Surgical technique and efficacy of P. R.E.S.S. bladder cuff excision / 中华泌尿外科杂志

Objective:To explore the surgical technique and efficacy of pure retroperitoneoscopic extravesical standardized seeable (P.R.E.S.S.) technique for bladder cuff excision (BCE).Methods:Ninety five patients with UTUC from five domestic centers (30 cases from Changzheng Hospital, 21 cases from Peking University First Hospital, 20 cases from Yuhuangding Hospital, 21 cases from Dalian Medical University affiliated No.2 Hospital and 3 cases from General Hospital of Eastern Theater Command)between August 2017 and December 2020 were retrospectively analyzed. There were 57 males and 38 females with a mean age of (67.7±10.0) years and median tumor size of 3.0 cm. All patients underwent pure retroperitoneoscopic radical nephroureterectomy with a single surgical position and four (36 cases) or five (59 cases) trocar layout according to the surgeon’s prefer habit and experience. The demographics of the two groups were the age of [(66.3±11.2)years vs. (68.6±9.1)years], male/female ratio of (25/11 cases vs. 32/27 cases), body mass index of [(25.0± 3.0)kg/m 2 vs. (24.8±3.4)kg/m 2], tumor maximum diameter of [2.8(1.6, 3.5)cm vs. 3.0(2.0, 4.0)cm], left/right side tumor of(19/17 cases vs. 34/25 cases), T 1-2/T 3-4/Tis stage of(25/10/4 cases vs. 49/10/0 cases), and multifocal tumors of(3 cases vs. 2 cases), and the difference was not statistically significant( P>0.05). On the other hand, the differences of hydronephrosis of the operated kidney(13 cases vs. 39 cases, P=0.004), and tumor location (in renal pelvis or calyx or upper/middle/lower ureter being 23/9/4 cases vs. 35/4/20 cases, P=0.005), were statistically significant. The umbilical artery cord was used as anatomical landmark in the process of P. R.E.S.S. bladder cuff excision. The pelvic floor and extraperitoneal space around the ureter were expanded, the bladder wall was opened to form pneumovesicum, and a sufficient bladder cuff resection and exact bladder cuff closure was performed. Perioperative outcomes and follow-up data were analyzed, and the clinical outcomes between the four and five trocars were compared to evaluate the impact of trocar layout on the surgical outcomes. Results:There were 91(95.8%) cases successfully undergoing P. R.E.S.S. BCE technique, with one case converted to open BCE due to bleeding and three cases converted to distal ureter Hem-o-lok clipping because of poor exposure. Median operative time was 180(125, 230)min, and estimated blood loss was 100(50, 100)ml. The overall complication rate was 10.5%(10/95), including 2 cases(2.1%) of intraoperative bleeding, with 1 case treated by transfusion (400 ml), the other case converted to open surgery without transfusion. There were 8 cases of postoperative complications(8.4%), including 7 cases of Clavien-Dindo grade Ⅱ(3 cases of secondary hemorrhage, one case for each of drug allergy, acute renal insufficiency, blood creatinine increased to 490 μmol/L, or lung infection with lymphatic leakage), 1 case of grade Ⅲa(intestinal obstruction treated with insertion of the intestinal obstruction catheter under local anesthesia), and all these patients were discharged smoothly. The difference between the four and five trocars was not statistically significant in the following variables, including the rate of surgical conversion(8.3% vs. 1.7%), estimated intraoperative blood loss(100 ml vs. 60 ml), ratio of intraoperative lymph node dissection (25.0% vs.20.3%), P. R.E.S.S. bladder cuff excision success rate(91.7% vs.98.3%), the incidence of intraoperative and postoperative complications (13.8% vs.8.5%), pT 1-2/pT 3-4/pTis stage(22/11/3 cases vs.37/19/3 cases) and the proportion of recurrence or metastasis(8.3% vs.3.4%)(all P>0.05). However, the differences in the operation time(190 min vs.170 min, P=0.011)and postoperative hospital stay(5 d vs.6 d, P=0.005) were statistically significant. Conclusions:P. R.E.S.S. bladder cuff resection technique is safe and feasible during the procedure of pure retroperitoneoscopic radical nephroureterectomy by a single surgical position and facilitates seeable adequate bladder cuff excision by establishing an enlarged pelvic lateral extraperitoneal space and pneumovesicum. Five-trocar technique is more suitable for patients with lower ureteral tumors but may be associated with a longer postoperative hospital stay compared with the four-trocar technique.

Error analysis and experience summary in setting up the retroperitoneal cavity for peritoneoscopy / 天津医药

Objective To explore errors and their causes in setting up the retroperitoneal cavity for peritoneoscopy. Methods The clinical data of 450 patients who were performed the laparoscopic surgery in our hospital from May 2009 to December 2016 were collected. According to the trocar puncture points, patients were divided into lumbar group (n=193) and iliac flap group (n=276). The problems were summarized and analyzed in the process of setting up the retroperitoneal cavity. Results The mistakes existed in setting up the retroperitoneal cavity including peritoneum rupture (10 cases), error in balloon expansion clearance (5 cases), homemade balloon rupture and fall off (7 cases), poor position of puncture port (34 cases), bleeding of puncture channel (6 cases), leaking around the trocar and subcutaneous emphysema. After peritoneal patching, re-establishment of the expansion of the gap, adjusting the trocar position and other appropriate measures for treatment, the operations were successfully in 450 patients. Conclusion We should choose the appropriate method for building cavity according to different conditions of patients, and know well the anatomy of the peritoneal cavity. All details should be emphasized in the process of building cavity to reduce the occurrence of errors.

Retroperitoneal laparoscopic with renal pedicle rotation for partial nephrectomy of ventro-renal tumor / 北京大学学报(医学版)

Objective: Retro-laparoscopic partial nephrectomy is a challenge for ventro-renal tumors, especially hilar tumors.The tumors are partial or entirely out of operative field and there is blind space for operation.To solve this problem, a set of techniques including renal pedicle rotation is developed.Methods: A set of techniques including renal pedicle rotation, double-layer suture, early artery unclamping for retro-laparoscopic nephrectomy for ventro-renal tumors, especially hilar tumors were developed.Hilar tumors were located anteriorly to the angle of the renal and renal arteries and in contact with the anterior surface of the renal artery.The evaluation of the outcomes included the operation time, warm ischemia time, estimated haemorrhage, surgical margin, renal function after operation, and complications.This study reviewed the data of 28 patients with ventro-renal tumor, including 15 patients with complex hilar tumors.Results: The average tumor size was (3.8±0.5) cm.The average R.E.N.A.L score was 8 (ranging from 7 to 9).The average warm ischemia time was (23.8±4.7) min, and suture time was (26.2±6.5) min, and operation time was (124.1±12.1) min.The median hospital stay was 4 days and the average estimated haemorrhage was (139.1±54.0) mL.All the surgeries were operated under laparoscope and no surgery switched to open surgery.Seven patients developed Clavien Dindo Ⅰ-Ⅱ complications after operation.Three patients (10.7%) developed collective system damage and received repair of collective system in time and three patients (10.7%) developed slightly gross hematuria (Clavien-DindoⅠ).Two patients developed wound infection (Clavien-DindⅡ).Three patients (10.7%) got renal vein clamped because of capillary hemorrhage from basilar part of tumors.There were 14 patients received early unclamping of renal artery, and no obvious renal vessel damage was found.There were statistically significant differences between the serum creatinine levels (P<0.05) and the estimated glomerular filtration rates (P=0.02) before and after surgery.All the patients'' serum creatinine levels were in normal range and no patient needed regular dialysis.There was no positive surgical margin and the median follow-up was 7 months without local recurrence or distant metastasis.Conclusion: It is safe and effective to apply renal pedicle rotation technique in retro-laparoscopic partial nephrectomy for ventro-renal tumors.The short-term follow-up results are optimistic, but long follow-up is required.

Retroperitoneal laparoscopic extravascular stent placement for nutcracker syndrome / 中华泌尿外科杂志

Objective To report our experience of retroperitoneal laparoscopic extravascular stent placement for nutcracker syndrome.Methods The clinical data of 12 nutcracker syndrome patients (10 males and 2 females;mean age 26 years) who underwent retroperitoneal laparoscopic extravascular stent placement from March 2014 to Febuary 2016 were retrospectively reviewed.The main symptoms were gross hematuria in 8 patients(one with proteinuria)and flank pain was noted in 1 patient.Three male patients had left-sided secondary varicoceles.Ultrasonography and computed tomography showed the left renal vein clamped by the superior mesenteric artery and the aorta.The anteroposterior diameter of the left renal vein in the renal hilum was three-fold than the aortomesenteric area,and the peak velocity ratio of the aortomesenteric area was much faster than the renal hilum.Twelve patients underwent laparoscopic extravascular stent placement under general anesthesia.The preaortic fibrous tissue between the aorta and the superior mesenteric artery was released intraoperatively.Renal vein became fiat when the superior mesenteric artery was elevated.The 6-8 cm extravascular stent was set on the surface of the renal vein to prevent the compression.Results Stenting was successfully accomplished in all 12 patients.Mean operative time was 62 min (50-125 min),estimated blood loss was 35 ml(20-100 ml),and the hospital stay after operation was 8 days (6-12 days).Three patients had a transient orthostatic intolerance,and they were cured by conservative treatment.With a mean follow up of 14 months (5-30 months),symptoms of hematuria and flank pain resolved in 7/8 and 1/1,respectively.Varicoceles were cured in all three patients.One case got partial relief because of recurrent hematuria due to excessive exercise.Ultrasonography showed that extravascular stent was in the right place,and the angle between abdominal aorta and superior mesenteric artery became normal.The inner diameter of left renal vein was decreased,and the narrow segment was diminished in diameter meanwhile the blood outflow was smooth.Conclusions Retroperitoneal laparoscopic extravascular stent placement in the renal vein is a safe and effective approach for nutcracker syndrome.

Application of barbed absorbable suture line in retroperitoneoscopic partial nephrectomy / 肿瘤研究与临床

Objective To investigate the safety and feasibility of barbed absorbable suture line in retroperitoneoscopic partial nephrectomy. Methods 45 patients who were suitable for retroperitoneoscopic partial nephrectomy from February 2013 to February 2014 were collected and randomly divided into V-Loc group and the control group. 23 cases of V-Loc barbed absorbable suture line were chosen by suture kidney in V-Loc group.There were 22 cases of coated vicryl plus antibacterial suture and Hem-o-lok clip in the control group. The differences of operative time, blood loss, warm ischemia time, suture time, hospital stay and suture material costs were compared respectively between the two groups. Results All 45 cases of retroperitoneoscopic partial nephrectomy were successfully performed, without conversion to open surgery and important intraoperative complications. Postoperative pathology report showed that there were 37 cases with renal clear cell carcinoma, 3 cases with papillary renal cell carcinoma, 2 cases with chromophobe renal cell carcinoma with negative surgical margin, 3 cases with renal angiomyolipomas. In the V-Loc group and the control group, the average operative time were (90.8±9.6) and (96.9±9.1) min (P>0.05), the mean blood loss were (80.4±24.2) and (99.5±24.8) ml (P>0.05), the mean warm ischemia time were (21.5±3.4) and (25.3±1.9) min (P0.05), the average cost of renal parenchymal suture material were (1 215.5±101.4) and (2 073.5±301.8) yuan (P<0.05). The warm ischemia time,suture time and suture material costs in the V-Loc group were significantly lower than those in the control group (all P<0.05). Conclusion The application of barbed absorbable suture line in retroperitoneoscopic partial nephrectomy can shorten warm ischemia time and suture time, and save hospitalization costs, with favorable safety and feasibility.

Anesthetic Management for Retroperitoneoscopic Nephrectomy Combined with Inferior Vena Cava Tumor Thrombectomy / 中国微创外科杂志

Objective To evaluate the key points of anesthetic management for retroperitoneoscopic nephrectomy combined with inferior vena cava ( IVC ) tumor thrombectomy. Methods Perioperative clinical data of 3 patients undergoing retroperitoneoscopic nephrectomy combined with IVC tumor thrombectomy from December 2010 to June 2014 were retrospectively analyzed.There were 2 cases of level Ⅰthrombus and 1 case of level Ⅱthrombus.All the patients were given general anesthesia with intubation.Brief inferior vena cava occlusion was performed in the patient with level Ⅱ thrombus. Results The operation was completed smoothly in all the cases without conversions to open surgery. The operating time was 244, 333, and 289 min, respectively. The total IVC control time for level Ⅱ thrombus was 10 min.No intraoperative pulmonary embolism and other severe anesthetic complications occurred. One patient with level ⅠIVC thrombus was extubated and sent back to surgical ward after surgery, and the remaining 2 patients underwent intensive care monitoring overnight and were extubated and discharged to surgical ward on the next day. Conclusions Retroperitoneoscopic nephrectomy and IVC thrombectomy is a brand-new, difficult but feasible procedure. Anesthesiologist should have a full recognition of surgical procedures and make perfect anesthetic plan to ensure close collaboration. Furthermore, circulatory swing during IVC clamping and perioperative severe complications such as pulmonary embolization and massive hemorrhage cannot be neglected.

Clinical analysis of the drainage of perinephric abscess with retroperitoneal laparoscopy / 中华泌尿外科杂志

Objective To discuss the safety and effectiveness of the drainage of perinephric abscess with retroperitoneal laparoscopy.Methods The clinical data of 12 cases undergoing the drainage of perinephric abscess with retroperitoneal laparoscopy were analyzed retrospectively.There were 3 males and 9 females,with a mean age of 47 years.All the 12 cases presented with lumbar pain and fever,7 cases had chill,5 cases had irritative symptom of bladder,and 4 cases had nausea and vomiting.The average course was 9 d,and the average diameter was 6.4 cm.Four cases were in the left side,and 8 in the right side.The main complications included type-2 diabetes (5 cases),type-1 diabetes (1 case),kidney stones (2 cases) and systemic lupus erythematosus (1 case).All the 12 cases were treated with antibiotics.The indexes were recorded,including operative time,intraoperative blood loss,purulent fluid volume,postoperative indwelling time of the drainage tube,postoperative time of body temperature returned to normal,postoperative hospital stay,and complication rate.Results All the 12 operations were successful without peritoneal damage,kidney damage or other complications.The mean operative time was 56 (48-95) min,the mean intraoperative blood loss was 127 (60-150) ml,the mean intraoperative purulent fluid volume drawed out was 128 (120-230) ml,the mean postoperative indwelling time of the drainage tube was 9 (6-12) d,the mean postoperative time of body temperature returned to normal was 3 (2-4) d,and the mean postoperative hospital stay was 10 (7-12) d.All the patients were followed up for an average of 6.5 (6-12) months,no recurrence occured.Conclusions The drainage of perinephric abscess with retroperitoneal laparoscopy has the advantages of definite effectiveness,complete drainage,little injury and rapid recovery.The drainage of perinephric abscess with retroperitoneal laparoscopy by skilled urologists is safe.

Study and clinical application of the anatomy of renal pedicles in retroperitoneoscopic nephrectomy / Estudio y aplicación clínica de la anatomía de los pedículos renales en la nefrectomía retroperitoneoscópica

This work aims to investigate the anatomical basis and clinical application value of renal pedicle locating in retroperitoneoscopic nephrectomy. To summarize the anatomical basis of renal pedicle locating through retrospective analysis of 278 cases of retroperitoneoscopic nephrectomy from July 2007 to September 2009, during which renal pedicle was located at about 2-4 cm below the medial arcuate ligament of the diaphragm in the space between the psoas major muscle and inferior vena cava (abdominal aorta) in the anatomical level of space before psoas. The operation of 278 patients was all successfully completed, where renal pedicle was quickly found. It took 3.5+/-1.3 min to locate the renal pedicle, and 95.6+/-23.8 min to operate. In retroperitoneoscopic nephrectomy, it is most preferable to locate renal pedicle in the space before psoas. The renal pedicle is located exactly at about 2-4 cm below the medial arcuate ligament of the diaphragm in the space between the psoas major muscle and inferior vena cava (abdominal aorta). The time for locating the renal pedicle can be shortened if the surgeon is familiar with the anatomic features of renal pedicle in retroperitoneoscopy, thereby saving the operation time.

El objetivo del estudio fue investigar las bases anatómicas y el valor de la aplicación clínica de la localización del pedículo renal en la nefrectomía retroperitoneoscópica. Para resumir las bases anatómicas de la localizacion del pedículo renal se realizó el análisis retrospectivo de 278 casos de nefrectomía retroperitoneoscópica desde Julio del 2007 a Septiembre del 2009. El pedículo renal se encontró a unos 2-4 cm por debajo del ligamento arqueado medial del diafragma en el espacio entre el músculo psoas mayor y vena cava inferior (o parte abdominal de la aorta) en el nivel anatómico del espacio anterior al músculo psoas mayor. La cirugía de los 278 pacientes fue completada exitosamente, encontrándose rápidamente el pedículo renal. El procedimiento para localizar el pedículo renal tomó 3,5+/-1,3 minutos y la cirugía completa 95.6+/-23.8 minutos. En la nefrectomía retroperitoneoscópica, es preferible localizar el pedículo renal en el espacio anterior al músculo psoas mayor. El pedículo renal se encuentra alrededor de 2-4 cm por debajo del ligamento arqueado medial de la membrana en el espacio entre el músculo psoas mayor y vena cava inferior (parte abdominal de la aorta). El tiempo para localizar el pedículo renal se puede disminuir si el cirujano está familiarizado con las características anatómicas del pedículo renal en la retroperitoneoscopía, ahorrando así el tiempo total de la cirugía.

Clinical analysis of retroperitoneal laparoscopic renal adipose capsule outer pathway in the treatment of chyluria / 重庆医学

Objective To evaluate the surgical techniques and clinical efficacy of retroperitoneoscopic ligation of renal lymphatic vessels outside adipose capsule and inside adipose capsule for comparison in the treatment of chyluria.Methods Retrospective anal-ysis of the retroperitoneal laparoscopic adipose capsule of kidney pedicle lymphatic duct ligation(group Ⅰ)and adipose capsule pathways in the kidney totally or subtotally free renal pedicle lymphatic ligation(group Ⅱ)and 1 1 1 patients with chyluria clinical data,compared two groups of operation time,bleeding volume,the rate of analgesia,postoperative gastrointestinal function recovery time,drainage time,postoperative recovery time,postoperative hospital stay and postoperative complications and other index differ-ence.Results Retroperitoneal laparoscopic operation group of adipose capsule in operation time,bleeding volume,postoperative an-algesia,postoperative gastrointestinal function recovery time,drainage time,postoperative recovery time,postoperative hospital stay and postoperative complications were better than the adipose capsule of kidney totally or subtotally free operation group,the differ-ence was statistically significant(P<0.05).Conclusion Retroperitoneal laparoscopic renal adipose capsule of kidney pedicle lym-phatic disconnection for the treatment of chyluria effect,and adipose capsule operation ways,the method less trauma,quicker recov-ery,can completely replace the renal adipose capsule total or Sub-total of free kidney pedicle lymphatic disconnection operation,wor-thy of clinical application.

Empleo de la cirugía lumboscópica en pacientes atendidos en el Centro Nacional de Cirugía de Mínimo Acceso / Use of lumboscopic surgery in patients cared for at the National Center for Minimal Access Surgery

Introducción: inicialmente los urólogos accedieron al tracto urinario superior mediante el abordaje transperitoneal para luego, desarrollar el abordaje lumboscópico o la retroperitoneoscopia, mediante la cual se accede directamente al retroperitoneo y se evitan las lesiones de los órganos intrabdominales y la contaminación de la cavidad abdominal con la orina. Objetivo: caracterizar los resultados obtenidos con el empleo de la cirugía lumboscópica como tratamiento quirúrgico. Métodos: se realizó una investigación retrospectiva, descriptiva y longitudinal en el Centro Nacional de Cirugía de Mínimo Acceso, en 327 pacientes a los que se les realizó cirugía mediante abordaje lumboscópico. Resultados: las intervenciones quirúrgicas que más se realizaron fueron la ureterolitotomía (55,9 por ciento) y la nefrectomía simple (17,7 por ciento). El tiempo quirúrgico medio fue de 120 min. La conversión fue necesaria en el 2,5 por ciento de los pacientes. Las complicaciones transoperatorias se produjeron en el 10,7 por ciento de los pacientes y de ellas fueron mayores solo el 1,2 por ciento. La hipercapnia fue una complicación transoperatoria que se presentó en un 11,9 por ciento en relación con la vía de acceso directa al retroperitoneo. Conclusiones: la ureterolitotomía fue la intervención más frecuente; los tiempos quirúrgicos dependieron de la complejidad de los procedimientos. Esta vía de abordaje fue factible por su bajo porcentaje de conversión a otro acceso quirúrgico, así como segura por su bajo índice de complicaciones mayores, lo que la hace útil para intervenciones quirúrgicas urológicas del tracto urinario superior

Introduction: at first, urologists accessed the upper urinary tract transperitoneally. Later on they developed the lumboscopic approach or retroperitoneoscopy, accessing the retroperitoneum directly, thus preventing intra-abdominal lesions and the contamination of the abdominal cavity with urine. Objective: characterize the results obtained with the use of lumboscopic surgery as surgical treatment. Methods: a retrospective longitudinal descriptive study was conducted at the National Center for Minimal Access Surgery with 327 patients, who underwent lumboscopic approach surgery. Results: the most common surgical interventions were ureterolithotomy (55.9 percent) and simple nephrectomy (17.7 percent). Mean surgical time was 120 min. Conversion was required in 2.5 percent of the patients. Transoperative complications occurred in 10.7 percent of the patients, and only 1.2 percent of them were major. Hypercapnia was a transoperative complication occurring in 11.9 percent in relation to the direct route of access to the retroperitoneum. Conclusions: ureterolithotomy was the most common intervention. Surgical times were in accordance with the complexity of procedures. Feasibility of this route of access was due to its low percentage of conversion to a different surgical access route. Its safety was due to its low rate of major complications, which makes it useful for urological surgical interventions of the upper urinary tract.

Retroperitoneoscopic adrenalectomy in pheochromocytoma

Since the first laparoscopic adrenalectomy, the technique has evolved and it has become the standard of care for many adrenal diseases, including pheochromocytoma. Two laparoscopic accesses to the adrenal have been developed: transperitoneal and retroperitoneal. Retroperitoneoscopic adrenalectomy may be recommended for the treatment of pheochromocytoma with the same peri-operative outcomes of the transperitoneal approach because it allows direct access to the adrenal glands without increasing the operative risks. Although technically more demanding than the transperitoneal approach, retroperitoneoscopy can shorten the mean operative time, which is critical for cases with pheochromocytoma where minimizing the potential for intra-operative hemodynamic changes is essential. Blood loss and the convalescence time can be also shortened by this approach. There is no absolute indication for either the transperitoneal or retroperitoneal approach; however, the latter procedure may be the best option for patients who have undergone previous abdominal surgery and obese patients. Also, retroperitoneoscopic adrenalectomy is a good alternative for treating cases with inherited pheochromocytomas, such as multiple endocrine neoplasia type 2A, in which the pheochromocytoma is highly prevalent and frequently occurs bilaterally.

Effect of auxiliary trocar on obese patients treated with retroperitoneoscopic radical nephrectomy / 中华泌尿外科杂志

Objective To evaluate the effect of auxiliary trocar located on various positions on obese patients treated with retroperitoneoscopic radical nephrectomy.MethodsRetrospective analysis was performed for 61 consecutive obese patients who underwent retroperitoneoscopic radical nephrectomy for localized renal cell carcinoma at our institution from March 2004 to December 2010.An auxiliary trocar was placed into retroperitoneal space according to the position of tumor.It was placed infro-costal magin in the mid-axillary line with uppre-median pole tumor,and 4 cm medial to mid-axillary line and 1 cm cephalad to illac spine with lower-median pole,respectively.ResultsAll 61 patients were completed successfully with no conversion to open surgery.Mean operating time was ( 153.1 ± 23.5 ) min.Mean estimated blood loss was (57.6 ±29.7) ml.Mean hospital stay after operation was (5.7 ±2.6) d.The rupture of peritoneum and liquefaction of fat were occurred in 5 and 4 patients respectively.There was no major intraoperative and postoperative complications occurred.Conclusions Reasonable position of the auxiliary trocar according to the tumor's location would be safe and feasible on obese patients treated with retroperitoneoscopic radical nephrectomy.Obese patients with localized renal cell carcinoma would better benefit from minimally invasive procedure.

Anestesia en procedimientos lumboscópicos: Experiencia en el Centro Nacional de Cirugía de mínimo acceso / Anesthesia to retroperitoneal procedures: Experience in the National Centre for Minimal Access Surgery

Introducción: La cirugía urológica laparoscópica ha avanzado de manera considerable en los últimos años, introduciéndose el abordaje retroperitoneal como una opción ventajosa. Objetivos: Presentar la experiencia en la conducción anestésica perioperatoria de los procedimientos lumboscópicos. Método: Investigación retrospectiva, descriptiva y longitudinal. Se incluyeron todas las historias clínicas de los pacientes programados para cirugía lumboscopica urológica en el Centro Nacional de Cirugía de Mínimo Acceso (CNCMA) desde agosto de 1999 a diciembre del 2010. De las Historias clínicas, se extrajeron las variables: edad, sexo, peso, tiempo quirúrgico, enfermedades asociadas, capnometría y complicaciones con significación clínica durante el acto anestésico quirúrgico y postoperatorio. Para todas las variables cuantitativas se determinaron estadígrafos descriptivos (media, mínimo, máximo, desviación estándar, coeficiente de variación). Para todas las variables cualitativas se realizaron tablas de frecuencias. El análisis estadístico se realizó a través del paquete SPSS versión 11.05. Los resultados fueron expresados a través de tablas y gráficos. Resultados. Se realizaron 324 casos, 211 hombres y 113 mujeres. El proceder quirúrgico fue: nefrectomías 58, pieloplastia 1, pielolitotomías 5, ureterolitotomías 183 y quistes renales 77. De ellos 30 pacientes presentaron enfisema subcutáneo lumbar y 82 % de los mostraron valores de CO2 al final de la espiración superior a 50 mmHg, al menos en una medición intraoperatoria. No se constató evidencia clínica de embolismo gaseoso. Conclusiones: El éxito de los procedimientos lumboscópicos depende de una correcta selección de los pacientes y del trabajo en equipo anestesiólogo cirujano.

The laparoscopic urological surgery has advanced considerably in recent years, introducing the retroperitoneal approach as an advantageous option. Objectives: To present the experience of driving anesthetic perioperative retroperitoneal procedures. Method: Research retrospective, descriptive and longitudinal. We included all medical records of patients scheduled for urological retroperitoneal surgery at the National Centre for Minimal Access Surgery (CNCMA) from August 1999 to December 2010. Stories of clinical variables were extracted: age, sex, weight, surgical time, associated diseases, capnometry and clinically significant complications during anesthesia and post surgical. For all quantitative variables were determined descriptive statistics (mean, minimum, maximum, standard deviation, coefficient of variation). For all variables were performed frequency tables. Statistical analysis was performed using SPSS version 11.05. The results were expressed through tables and graphs. Results: 324 cases were performed, 211 men and 113 women. The surgical procedure was: 58 nephrectomy, pyeloplasty 1, pyelolithotomies 5, 183 and renal cysts ureterolithotomies 77. Of these 30 patients had lumbar subcutaneous emphysema and showed 82% of CO2 values at the end of expiration than 50 mmHg, at least one intraoperative measurement. Not found clinical evidence of air embolism. Conclusions: The success of retroperitoneal procedures depends on proper patient selection and teamwork anesthesiologist-surgeon.

A Study of the anatomy of the renal pedicle during retroperitoneoscopic nephrectomy / 中华泌尿外科杂志

ObjectiveTo study the anatomical characteristics of the renal pedicle and its clinical application during retroperitoneoscopic nephrectomy.MethodsThe imaging, surgical video and clinical data of 278 cases undergoing retroperitoneoscopic nephrectomy between July 2007 and September 2009 were retrospectively analyzed. The renal pedicle was found located at the psoas and the medial arcuate ligament of the diaphragm for anatomic landmark before the gap of the psoas. A statistical analysis of the mean operative time, the mean time to look for the renal pedicle, the mean intraoperative estimated blood loss, the mean time to ambulation, the mean time to resuming oral intake, the mean postoperative hospital stay day and the rate of complications was performed.ResultsAll the operations were performed successfully, with no conversion to open and blood transfusion. The mean time to find the renal pedicle was (3.5 ± 1.3 ) min, the mean operative time was (95.6 ±23.8) min, the mean estimated blood loss was (72.4 ±27.5) ml, the mean time to resuming oral intake was (2.1 ±0.7) d, the mean time to ambulation was (1.8 ±0.9) d, the mean postoperative hospital stay was (8.5 ± 2.7 ) d.ConclusionsDuring retroperitoneoscopic nephrectomy, the best anatomical space to look for the renal pedicle is the space before the psoas muscle. The exact location of the renal pedicle is under the diaphragm medial arcuate ligament about 2 - 4 cm, in the gap of the psoas muscle and the vena cava (abdominal aorta). Following this procedure could reduce the time to look for the renal pedicle, thus reducing operative time.

Schwannoma retroperitoneal benigno tratado por retroperitoneoscopia: relato de caso / Retroperitoneal benign schwannoma treated by retroperioneal laparoscopic approach: a case report

Apesar da laparoscopia ser amplamente utilizada na abordagem de doenças retroperitoneais, ainda são poucos os relatos de ressecção laparoscópica de tumores retroperitoneais. Este estudo descreve um caso de Schwannoma retroperitoneal benigno tratado por retroperitoneoscopia e discute a dificuldade no diagnóstico e as vantagens do acesso retroperioneal por via laparoscópica.

In spite laparoscopy has been widely utilized in the management of retroperitoneals pathologies, there are still few reports of laparoscopic resections of retroperitoneals tumors. We report a case of a retroperitoneal benign Schwannoma treated by retroperitoneoscopy. The troubles on diagnostic and advantages of the retroperitoneal approach by laparoscopic way are discussed.

Safety,efficacy and reliability of the IUPU technique in setting up the retroperitoneal cavity for retroperitoneoseopy——with 1114 cases experience / 中华泌尿外科杂志

Objective To assess the safety,efficacy and reliability of IUPU(Abbreviation of Institute of Urology,Peking University)technique in setting up the retroperitoneal cavity for retroperitoneoscopy. Methods From February 1996 to March 2006,more than 1100 retroperitoneoscopic procedures were performed with the IUPU technique in setting up the retroperitoneal cavity,First,at the cross point of the line 2 cm above the iliac crest and the longitudirml line close to the anterior auxiliary line,a 1 cm skin incision was made and the Veress needle was penetrated into the retroperitoneal space(RPS)with a 0°-30° angle to the perpendicular line.The CO2 gas was pumped into the RPS till the pressure increases to 14mmHg and the first port was inserted into the RPS.The laparoscope was then inserted into the RPS through the first port and kept swinging right and left with its tip and trunk tO set up the retroperitoneal cavity.Other 2 ports were put into the RPS at cross points of the sub-costal line and anterior and posterior auxiliary lines under monitor observation.Then other appliances are introduced into the RPS to expand the cavity.More than 1100 procedures had been done with the IUPU technique,including 54 cases of simple nephrectomy (loss of function due to tuberculosis,hydronephrosis and atrophy), 188 radical nephrectomy, 154 ureteronephrectomy, 344 adrenalectomy, 302 renal cyst decortications, 35 partial nephrectomy, 37 pyeloplasty. Results The average time for the IUPU technique was (5.4±2.8)min (range 4. 5 to 14. 5 min) to set up the RPS. Complications included converting to open surgery due to bleeding in 8 cases(8/1114,0. 72%) when the first port was inserted into the RPS and entered into the peritoneal cavity for the first port penetration in 32 cases (32/1114,2. 87%),although the retroperitoneal cavity could be set up successfully by adjusting the laparoscope into the RPS.There was no injury to other viscera. Conclusions The IUPU technique is safe, efficient and reliable in setting up the RPS and no other special instrument is needed. It can be finished within 5 min on skilled hands and is valuable as a routine method to set up the retroperitoneal cavity.

Preliminary study on the value of laparoscopic ultrasound in urinary laparoscopic surgery / 中国医师杂志

Objective To evaluate the clinical value of laparoscopic uItrasonography ( LUS) in u-rinary laparoscopic surgery .Methods In 6 cases of urological laparoscopic surgery , laparoscopic ultra-sound examination were taken , including 3 cases of simple renal cysts , 1 case of adrenal pheochromocyto-ma, 2 cases of hamartoma , were excised under the LUS guidance and the results were compared with the traditional simple laparoscopic surgery .Results With laparoscopic uItrasonography guidance , the bounda-ry and blood supply of cyst or tumor could be shown more clearly compared with trans -abdominal ultrasound . We could differ the tumors from dilated pelvis and renal calices , So the damage to the collecting system and renal blood vessels were avoided .With LUS guidance , tumors were excised more completely , so that re-mained tumor tissues would be avoided and normal renal tissues would be protected .Conclusion LUS may provide more precise surgical information and may play an important role guiding laparoscopic operation in urinary surgery .

Extroperitoneal laparoscopic retroperitoneal lymph node dissection(report of 7 cases) / 中华泌尿外科杂志

Objective To investigate the techniques of laparoscopic retroperitoneal lymph node dissection(LRPLND)through extraperitoneal approach. Methods Seven non-seminomatous germ cell testicular tumor(NSGCT)patients of clinical stage Ⅰ underwent LRPLND through extraperitoneal approach.The average age was 31(27-39 years old),the average weight was 62 kg(weight 58-72 kg).Pathological examination revealed 2 testis mixed carcinoma(major of embryonal carclnoma and seminoma),2 yolk sac tumor,1 ehoriocarcinoma,2 teratoma with seminoma.Two of them were in right side,and 5 in left.All the chest X-ray,abdominal CT and bone scanning of them were normal before operation.All patients were general anesthetized.Three or 4 trocars were placed,from 2 of them two gasbags were used to expand the retroperitoneal space at volume of 800-900 ml.The retroperitoneal fat was cleared off from the surface of Gerota's fascia to iliac fossa and the plane spance betwwwn anterior rena fascia and posterior peritoneum was separated In the same way the Plane between dorsal renal and the surface of psoas major and quadratus lumborum unto iliae lossa was exposed.Abdominal aorta or vena cava was exposed,then divided and dissected free from surfaee of psoas maior.The conflux of renal vein and testicular vein at the deep face of renal artere(left)was exposed,then testicular vein was ligated and divided it at its end.Fat and lymph tissue between ureter and vessels was dissected to the crotch of abdominal aorta or inferior vena cava.The primary inguinal incision of testectomy was then excided.Normal antegrade ejaculation recovered in 1 month postoperatively. Results The initial 2 operations were converted to open way as the peritoneum were penetrated largely.The other 5 operations were successful.The average operating time was 285 min(245-350 min),intraoperative blood loss was 100-250 ml.Four patients'pathologic results accorded with clinical staging,and 2 positive lymph nodes were found in the other one.The average number of lymph node resected was 25.6 counts(22-31).Follow-up for 3-20 months,chest X-ray and abdominal CT revealed no evidence of recurrence or distant metastasis,and serum tumor markers were in normal range.Normal antegrade ejaculation recovered in 1 month postoperatively. Conclusions The technique through extraperitoneal approach could be applied for LRPLND.It might be an approach for diagnosis and treatment of stage Ⅰ NSGCT.

Cirugía renal retroperitoneoscópica con un instrumento en posición prono; una alternativa al espacio / Retroperitoneoscopic renal surgery performed with a single instrument in prone position, an alternative for endoscopic surgical space

Objetivo: El espacio retroperitoneal es limitado, hecho que se hace más evidente en laparoscopia pediátrica. El objetivo es presentar nuestra experiencia con la posición retroperitoneoscópica en prono utilizando un instrumento de trabajo, analizando las ventajas y detalles técnicos que favorecerían su aplicación. Metodos: Seguimiento prospectivo de pacientes operados por el autor principal con técnica retroperitoneoscopia en posición prono. Con el paciente en posición prono, se crea el espacio retroperitoneal con técnica cerrada y balón realizado con dedo guante. Bajo visón directa, un segundo trocar es insertado en la punta de la 11ª costilla. La fascia de Gerota es disecada hasta identificar el hilio renal. Luego de dividir los vasos ayudado por la fuerza de gravedad, se realiza la nefrectomía. La pieza es removida íntegramente o con bolsa ad-hoc. Se analizó datos epidemiológicos, diagnóstico, seguimiento, complicaciones y comparación entre centros. Resultados: Entre el 1 de septiembre de 2005 y el 31 de agosto de 2006, se operaron 8 pacientes con la técnica descrita; 5 niñas y 3 niños. Su edad y peso promedio fueron 3 años (rango 1-4a) y 19 kilos (rango 9-30k) respectivamente. Los diagnósticos fueron riñón multicístico (n=4) atrofia renal por RVU (n=3) y doble sistema renal (n=1). Se realizaron 5 nefrectomías y 3 nefroureterectomías con un tiempo promedio de cirugía de 103 min. (rango 60-180). Todos los pacientes fueron completados laparoscópicamente con 1 instrumento de trabajo. El tiempo de hospitalización promedio del grupo fue de 24 hrs (rango 20-36). No hubo complicaciones perioperatorias. El tiempo de seguimiento promedio es de 11 meses (rango 7-15) sin complicaciones hasta la fecha. Conclusión: Esta serie muestra que la retroperitoneoscopia en posición prono ofrece un espacio de trabajo adecuado. Esto podría explicarse por el uso de la fuerza de gravedad como tracción...

Objective: The retroperitoneal space is limited for endoscopic surgery; this is a more obvious fact in paediatric laparoscopy. The aim of this study is to show our experience with the posterior prone retroperitoneoscopy (RP) using a single working instrument, analyzing advantages and technical issues, which may improve its application. Methods: Prospective study of all patients operated by the main author using a posterior prone RP technique in two institutions. With the patient in prone position, a retroperitoneal working space is created using close technique and the aid of a homemade balloon. Under direct vision, the working port is placed at the tip of the 11th rib. Gerota´s fascia is incised and hilar vessels identified. The vessels are divided using gravity as traction. The specimen is removed via camera port or using endobag. Demographic, follow-up and complications data were compared between both centres. Results: In a year period (1st September 2005- 31st August 2006), 8 patients underwent the described technique; 5 girls and 3 boys. Mean age and weight were 3 years (1-4) y 19 kilos (9-30), respectively. Clinical diagnoses were Multicystic Dysplastic Kidney (n=4) dysplastic kidney with VUR (n=3) y and Duplex Kidney (n=1). 5 nephrectomies and 3 nephroureterectomies were performed with a mean surgical time of 103 min (60-180). All procedures were completed with a single working instrument. Mean hospital stay was 24 hrs. (20-36). There were no perioperative complications. Mean follow-up time was 11 month (7-15). Conclusions: This series showed that posterior prone PR offers an adequate working endoscopic space. This might be explained by the use of gravity as a traction, which allows surgical team to work with a single instrument.The authors recommend this technique for RP in children, especially for nephrectomies.

Retroperitoneoscopic renal pedicle lymphatic disconnection in the management of chyluria / 重庆医科大学学报

Objective:To summarize the experience of retroperitoneoscopic renal pedicle lymphatic disconnection in the management of chyluria,and to investigate a new minimally invasive treatment of chyluria. Methods:9 cases of chyluria were treated by retroperitoneoscopic renal pedicle lymphatic disconnection from Jan 2005 to Dec 2008 with 7 male ones and 2 female ones. The average age was 48 years. 8 of 9 cases obtained success and 1 of 9 cases was converted to open surgery. Operation time, blooding volume, postoperative complication and hospitalization stay, and the operative effect were observed. Results:The operation time was from 65 to 105 min,with the average of 70 min. The blooding volume was from 50 to 100ml, with the average of 60ml. Chyluria disappeared immediately after operation in all patients. Postoperative stay was from 5 to 7d and no complication happened. Conclusion:Retroperitoneoscopic renal pedicle lymphatic disconnection for chyluria is a effective and efficienl method in the management of chyluria. And it is also safe , minimally invasive , with less blood loss, fewer complications , and short hospital stay .