistically significant differences were observed in stoma retraction, colostomy construction time, stoma ischemia, or stoma necrosis.ConclusionExtraperitoneal colostomies are associated with lower rates of postoperative complications than transperitoneal colostomies. A randomized controlled trial meta-analysis found that permanent colostomies after abdominoperineal resection resulted in better outcomes.

A Prospective Evaluation of Laparoscopic Management of Renal Hydatidosis: Our Experience

Introduction: Hydatid cyst is a parasitic disease affecting various organs like liver, lungs, spleen or rarely kidneys, caused by the tapeworm Echinococcus granulosus. Its presentation may be atypical leading to diagnostic and management difficulties. A high index of suspicion for hydatid disease should be maintained while evaluating complex cystic renal masses. Accurate diagnosis of primary renal hydatid disease is difficult in spite of latest imaging modalities. With the technological advancements and increasing experience in laparoscopy, nowadays renal hydatid disease has been reported to be managed by transperitoneal and retroperitoneal laparoscopic approach. Objective/Aim: To present a prospective evaluation of renal hydatidosis managed laparoscopically. Material Methods: All 22 consecutive patients underwent laparoscopic management of renal hydatid disease from August 2019 to July 2021. Prior to surgery all patients were preoperatively evaluated with CT urography. All patients were operated with total laparoscopic transperitoneal route by standard three ports as for renal surgery. Patients demographic and perioperative data were recorded prospectively and analysed. Outcome measures were demographic data, perioperative data, complications and follow-up at 12 months. Results: The mean operative time was 190.3 minutes and average blood loss was 180.4 ml in our study. There were 4 cases converted to open method in our study. There were 7 cases managed with cyst excision, 3 cases managed with cyst deroofing and marsupilisation, 9 cases required pericystectomy and 3 cases required nephrectomy as there was no salvageable parenchyma in our study. Conclusion: Laparoscopic treatment of renal hydatid cyst is safe, feasible and effective due to its advantages to open surgery, if surgical expertise is available. It can minimize morbidity, as surgery is the treatment of choice.

Retroperitoneal Robot-Assisted Partial Nephrectomy (rRAPN): Surgical Technique and Review.

We aim to offer a description of the surgical technique and to review the current state retroperitoneal robot-assisted partial nephrectomy (rRAPN). Partial nephrectomy is the standard treatment for localized kidney tumours. rRAPN is especially useful for kidney tumours of posterior location. It offers advantages such as direct access to the renal artery and no need for bowel mobilization. The disadvantages are the small working space and the less familiar anatomical landmarks. It is a reproducible technique that achieves similar oncological and functional results to the more traditional transperitoneal route (tRAPN). High-quality randomized studies are needed to ascertain the role of new technologies as modern high-flow insufflation systems, intracavitary ultrasound, 3D planning, and augmented reality (AR), in the performance of this operation. rRAPN is especially useful for kidney tumours of posterior location. Robotic surgeons ideally should become familiar with both approaches, transperitoneal or retroperitoneal.

How safe and effective is stentless laparoscopic ureterolithotomy in elderly patients?

With the improvement of minimally invasive urology procedures, open surgical interventions are less common to treat ureteral calculus. Laparoscopic ureterolithotomy (LU) indications are large multiple and/or impacted ureteral calculus that may not be treated with shock-wave lithotripsy or ureterorenoscopy approaches. The aim of our study was to investigate the feasibility and safety of stentless LU in elderly patients. Between October 2011 and December 2019, 38 geriatric patients underwent stentless transperitoneal LU for upper/mid ureteral calculi. The transperitoneal route was applied in all patients by two surgeons. No double J stent inserted in any patient. The data of all patients reviewed retrospectively. The average age was 64.60±3.70years. The mean calculi size was 19.42±1.41mm. Ten patients had unsuccessful shock wave lithotripsy or ureterorenoscopy history. The calculi-free rate was 100%. Clavien grade 1 complications were seen in 11 (28.9%) cases. No major perioperative and postoperative complications were encountered. The average length of hospital stay was 3.24±1.53days. The significant advances in medical technology and healthcare, lead a rising number of geriatric patients to take benefit of even complicated surgery. Although laparoscopy and its safety in the geriatric population pursues a challenge and the assessment of this procedure is hence obligatory, we think that stentless LU is safe, economical and less uncomfortable for elderly patients.

Robotic gastric mobilization during Ivor Lewis esophagectomy (with video).

Compare the rates of major intra- and postoperative complications, surgical conversion and mortality between transperitoneal versus retroperitoneal laparoscopic adrenalectomy.In a series of 344 consecutive unilateral laparoscopic adrenalectomies, performed from January 1997 to December 2017, we evaluated the rates of major intra- and postoperative complications (Clavien-Dindo ≥ III) and surgical conversion of the two approaches.The retroperitoneal laparoscopic route was used in 259 patients (67.3%) and the transperitoneal laparoscopic route in 85 patients (22.1%). A total of 12 (3.5%) major postoperative complications occurred, with no statistically significant difference between the two approaches (P = 0.7). In univariate analysis, the only predictor of major postoperative complication was Cushing's syndrome (P = 0.03). The surgical conversion rate was higher in the transperitoneal route group (10/85 (11.8%) compared to 6/259 (2.3%), P = 0.0003) in the retroperitoneal route group. One death occurred in each group. Independent predictors of surgical conversion in multivariate analysis included the transperitoneal laparoscopic approach (OR 1.7, 95% CI 1.3–1.9, P = 0.02), advanced age (OR 1.2, 95% CI 1.1–1.6, P = 0.04) and large tumor size (OR 1.3, 95% CI 1.1–1.7, P = 0.01).Both transperitoneal and retroperitoneal approaches for laparoscopic adrenalectomy are safe, with an equivalent rate of major complications and mortality. The surgical conversion rate was higher for the transperitoneal route. The retroperitoneal approach should be reserved for small adrenal lesions.

Retroperitoneoscopic nephrectomy: current status

The classic retroperitoneal open surgical access to the kidney has been duplicated while performing laparoscopy but is less common than transperitoneal laparoscopy. We reviewed minimally invasive retroperitoneoscopic nephrectomy as a part of the international consultation on urological diseases and European Association of Urology international consultation on minimally invasive surgery in urology. A Pubmed/Medline search was performed to identify studies assessing the feasibility, safety and efficacy of laparoscopic and robotic retroperitoneoscopic nephrectomy. The articles were reviewed to assess outcomes after simple, radical and donor nephrectomy and comparative trials between retroperitoneoscopic versus the open and transperitoneal route were evaluated. Retroperitoneoscopic nephrectomy is feasible for most cases of benign non-functioning kidneys. Retroperitoneoscopic radical nephrectomy is also feasible for most tumours and may be better suited for posteriorly located tumours. Both retroperitoneoscopic and transperitoneal nephrectomy have similar outcomes but the operative time may be shorter for the former. The data are insufficient for robotic retroperitoneoscopic nephrectomy probably because of limited space and lack of benefit of a robot in ablative surgeries. Level of evidence: 3a

Comparison between retroperitoneal and transperitoneal laparoscopic adrenalectomy: Are both equally safe?

Compare the rates of major intra- and postoperative complications, surgical conversion and mortality between transperitoneal versus retroperitoneal laparoscopic adrenalectomy. In a series of 344 consecutive unilateral laparoscopic adrenalectomies, performed from January 1997 to December 2017, we evaluated the rates of major intra- and postoperative complications (Clavien-Dindo≥III) and surgical conversion of the two approaches. The retroperitoneal laparoscopic route was used in 259 patients (67.3%) and the transperitoneal laparoscopic route in 85 patients (22.1%). A total of 12 (3.5%) major postoperative complications occurred, with no statistically significant difference between the two approaches (P=0.7). In univariate analysis, the only predictor of major postoperative complication was Cushing's syndrome (P=0.03). The surgical conversion rate was higher in the transperitoneal route group (10/85 (11.8%) compared to 6/259 (2.3%), P=0.0003) in the retroperitoneal route group. One death occurred in each group. Independent predictors of surgical conversion in multivariate analysis included the transperitoneal laparoscopic approach (OR 1.7, 95% CI 1.3-1.9, P=0.02), advanced age (OR 1.2, 95% CI 1.1-1.6, P=0.04) and large tumor size (OR 1.3, 95% CI 1.1-1.7, P=0.01). Both transperitoneal and retroperitoneal approaches for laparoscopic adrenalectomy are safe, with an equivalent rate of major complications and mortality. The surgical conversion rate was higher for the transperitoneal route. The retroperitoneal approach should be reserved for small adrenal lesions.

Robotic Perineal Radical Prostatectomy: Initial Experience with the da Vinci Si Robotic System

Purpose: To investigate the feasibility and surgical technique of robotic perineal radical prostatectomy (RPRP). Materials and Methods: We retrospectively analyzed 6 consecutive patients diagnosed with prostate cancer from December 2018 to May 2019 who underwent RPRP at our center. Perioperative outcomes were recorded for safety and feasibility analysis. Results: Six patients successfully underwent RPRP with no conversion to open procedures. Operative time was 140 (interquartile range [IQR] 123.75–148.75) min, console time was 70 (IQR 62.5–70) min, with an estimated blood loss of 125 (IQR 100–187.5) mL. Patients were discharged 2 days postoperatively (IQR range 1–3) with pelvic drainages removed. The Foley catheter was removed 2 weeks after surgery. Postoperative pathology revealed 5 patients with locally advanced disease (apical margin-positive prostate cancer [pT3a]bNx). Two patients had a positive surgical margin (33.3%). No complications of Clavien grade 3 and above were recorded; 1 patient had a delay in wound-healing of 1 week. Postoperative continence was achieved for 2 patients immediately after Foley catheter removal, 2 recovered 1-month postoperatively, and 1 recovered within 3 months, and 1 still had mild incontinence at the latest follow-up 1-month postoperatively. Conclusion: RPRP is a safe and feasible alternative for the transperitoneal route in selected patients. Further investigation is required to assess its oncological and quality-of-life results.