Transperitoneal Research Articles

Retroperitoneal vs transperitoneal approach for nonruptured open conversion after endovascular aneurysm repair

ObjectiveSeveral studies comparing the transperitoneal (TP) and retroperitoneal (RP) approach for abdominal aortic aneurysm (AAA) repair suggest that the RP approach may result in lower rates of perioperative mortality and morbidity. However, data comparing these approaches for open conversion are lacking. This study aims to evaluate the association between the type of approach and outcomes following open conversion after endovascular aneurysm repair (EVAR). MethodsWe included all patients who underwent open conversion after EVAR between 2010 and 2022 in the Vascular Quality Initiative. Patients presenting with rupture were excluded. The primary outcome was perioperative mortality. The secondary outcomes included perioperative complications and 5-year mortality. Inverse probability weighting was used to adjust for factors with statistical or clinical significance. Logistic regression was used to assess perioperative mortality and complications in the weighted cohort. The 5-year mortality was evaluated using Kaplan-Meier and Cox regression. ResultsWe identified 660 patients (39% RP) who underwent open conversion after EVAR. Compared with TP, RP patients were older (75 years [interquartile range, 70-79 years] vs 73.5 years [interquartile range, 68-79 years]; P < .001), and more frequently had prior myocardial infarction (33% vs 22%; P = .002). Compared with the TP approach, the RP approach was used less frequently in cases of associated iliac aneurysm (19% vs 27%; P = .026), but more frequently with associated renal bypass (7.8% vs 1.7%; P < .001) and by high-volume physicians (highest quintile, >7 AAA annually: 41% vs 17%; P < .001) and in high-volume centers (highest quintile, >35 AAA annually: 36% vs 20%; P < .001). RP patients, compared with TP patients, were less likely to have external iliac or femoral distal anastomosis (8.2% vs 21%; P < .001), and an infrarenal clamp (25% vs 36%; P < .001). Unadjusted perioperative mortality was not significantly different between approaches (RP vs TP: 3.8% vs 7.5%; P = .077). After risk adjustment, RP patients had similar odds of perioperative mortality (adjusted odds ratio [aOR], 0.49; 95% confidence interval [CI], 0.22-1.10; P = .082), and lower odds of intestinal ischemia (aOR, 0.26; 95% CI, 0.08-0.86; P = .028) and in-hospital reintervention (aOR, 0.43; 95% CI, 0.22-0.85; P = .015). No significant differences were found in the other perioperative complications or 5-year mortality (aHR, 0.79; 95% CI, 0.47-1.32; P = .37). ConclusionsOur findings suggest that the RP approach may be associated with a lower adjusted odds of perioperative complications compared with the TP approach. The RP approach should be considered for open conversion after EVAR when feasible.

Surgical outcomes of novel retroperitoneal low anterior vs posterior and transperitoneal access in single-port partial nephrectomy.

Single-Port Robot-Assisted Partial Nephrectomy (SP-RAPN) can be performed by transperitoneal and retroperitoneal approaches. However, there is a lack of surgical outcomes for novel Retroperitoneal Low Anterior Access (LAA) in SP-RAPN. The study compared outcomes of the standard approach (SA), considering transperitoneal (TP) and posterior retroperitoneal (RP) access vs LAA in SP-RAPN series. 102 consecutive patients underwent SP-RAPN between 2019 and 2023 at a tertiary referral robotic center were identified. Baseline characteristics, peri- and post-operative outcomes were collected. Patients were stratified according to surgical approach into standard (RP or TP) vs LAA and, subsequently, RP vs LAA. Multivariable logistic regression analysis was used to test the probability of the same-day discharge adjusting for comorbidity indexes. Overall, 102 consecutive patients were included in this study (68 SA - 26 TP and 42 posterior RP vs 34 LAA). Median age was 60 (IQR 51.5-66) years and median BMI was 31 (IQR 26.3-37.6). No baseline differences were observed. LAA exhibited significantly shorter length of stay (LOS) (median 10 [IQR 8-12] vs 24 [IQR 12-30.2.] hours, p < .0001), reduced post-operative pain (p < .0001) and decreased narcotic use on 0-1 PO Day (p < .001) compared to SA and RP only. Multivariate analysis, adjusting for comorbidities, identified LAA as a strong predictor for Same-Day Discharge. LAA is an effective approach as well as RP and TP, regardless of the renal mass location, whether it is anterior or posterior, upper/mid or lower pole, yielding favorable outcomes in LOS, post-operative pain and decreased narcotics use compared to SA in SP-RAPN.

No difference in midterm outcomes and complication rate between retroperitoneal and transperitoneal open aortic aneurysm repair in females.

Abdominal Aortic Aneurysms (AAA) in females are less prevalent, have higher expansion rates and experience rupture at smaller diameters than in males. Studies have compared outcomes of the retroperitoneal (RP) and transperitoneal (TP) approach in open aortic aneurysm repair (OAR) with conflicting results. No study to date has compared the two approaches solely in females. In this study we compare midterm outcomes of the RP and TP approach in females undergoing OAR. Single-center, retrospective review of all females undergoing OAR from 2010 to 2021. Patients undergoing elective, symptomatic and ruptured OAR were included. The cohort was stratified by surgical approach RP versus TP and midterm outcomes were compared amongst the groups. Outcomes included mortality, graft related, and non-graft related complications. A total of 244 patients (RP n = 133; TP n = 111) were identified. Follow-up period was 28 ± 30.7months. Baseline perioperative characteristics were similar except that more people in the RP group had ejection fraction ((EF) > 50% (82% vs 68%), p = .037). Patients who underwent RP repair had longer visceral/renal ischemia time (p = .01), larger graft diameter (18 vs 16mm; p = <0.001), were more likely to have a suprarenal clamp placed(70.5 vs 48.2; p < .001), and had decreased autotransfusion volume (611 vs 861mL; p < .01) compared to those who underwent TP repair. Number of deaths was higher in the TP group during study follow-up period (36.4 vs 23.8; p = .035), but the difference of the time to event analysis was not significant. There was no difference in all-cause survival at 36 months between RP and TP (77.8 vs 76.8; p = .045). Overall midterm complications were 9.5% in both groups. Any graft related complication was 1.8% in TP versus 3% RP (p = .69). In a multivariable model, after adjusting for age, urgency, smoking, prior aneurysm repair, and ASA level, the hazard ratio decreases with the RP approach, however this did not reach significance (p = .052). In a 12-year period of OAR in females, TP and RP results were comparable at midterm analysis. The RP approach appeared to be used more often for OAR requiring suprarenal clamping. Although the TP group had increased mortality, the difference of the time to event analysis was not significant. Midterm postoperative complications in both groups were low. This suggests that both approaches are safe in the female population and decision should be driven by anatomy and surgeon's preference.

Transperitoneal versus retroperitoneal robot-assisted partial nephrectomy: a systematic review and meta-analysis.

Robot-assisted partial nephrectomy (RAPN) can be performed either by a transperitoneal (TP) or a retroperitoneal (RP) approach. However, the superiority of one approach over the other is not established. Hence, the primary aim of this review was to compare perioperative outcomes between these two surgical approaches. Literature was systematically searched to identify studies reporting perioperative outcomes following TP RAPN and RP RAPN. The study protocol was registered with PROSPERO (CRD42023399496). The primary outcome was comparing complication rates between the two approaches. This review included 22 studies, 5675 patients, 2524 in the RP group, and 3151 in the TP group. The overall complications were significantly lower in the RP group [Odds ratio (OR) 0.80 (0.67, 0.95), p = 0.01]. However, the rate of major complications was similar between the two groups. The operative time was significantly shorter with the RP group [Mean Difference (MD)-16.7 (- 22.3, - 11.0), p = < 0.0001]. Estimated blood loss (EBL) and need for blood transfusion (BT) were significantly lower in the RP group. There was no difference between the two groups for conversion to radical nephrectomy [OR 0.66 (0.33, 1.33), p = 0.25] or open surgery [OR 0.68 (0.24, 1.92, p = 0.47] and positive surgical margins [OR 0.93 (0.66, 1.31, p = 0.69]. Length of stay (LOS) was shorter in the RP group [MD - 0.27 (- 0.45, - 0.08), p = < 0.00001]. RP approach, compared to TP, has significantly lower complication rates, EBL, need for BT and LOS. However, due to the lack of randomized studies on the topic, further data is required.

Robotic transperitoneal versus retroperitoneal approach for anterior renal mass nephron-sparing surgery.

Robotic nephron-sparing surgery is traditionally performed via a transperitoneal (TP) approach. However, the retroperitoneal (RP) approach has gained popularity, particularly for posterolateral renal masses. The RP approach is associated with shorter operative time, less blood loss, and shorter length of stay, while preserving oncologic outcomes in selected masses. Here, we aim to assess the feasibility of the RP approach in excising anterior renal masses. Patients ≥ 18years of age who underwent robotic nephron-sparing surgery for anterior renal masses were retrospectively identified (2008-2022). Baseline demographics, tumor characteristics, and perioperative data were collected and characterized based on TP vs RP approaches. Wilcoxon rank sum test and Pearson's Chi-squared test were used to compare continuous and categorical variables, respectively. Two hundred and sixteen patients were included-178 (82.4%) underwent TP approach and 38 (17.6%) underwent RP approach. Baseline demographics, preoperative tumor size, and renal nephrometry scores were similar. The RP approach was associated with shorter operative (150 vs 203min, p < 0.001) and warm ischemia time (12 vs 21min, p < 0.001), and less blood loss (20 vs 100cc, p = 0.002) (Table1). The RP approach was associated with shorter length of stay (1 vs 2days, p < 0.001) and less total complications (5.3% vs 19.1%, p = 0.038). Major complication (Clavien-Dindo Grade > 3) rates were similar. There was no difference in positive surgical margin rates or pathologic characteristics. Robotic RP approach for nephron-sparing surgery is feasible for eligible anterior tumors and is associated with favorable perioperative outcomes with preserved negative surgical margin rates. Table1 Patient baseline demographics Overall Transperitoneal Retroperitoneal p value Median/N IQR/% Median/N IQR/% Median/N IQR/% N 216 178 82.4% 38 17.6% Age (years) 60.5 (52.1-67.7) 60.4 (52.8-67.7) 61.6 (49.1-69.2) 0.393 Sex Male 126 58.3% 100 56.2% 26 68.4% Female 90 41.7% 78 43.8% 12 31.6% 0.165 Race White 162 75.0% 137 77.0% 25 65.8% Asian 4 1.9% 2 1.1% 2 5.3% Black 21 9.7% 18 10.1% 3 7.9% Hispanic 26 12.0% 18 10.1% 8 21.1% Other 2 0.9% 2 1.1% 0 0.0% 0.197 Body mass index (kg/m2) < 25 32 14.8% 25 14.0% 7 18.4% 25-30 68 31.5% 55 30.9% 13 34.2% 30-35 60 27.8% 50 28.1% 10 26.3% 35 + 56 25.9% 48 27.0% 8 21.1% 0.808 Prior abdominal surgery Yes 118 54.6% 104 58.4% 14 36.8% No 98 45.4% 74 41.6% 24 63.2% 0.015 Prior kidney surgery Yes 10 4.6% 9 5.1% 1 2.6% No 206 95.4% 169 94.9% 37 97.4% 0.518 Chronic kidney disease stage ≥ 3 Yes 45 20.8% 38 21.3% 7 18.4% No 171 79.2% 140 78.7% 31 81.6% 0.687 Charlson comorbidity index 0 138 63.9% 116 65.2% 22 57.9% 1 46 21.3% 38 21.4% 8 21.1% 2 19 8.8% 13 7.3% 6 15.8% ≥ 3 13 6.0% 11 6.2% 2 5.3% 0.412 Tumor size (cm) 2.7 (2-3.6) 2.8 (2-3.5) 2.55 (2-3.7) 0.796 Tumor laterality Left 100 46.3% 78 43.8% 22 57.9% Right 116 53.7% 100 56.2% 16 42.1% 0.114 Clinical T stage cT1a 186 86.1% 152 85.4% 34 89.5% cT1b 30 13.9% 26 14.6% 4 10.5% 0.509 RENAL Nephrometry score Low (4 to 6) 94 43.5% 76 42.7% 18 47.4% Intermediate (7 to 9) 112 51.9% 94 52.8% 18 47.4% High (≥ 10) 19 4.6% 8 4.5% 2 5.3% 0.829 TE tumor enucleation, SPN standard margin partial nephrectomy, IQR interquartile range.

The Transition Toward Opioid-sparing Outpatient Radical Prostatectomy: A Single Institution Experience With Three Contemporary Robotic Approaches

To evaluate for differences in the perioperative and early postoperative outcomes between three different contemporary approaches of robotic radical prostatectomy (RARP), namely Single-Port (SP) Transvesical (TV), SP Extraperitoneal (EP), and Multi-Port (MP) Transperitoneal (TP). Retrospective review was performed on 865 consecutive patients with localized prostate cancer who underwent SP-TV, SP-EP, and MP-TP RARP. SP-TV and SP-EP RARP were performed using the purpose-built SP robotic platform. All procedures were performed by a single, experienced robotic surgeon. Demographics, perioperative, and early postoperative data were collected from the prospectively-maintained database. Statistical analysis was performed with descriptive statistics as presented. All SP cases were completed without any need for conversion or additional ports. When compared with MP-TP RARP, both SP-EP and SP-TV RARP were associated with significantly reduced length of stay (median, SP-TV 5.07 vs SP-EP 5.1 vs MP-TP 26.6hours, P=<.05) and with most patients being discharged within 24hours (SP-TV 92.3% vs SP-EP 84.6% vs MP-TP 30.4%, P=<.05). Postoperative analgesia requirements were significantly reduced following SP-TV RARP with 95% did not require opioid analgesia after discharge, as opposed to 77.6% and 12.1% of patients in the SP-EP and MP-TP RARP cohorts, respectively (P=<.05). Additionally, SP-TV RARP demonstrated the added benefit of a shorter Foley catheter duration of 4 days with an earlier return of urinary continence. The localization of RARP, as facilitated by the SP robotic platform, provided the opportunity for enhanced postoperative recovery resulting in decreased length of admission and postoperative pain, which allowed for increasing adoption of opioid-sparing outpatient prostatectomy.

Transperitoneal Versus Retroperitoneal Single-port Robotic-assisted Partial Nephrectomy: An Analysis from the Single Port Advanced Research Consortium

BackgroundIn the surgical management of kidney tumors, such as in multiport technology, single-port (SP) robotic-assisted partial nephrectomy (RAPN) can be performed using the transperitoneal (TP) or retroperitoneal (RP) approach. However, there is a dearth of literature on the efficacy and safety of either approach for SP RAPN. ObjectiveTo compare the peri- and postoperative outcomes of the TP and RP approaches for SP RAPN. Design, setting, and participantsThis is a retrospective cohort study using data from the Single Port Advanced Research Consortium (SPARC) database of five institutions. All patients underwent SP RAPN for a renal mass between 2019 and 2022. InterventionTP versus RP SP RAPN. Outcome measurements and statistical analysisBaseline characteristics, and peri- and postoperative outcomes were compared between both the approaches using χ2 test, Fisher exact test, Mann-Whitney U test, and Student t test. Results and limitationsA total of 219 patients (121 [55.25%] TP, 98 [44.75%] RP) were included in the study. Of them, 115 (51.51%) were male, and the mean age was 60 ± 11 yr. RP had a significantly higher proportion of posterior tumors (54 [55.10%] RP vs 28 [23.14%] TP, p < 0.001), while other baseline characteristics were comparable between both the approaches. There was no statistically significant difference in ischemia time (18 ± 9 vs 18 ± 11 min, p = 0.898), operative time (147 ± 67 vs 146 ± 70 min, p = 0.925), estimated blood loss (p = 0.167), length of stay (1.06 ± 2.25 vs 1.33 ± 1.05 d, p = 0.270), overall complications (5 [5.10%] vs 7 [5.79%]), and major complication rate (2 [2.04%] vs 2 [1.65%], p = 1.000). No difference was observed in positive surgical margin rate (p = 0.472) or delta eGFR at median 6-mo follow-up (p = 0.273). Limitations include retrospective design and no long-term follow-up. ConclusionsWith proper patient selection based on patient and tumor characteristics, surgeons can opt for either the TP or the RP approach for SP RAPN, and maintain satisfactory outcomes. Patient summaryThe use of a single port (SP) is a novel technology for performing robotic surgery. Robotic-assisted partial nephrectomy (RAPN) is a surgery to remove a portion of the kidney due to kidney cancer. Depending on patient characteristics and surgeons’ preference, SP can be performed via two approaches for RAPN: through the abdomen or through the space behind the abdominal cavity. We compared outcomes between these two approaches for patients receiving SP RAPN, finding that they were comparable. We conclude that with proper patient selection based on patient and tumor characteristics, surgeons can opt for either the TP or the RP approach for SP RAPN, and maintain satisfactory outcomes.

Transperitoneal Versus Retroperitoneal Robotic-Assisted Partial Nephrectomy in Patients with Obesity.

Introduction: We aim to compare transperitoneal (TP) and retroperitoneal (RP) robotic partial nephrectomy (RPN) in obese patients. Obesity and RP fat can complicate RPN, especially in the RP approach where working space is limited. Materials and Methods: Using a multi-institutional database, we analyzed 468 obese patients undergoing RPN for a renal mass (86 [18.38%] RP, 382 [81.62%] TP). Obesity was defined as body mass index ≥30 kg/m2*. A 1:1 propensity score matching was performed adjusting for age, previous abdominal surgery, tumor size, R.E.N.A.L nephrometry score, tumor location, surgical date, and participating centers. Baseline characteristics and perioperative and postoperative data were compared. Results: In the propensity score-matched cohort, 79 (50%) TP patients were matched with 79 (50%) RP patients. The RP group had more posterior tumors (67 [84.81%], RP versus 23 [29.11%], TP; P < .001), while the other baseline characteristics were comparable. Warm ischemia time (interquartile range; 15 [10, 12], RP versus 14 [10, 17] minutes, TP; P = .216), operative time (129 [116, 165], RP versus 130 [95, 180] minutes, TP; P = .687), estimated blood loss (50 [50, 100], RP versus 75 [50, 150] mL, TP; P = .129), length of stay (1 [1, 1], RP versus 1 [1, 2] day, TP; P = .319), and major complication rate (1 [1.27%], RP versus 3 [3.80%], TP; P = .620) were similar. No significant difference was observed in positive surgical margin rate and delta estimated glomerular filtration at follow-up. Conclusion: TP and RP RPN yielded similar perioperative and postoperative outcomes in obese patients. Obesity should not be a factor in determining optimal approach for RPN.

Perioperative and oncologic outcomes of transperitoneal versus retroperitoneal laparoscopic nephroureterectomy for upper urinary tract urothelial carcinoma: a systematic review and pooled analysis of comparative outcomes

BackgroundThe debate on whether to choose a transperitoneal (TP) or retroperitoneal (RP) approach for treating upper urinary tract urothelial carcinoma (UTUC) with laparoscopic surgery has been drawing attention. This study aimed to systematically review and meta-analyze the existing evidence regarding oncologic and perioperative outcomes of transperitoneal laparoscopic radical nephroureterectomy (TLNU) and retroperitoneal laparoscopic radical nephroureterectomy (RLNU) in managing UTUC.MethodsA comprehensive literature search was conducted using PubMed, Scopus, Embase, and Google Scholar for identifying randomized controlled trials (RCTs) and observational studies that evaluated the outcomes of TLNU and RLNU for UTUC. Continuous variables were represented by weighted mean difference (WMD) and standard mean difference (SMD), while binary variables were represented by odds ratio (OR), with 95% confidence intervals (CIs). The quality was assessed using the Newcastle–Ottawa scale. A sensitivity analysis was performed to evaluate the robustness of the estimates.ResultSix observational studies were incorporated into this meta-analysis. The overall TLNU was associated with significantly shorter operating time (WMD − 19.85; 95% CI − 38.03 to − 1.68; P = 0.03); longer recovery time of intestinal function (SMD 0.46; 95% CI 0.08 to 0.84; P = 0.02). However, the terms of estimated blood loss (WMD − 5.72; 95% CI − 19.6 to − 8.15; P = 0.42); length of stay (WMD − 0.35; 95% CI − 1.61 to 0.91; P = 0.59), visual analog pain scale (WMD − 0.38; 95% CI − 0.99 to 0.84; P = 0.22); drainage duration (WMD − 0.22; 95% CI − 0.61 to 0.17; P = 0.26); overall complication rates (OR 1.24; 95% CI 0.58 to 2.63; P = 0.58); local recurrence rate (OR 0.6; 95% CI 0.3 to 1.21; P = 0.16); distant metastasis (OR 0.94; 95% CI 0.04 to 20.77; P = 0.97); 1-year overall survival (OS) (OR 0.45; 95% CI 0.1 to 2.01; P = 0.3) showed no difference between TLNU and RLUN.ConclusionTLNU provides similar surgical outcomes and oncologic results compared to RLUN; however, TLNU has a shorter procedure time and prolonged intestinal function recovery time. Due to the heterogeneity among the studies, randomized clinical trials with follow-ups in the long term are required to obtain more definite results.Trial registrationwww.crd.york.ac.uk/prospero/, identifier CRD42023388554.

Comparison of Transperitoneal and Retroperitoneal Partial Nephrectomy with Single-Port Robot.

Purpose: To investigate the efficacy and safety of single-port (SP) robotic transperitoneal (TP) and retroperitoneal (RP) partial nephrectomy. Materials and Methods: We sequentially analyzed 30 partial nephrectomy performed after the SP robot was introduced to the hospital in September 2021 to June 2022. All patients were found to have T1 renal cell carcinoma (RCCs) and were operated by a single expert in conventional robot with da Vinci SP platform. Results: Total of 30 patients underwent SP robotic partial nephrectomy with 16 (53.33%) by TP approach and 14 (47.67%) by RP. Body mass index was slightly higher in TP group (25.37 vs 23.53, p-value = 0.040). The other demographic information was not significantly different. There was no statistical difference in ischemic time (727.41 ± 561.18 seconds for TP and 698.56 ± 299.23 seconds for RP, p-value = 0.812), and console time (67.97 ± 24.06 minutes for TP and 69.71 ± 28.66 minutes for RP, p-value = 0.724). There was no statistical difference in perioperative and pathologic outcomes either. Postoperative renal function calculated from diethylenetriaminepentacetate was 103.33 mL/min/1.73 m2 for TP and 101.33 mL/min/1.73 m2 for RP (p-value = 0.214). And 90.36 mL/min/1.73 m2 for TP and 87.74 mL/min/1.73 m2 for RP at 90 days after surgery (p-value = 0.592). Conclusion: SP robot partial nephrectomy can be performed effectively and safely regardless of the approach. TP and RP approach offers similar perioperative and postoperative outcomes for T1 RCC. The Clinical Trial Registration number KC22WISI0431.

V03-11 LAPAROSCOPIC NEPHRECTOMY FOR POLYCYSTIC KIDNEY: A VIDEO-ILLUSTRATED CASE SERIES OF TRANSPERITONEAL AND RETROPERITONEAL APPROACHES

You have accessJournal of UrologyCME1 Apr 2023V03-11 LAPAROSCOPIC NEPHRECTOMY FOR POLYCYSTIC KIDNEY: A VIDEO-ILLUSTRATED CASE SERIES OF TRANSPERITONEAL AND RETROPERITONEAL APPROACHES Daniele D'Agate, Giorgio Calleris, Marco Allasia, Marco Oderda, Alessandro Marquis, Giancarlo Marra, Federico Vitiello, Federico Lavagno, Matteo de Bellis, Gabriele Montefusco, Francesco Bracco, and Paolo Gontero Daniele D'AgateDaniele D'Agate More articles by this author , Giorgio CallerisGiorgio Calleris More articles by this author , Marco AllasiaMarco Allasia More articles by this author , Marco OderdaMarco Oderda More articles by this author , Alessandro MarquisAlessandro Marquis More articles by this author , Giancarlo MarraGiancarlo Marra More articles by this author , Federico VitielloFederico Vitiello More articles by this author , Federico LavagnoFederico Lavagno More articles by this author , Matteo de BellisMatteo de Bellis More articles by this author , Gabriele MontefuscoGabriele Montefusco More articles by this author , Francesco BraccoFrancesco Bracco More articles by this author , and Paolo GonteroPaolo Gontero More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003241.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Both transperitoneal (TP) and retroperitoneal (RP) laparoscopic nephrectomies (NT) have been described for autosomal dominant polycystic kidney disease (APKD), and no conclusive evidence exists about the best approach. We present in this video the step-by-step procedure for both techniques. Perioperative data of a single-institutional case-series are reported. METHODS: A retrospective review of the NTs in APKD patients in between June 2020 and April 2022 was conducted. The TP approach requires the positioning of three 12-mm ports and one 5-mm ports, the mobilisation of the colon, the incision of Gerota’s fascia and the development of the psoas plane to identify the renal pedicle. Renal vessels and ureter are clipped by Hem-o-lok ® and divided. The RP approach usually requires the positioning of a first 12-mm trocar at the apex of the XII rib; the RP space is developed using a dedicated balloon; two more 12-mm trocars are placed at the posterior axillary line and in the iliac fossa. The psoas plane allows an early access to the renal pedicle; the renal vessels and the ureter are ligated by Hem-o-lok ® and divided. In both approaches, the puncture and the suction of the major cysts is frequent during dissection; adrenal-sparing approach was feasible in all cases; a modified Gibson incision is made for kidney extraction. RESULTS: Six consecutive patients were enrolled, 3 of whom were treated by TP and 3 by RP-NT. Two patients were on haemodialysis and 2 had already undergone a renal transplantation. Mean age was 49 and 57 years, maximum kidney diameter was 28.25 and 30 cm and mean operative time was 171 and 210 min, respectively for RP and TP. No conversion to open surgery was made. The reason for NT was represented by symptomatic polycystic kidney in 5 cases; surgery was required solely in preparation to kidney transplantation in 1 TP case. No Clavien 3 grade complications or greater were recorded; postoperative sepsis occurred in 2 TP patients, haematoma in 1 TP and 1 RP cases, blood transfusions were required in 2 TP and 1 RP cases, 1 RP patient experienced a deep venous thrombosis. The hospitalization time ranged from 5 to 31 days. No significant worsening of the renal function was observed at discharge. CONCLUSIONS: At present, the scarce existing data do not suggest the superiority of an approach over the other one. Both RP and TP approaches for nephrectomy of polycystic kidneys are feasible in experienced hands and the choice must be tailored on patient characteristics and surgeon’s preference. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e249 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Daniele D'Agate More articles by this author Giorgio Calleris More articles by this author Marco Allasia More articles by this author Marco Oderda More articles by this author Alessandro Marquis More articles by this author Giancarlo Marra More articles by this author Federico Vitiello More articles by this author Federico Lavagno More articles by this author Matteo de Bellis More articles by this author Gabriele Montefusco More articles by this author Francesco Bracco More articles by this author Paolo Gontero More articles by this author Expand All Advertisement PDF downloadLoading ...

MP68-07 A COMPARISON OF TRANSPERITONEAL AND RETROPERITONEAL APPROACH IN PATIENTS UNDERGOING SINGLE-PORT ROBOTIC-ASSISTED PARTIAL NEPHRECTOMY: A REPORT FROM THE SINGLE PORT ADVANCED RESEARCH CONSORTIUM (SPARC)

You have accessJournal of UrologyCME1 Apr 2023MP68-07 A COMPARISON OF TRANSPERITONEAL AND RETROPERITONEAL APPROACH IN PATIENTS UNDERGOING SINGLE-PORT ROBOTIC-ASSISTED PARTIAL NEPHRECTOMY: A REPORT FROM THE SINGLE PORT ADVANCED RESEARCH CONSORTIUM (SPARC) Kennedy Okhawere, Jordan Rich, Laura Zuluaga, Indu Saini, Alp Tuna Beksac, Burak Upcinar, Jennifer Nguyen, Ruben C. Sauer, Mutahar Ahmed, Reza Mehrazin, Ronney Abaza, Michael D. Stifelman, Jihad Kaouk, Simone Crivellaro, and Ketan Badani Kennedy OkhawereKennedy Okhawere More articles by this author , Jordan RichJordan Rich More articles by this author , Laura ZuluagaLaura Zuluaga More articles by this author , Indu SainiIndu Saini More articles by this author , Alp Tuna BeksacAlp Tuna Beksac More articles by this author , Burak UpcinarBurak Upcinar More articles by this author , Jennifer NguyenJennifer Nguyen More articles by this author , Ruben C. SauerRuben C. Sauer More articles by this author , Mutahar AhmedMutahar Ahmed More articles by this author , Reza MehrazinReza Mehrazin More articles by this author , Ronney AbazaRonney Abaza More articles by this author , Michael D. StifelmanMichael D. Stifelman More articles by this author , Jihad KaoukJihad Kaouk More articles by this author , Simone CrivellaroSimone Crivellaro More articles by this author , and Ketan BadaniKetan Badani More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003331.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Single-Port (SP) robotic-assisted partial nephrectomy (RAPN) has been established as a reasonable alternative to the (MP) multiport platform motivated by the potential to regionalize surgery and decrease morbidity. However, there is a dearth of literature on its efficiency and safety for either the transperitoneal (TP) or retroperitoneal (RP) approach. We sought to compare the perioperative and post-operative outcomes of the TP and RP approach for the SP RAPN. METHODS: Using data from the Single Port Advanced Research Consortium (SPARC) database, we conducted a retrospective analysis of 219 patients who underwent SP RPN for a renal mass between 2019 and 2022 (121 [55.25%] TP, 98 [44.75%] RP). Baseline characteristics, perioperative and postoperative data were compared between both approaches using χ2 test, Fisher exact test, Mann Whitney U test, student’s t test. RESULTS: Of the 148 patients in this study, 76 (51.35%) were male and the mean (SD) age was 60 (11) years. The RP group had a significantly higher proportion of posterior tumors [54 (55.10%), RP vs. 28 (23.14 %%), TP; p<0.001], while other baseline characteristics were comparable between the two approaches. Compared to transperitoneal approach, retroperitoneal approach had similar ischemia time (18 [SD=9] mins vs. 18 [SD=11] mins, p=0.898), operative time (147[SD=67] mins vs. 146 [SD=70] mins, p=0.925), estimated blood loss EBL (76 ml [SD=100] vs. 98 ml[SD=124], p=0.167), length of stay (1.07 [SD=2.25] day vs. 1.33 [SD=1.05] day, p=0.270), overall complication rate (5 [5.10%] vs 7 [5.79%], and major complication rate (2 [2.04%] vs. 2 [1.65%], p=1.000). No difference was observed in positive surgical margin rate (p=0.472) or delta eGFR (p=0.273). CONCLUSIONS: Trans peritoneal and retroperitoneal SP RAPN yielded similar perioperative and postoperative outcomes. The SP platform is a safe platform to perform transperitoneal and retroperitoneal RAPN. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e955 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kennedy Okhawere More articles by this author Jordan Rich More articles by this author Laura Zuluaga More articles by this author Indu Saini More articles by this author Alp Tuna Beksac More articles by this author Burak Upcinar More articles by this author Jennifer Nguyen More articles by this author Ruben C. Sauer More articles by this author Mutahar Ahmed More articles by this author Reza Mehrazin More articles by this author Ronney Abaza More articles by this author Michael D. Stifelman More articles by this author Jihad Kaouk More articles by this author Simone Crivellaro More articles by this author Ketan Badani More articles by this author Expand All Advertisement PDF downloadLoading ...

Transhepatic or transperitoneal technique for cholecystostomy: results of the multicentre retrospective audit of cholecystostomy and further interventions (MACAFI)

Objective: This analysis of the MACAFI (multicentre audit of cholecystostomy and further interventions) data aims to assess the procedural technique and technical specifications related to percutaneous cholecystostomy (PC) insertion in patients with acute calculous cholecystitis (ACC). PC can be performed either with transperitoneal (TP) or a transhepatic (TH) approach. There is no clear evidence for the superiority of either technique. Methods: The data set included patients who underwent PC for ACC between first January 2019 and first January 2021. Data included patient demographics, imaging diagnosis, insertion technique, tube size, and outcomes including 6 month follow-up. Results: 1186 patients from 36 sites were identified through the MACAFI study with 913 patients having access route recorded. A transhepatic route was used in 572 [62.6%] compared to 308 TP [33.7%]. There was an increased rate of bleeding when using the TH route (2.6% vs 0.3%, p = 0.01) although other post-procedural complications (such as bile leak) were similar between the two groups. No significant difference was demonstrated in 30- or 90-day mortality (TH vs TP, 8.7vs 9.3%, p = 0.86 and 13.8vs 15.4%, p = 0.58, respectively). The readmission rate with recurrent cholecystitis was significantly greater in those with TH compared to TP approach (22.0% vs 14.9%, p = 0.01, respectively). Conclusion: The TP PC approach may be safer than TH, with lower bleeding complication rate and fewer readmissions. Advances in knowledge: A transperitoneal approach for cholecystostomy was associated with lower bleeding complication rate and lower rate of readmissions with recurrent cholecystitis compared to the transhepatic approach.

Retroperitoneal Compared to Transperitoneal Approach for Open Abdominal Aortic Aneurysm Repair Is Associated with Reduced Systemic Inflammation and Postoperative Morbidity.

In the United Kingdom, the most common surgical approach for repair of open abdominal aortic aneurysms (AAAs) is transperitoneal (TP). However, retroperitoneal (RP) approach is favored in those with more complex vascular anatomy often requiring a cross-clamp on the aorta superior to the renal arteries. This study compared these approaches in patients matched on all major demographic, comorbid, anatomic, and physiological variables. Fifty-seven patients (TP: n = 24; RP: n = 33) unsuitable for endovascular aneurysm repair underwent preoperative cardiopulmonary exercise testing prior to open AAA repair. The surgical approach undertaken was dictated by individual surgeon preference. Postoperative mortality, complications, and length of hospital stay (LoS) were recorded. Patients were further stratified according to infrarenal (IR) or suprarenal/supraceliac (SR/SC) surgical clamping. Systemic inflammation (C-reactive protein) and renal function (serum creatinine and estimated glomerular filtration rate) were recorded. Twenty-three (96%) of TP patients only required an IR clamp compared with 12 (36%) in the RP group. Postoperative systemic inflammation was lower in RP patients (p = 0.002 vs. TP) and fewer reported pulmonary/gastrointestinal complications whereas renal impairment was more marked in those receiving SR/SC clamps (p < 0.001 vs. IR clamp). RP patients were defined by lower LoS (p = 0.001), while mid-/long-term mortality was low/comparable with TP, resulting in considerable cost savings. Despite the demands of more complicated vascular anatomy, the clinical and economic benefits highlighted by these findings justify the more routine adoption of the RP approach for complex AAA repair.

Comparison of Three Approaches to Single-Port Robot-Assisted Radical Prostatectomy: Our Institution's Initial Experience.

Background: We aimed to compare three robot-assisted radical prostatectomy (RARP) approaches-Retzius sparing (RS), extraperitoneal (EP), and transperitoneal (TP)-performed at our institution using the da Vinci® single-port (SP) platform (Intuitive Surgical, Sunnyvale, CA). Materials and Methods: We retrospectively reviewed the records of 101 patients who underwent SP-RARP at our institution and stratified them into three cohorts based on the RARP approach: RS (n = 32), EP (n = 30), and TP (n = 39). Data regarding preoperative patient characteristics, perioperative characteristics, oncologic outcomes, and early functional outcomes were collected. The Fisher's exact test and chi-square tests were utilized for categorical variables, and the Kruskal-Wallis test was utilized for numerical variables. Wilcoxon rank-sum tests were utilized for pairwise comparisons. A two-tailed p < 0.05 was considered significant. Results: All three cohorts were largely similar in terms of preoperative patient characteristics. Operative time was significantly different between cohorts (p < 0.001), with the RS approach having a faster mean operating time than the TP approach (208 ± 40 minutes vs 248 ± 36 minutes, p < 0.001). Clinically significant margin rates did not differ significantly between cohorts (p = 0.861). Postoperative continence differed significantly between cohorts (p < 0.001); higher continence rates were observed in RS vs EP-94% (30/32) vs 52% (15/29), respectively, p < 0.001. Return of erectile function also differed significantly between cohorts (p = <0.001); higher erectile function recovery rates were observed in RS vs EP-88% (28/32) vs 41% (11/27), respectively, p < 0.001-and in RS vs TP-88% (28/32) vs 60% (22/37), respectively, p = 0.014. Median (IQR) follow-up time was 150 (88-377) days. Conclusions: RS SP-RARP is associated with improved early functional outcomes when compared with both EP and TP approaches. These benefits are achieved while maintaining equivalent oncologic outcomes. Further research is needed to optimize the patient selection paradigm for the SP-RARP approach.

Minimally invasive adrenalectomy – Operative and perioperative results of transperitoneal and retroperitoneal adrenalectomies performed at the University of Szeged Department of Surgery during 23 years

Aim. Our goal was to evaluate operative and perioperative data of retroperitoneal (RP) and transperitoneal (TP) adrenalectomies performed at the University of Szeged Department of Surgery. Patients and method. During aretrospective cohort study including 174 adrenalectomies (28 RP; 146 TP) performed between 1998 and 2021, the following parameters were evaluated: rate of previous abdominal surgeries, conversion rate, operative time, intraoperative blood loss, tumor size, histology, hospital stay, early and late complications. Results. With significantly higher rate of previous abdominal surgeries [TP vs RP: 68 (46.57%) vs 4 (14%)P= 0.0021], there was no markable difference in conversion rate [TP vs RP: 7 (4.79%) vs 5 (18%),P= 0.312]. Significantly larger tumours were removed with TP (TP vs RP: 58.05 vs 34.8 mm,P= 0.016), with no markable difference in intraoperative blood loss (TP vs RP: 67.85 vs 50.2 ml,P= 0.157). Operative time was significantly shorter in TP (TP vs RP: 86.3 vs 134.5 min;P= 0.024). The most frequent histology was adenoma (TP vs RP:n= 95; 65.06% vs 64.3%). Pheochromocytoma occurred in 11 (7.53%) and 5 (17.8%) cases in TP and RP, respectively. We found no significant difference in hospital stay (TP vs RP: 5.125 vs 4.61 day;P= 0.413). Five- and 2 cases of early complications were seen in TP (splenic injury, postoperative fever, severe intraoperative bleeding, severe hypokalemia, surgical site infection) and RP (2 severe intraoperative bleeding), respectively. One lethal case of ventricular fibrillation and one delayed complication (postoperative abdominal wall hernia) were observed in TP. Conclusions. Both TP and RP are safe and simply reproducible minimally invasive techniques. According to our observation, RP adrenalectomy seems to be reserved for smaller lesions, while TP proves to be successful in removing enlarged and also malignant lesions with significantly shorter operative time.

Association between biopsy method and development of peritoneal metastases in perihilar cholangiocarcinoma.

In patients with perihilar cholangiocarcinoma (PHC), there is concern that transperitoneal (TP) biopsy may seed tumor in the peritoneal cavity, increasing risk of peritoneal metastases (PM). A retrospective review of patients undergoing surgery for PHC (1991-2014) was performed. Clinicopathologic characteristics and incidence of PM at the time of index surgery, and one and two years after surgery were compared in patients who did vs. did not undergo TP biopsy. Among 262 patients who underwent surgery, 37 had undergone TP biopsy, and 225 had undergone intraluminal biopsy or had no biopsy. No differences in demographic or clinicopathologic characteristics were noted between groups. The incidence of PM at surgery was not significantly different between TP and non-TP biopsy patients (5.4% vs. 7.6%, p>0.9). Among 243 patients who did not have PM at surgery, the cumulative incidence of PM in the TP and non-TP biopsy groups were not different at one year (11.4% [95%CI 3.5-24.4] vs. 10.8% [95%CI 7.0-15.5]) or two years (20.3% [95%CI 8.7-35.2] vs. 20.1% [95%CI 14.9-25.9]) (p=0.7). Although PM commonly occurs in patients with PHC, TP biopsy was not associated with higher incidence of PM at surgery or at one or two years after surgery.

Open Retroperitoneal Repair for Complex Abdominal Aortic Aneurysms

Open surgical repair (OSR) of complex abdominal aortic aneurysms (CAAAs) can be challenging. We frequently utilize the retroperitoneal (RP) approach for such cases. We audited our outcomes with the aim of establishing the utility and safety of this approach. Retrospective analysis was performed of all patients undergoing OSR of an unruptured CAAA via a RP approach in our center over a 7-year period. Data on repairs via a transperitoneal (TP) approach were collected to provide context. Demographic, operative, radiological, and biochemical data were collected. The primary outcome measure was 30-day/inpatient mortality. Secondary outcomes included the need for reoperation, incidence of postoperative chest infection, acute kidney injury (AKI) and length of stay (LOS). All patients received aortic clamping above at least one main renal artery. One hundred and three patients underwent OSR of an unruptured CAAA; 55 via a RP approach, 48 TP. The RP group demonstrated a more advanced pattern of disease with a larger median maximum diameter (65 vs. 61 mm, p= 0.013) and a more proximal extent. Consequently, the rate of supravisceral clamping was higher in RP repair (66 vs. 15%, p < 0.001). Despite this there were no differences in the observed early mortality (9.1 vs. 10%, NS); incidence of reoperation (10.9 vs. 12.5%, NS), chest infection (32.7 vs. 25%, NS), and AKI (52.7 vs. 45.8%, NS); or median LOS (10 vs. 12 days, NS) following RP and TP repair. OSR of CAAAs carries significant 30-day mortality. In patients unsuitable for fenestrated endovascular aortic repair or those desiring a durable long-term solution, OSR can be performed through the RP or TP approach. This study has demonstrated that in our unit RP repair facilitates treatment of more advanced AAA utilizing complex proximal clamp zones with similar perioperative morbidity and mortality compared with TP cases utilizing more distal clamping.

PD54-08 SINGLE-PORT EXTRAPERITONEAL VS TRANSPERITONEAL ROBOTIC-ASSISTED RADICAL PROSTATECTOMY: A MULTI-INSTITUTIONAL MATCHED-PAIR COMPARISON OF OUTCOMES

You have accessJournal of UrologyCME1 May 2022PD54-08 SINGLE-PORT EXTRAPERITONEAL VS TRANSPERITONEAL ROBOTIC-ASSISTED RADICAL PROSTATECTOMY: A MULTI-INSTITUTIONAL MATCHED-PAIR COMPARISON OF OUTCOMES Mahmoud Abou Zeinab, Ethan Ferguson, Aaron Kaviani, Alp T. Beksac, Marcio Moschovas, Luca Morgantini, Sij Hemal, Susan Talamini, Jean Joseph, Moses Kim, Simone Crivellaro, Vipul Patel, Jeffrey Nix, and Jihad Kaouk Mahmoud Abou ZeinabMahmoud Abou Zeinab More articles by this author , Ethan FergusonEthan Ferguson More articles by this author , Aaron KavianiAaron Kaviani More articles by this author , Alp T. BeksacAlp T. Beksac More articles by this author , Marcio MoschovasMarcio Moschovas More articles by this author , Luca MorgantiniLuca Morgantini More articles by this author , Sij HemalSij Hemal More articles by this author , Susan TalaminiSusan Talamini More articles by this author , Jean JosephJean Joseph More articles by this author , Moses KimMoses Kim More articles by this author , Simone CrivellaroSimone Crivellaro More articles by this author , Vipul PatelVipul Patel More articles by this author , Jeffrey NixJeffrey Nix More articles by this author , and Jihad KaoukJihad Kaouk More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002631.08AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The introduction of the ‘purpose-built’ Single-port (SP) robot successfully expanded the surgical approaches in the management of localized prostate cancer to include the extraperitoneal, in addition to the standard transperitoneal approach. We sought to perform a multi-institutional study to assess the perioperative, and functional outcomes between SP extraperitoneal (ERP) and SP transperitoneal (TRP) radical prostatectomy. METHODS: From February 2019 to October 2021, a prospective data collection from six different robotic centers was performed. Data of 412 patients who underwent ERP and 241 patients who underwent TRP were analyzed. All procedures were performed by surgeons with extensive robotic experience. A 1:1 matched-pair analysis for the National Comprehensive Cancer Network (NCCN) risk was performed. Baseline characteristics, intraoperative, postoperative and functional outcomes were evaluated. RESULTS: Before matching, there was a significantly higher percentage of NCCN high risk in the ERP group compared to the TRP group. After matching, patients in the ERP had a higher rate of previous abdominal surgery (p <.001). The median operative time was 203 vs 169 minutes, median estimated blood loss was 150 vs 87 cc for ERP and TRP, respectively (p <.001). TRP was more likely to include an additional surgical port (SP+1). 37.6% of the ERP group had more extraprostatic extension on pathology compared to 26.8% in the TRP, with no significant difference in the positive surgical margins (25.3% and 26.8%). The median lymph node yield was higher in the ERP group (6 vs 3 nodes, p=.017). ERP patients were more likely to be discharged the same day after the surgery (7 vs 14 hours, p <.001), and had their median Foley catheter stay for 7 days compared to 5 days In the TRP group (p <.007). There was no difference in the perioperative complications or continence rates after the surgery. Median follow-up was 6 months. CONCLUSIONS: Both SP ERP and TRP are comparable surgical options for the treatment of localized prostate cancer. ERP is more associated with same-day discharge and higher lymph node yield. TRP has a shorter operative time and less estimated blood loss. The two techniques have similar complications, positive surgical margin, and continence rates. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e918 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mahmoud Abou Zeinab More articles by this author Ethan Ferguson More articles by this author Aaron Kaviani More articles by this author Alp T. Beksac More articles by this author Marcio Moschovas More articles by this author Luca Morgantini More articles by this author Sij Hemal More articles by this author Susan Talamini More articles by this author Jean Joseph More articles by this author Moses Kim More articles by this author Simone Crivellaro More articles by this author Vipul Patel More articles by this author Jeffrey Nix More articles by this author Jihad Kaouk More articles by this author Expand All Advertisement PDF DownloadLoading ...

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.