Side-specific factors for intraoperative hemodynamic instability in laparoscopic adrenalectomy for pheochromocytoma: a comparative study.

BACKGROUND: Adrenalectomy for pheochromocytoma (PHEO) is challenging because of the high risk of intraoperative hemodynamic instability (HDI). This study aimed to compare the incidence and risk factors of intraoperative HDI between laparoscopic left adrenalectomy (LLA) and laparoscopic right adrenalectomy (LRA). METHODS: We retrospectively analyzed two hundred and seventy-one patients aged > 18 years with unilateral benign PHEO of any size who underwent transperitoneal laparoscopic adrenalectomy at our hospitals between September 2016 and September 2023. Patients were divided into LRA (N = 122) and LLA (N = 149) groups. Univariate and multivariate logistic regression analyses were used to predict intraoperative HDI. In multivariate analysis for the prediction of HDI, right-sided PHEO, PHEO size, preoperative comorbidities, and preoperative systolic blood pressure were included. RESULTS: Intraoperative HDI was significantly higher in the LRA group than in the LLA (27% vs. 9.4%, p < 0.001). In the multivariate regression analysis, right-sided tumours showed a higher risk of intraoperative HDI (odds ratio [OR] 5.625, 95% confidence interval [CI], 1.147-27.577, p = 0.033). The tumor size (OR 11.019, 95% CI 3.996-30.38, p < 0.001), presence of preoperative comorbidities [diabetes mellitus, hypertension, and coronary heart disease] (OR 7.918, 95% CI 1.323-47.412, p = 0.023), and preoperative systolic blood pressure (OR 1.265, 95% CI 1.07-1.495, p = 0.006) were associated with a higher risk of HDI in both LRA and LLA, with no superiority of one side over the other. CONCLUSION: LRA was associated with a significantly higher intraoperative HDI than LLA. Right-sided PHEO was a risk factor for intraoperative HDI.

Feasibility of laparoscopic adrenalectomy in adrenal masses greater than 5 centimeters: a systematic review and meta-analysis.

Background: Laparoscopic adrenalectomy (LA) has emerged as the primary treatment for adrenal masses. This systematic review and meta-analysis assessed LA's feasibility, safety, effectiveness, and complications for adrenal masses exceeding 5 cm. Methods: The study was conducted using PRISMA guidelines with PROSPERO registration No. CRD42023462901. Adults with unilateral adrenal masses >5 cm who underwent unilateral LA were included. Intraoperative and postoperative measurements and complications were assessed. A systematic literature review employed a comprehensive search strategy which was last searched on September 8, 2023, through PubMed, Google Scholar, Web of Science, and ProQuest databases. Meta-analysis was utilized to analyze the outcomes. Risk of bias was assessed using the Newcastle-Ottawa scale. Results: This systematic review encompassed 25 studies involving 963 patients who underwent LA. Tumor size varied 7.05 cm [95% confidence interval (CI): 6.24-7.70], with 50% on the right and 45% on the left. The subgroup meta-analysis comparing the transperitoneal and retroperitoneal approaches revealed the transperitoneal approach h was utilized for the largest tumor size with a mean of 12.10 cm (95% CI: 11.30-12.96), compared to the retroperitoneal approach 5.83 cm (95% CI: 5.52-6.14). Notably, the mean operative time across studies was 137.4 minutes (95% CI: 113.36-150.94), bleeding prevalence was 0.02% (95% CI: 0.01-0.03%), and average blood loss was 110.6 mL (95% CI: 78.2-156.3). Postoperative complications such as pulmonary edema, pulmonary embolism, gastric dysfunction, and wound infection were very low, ranging from 0.03% to 0.4%. Out of 963 patients, only 49 were converted to open surgery. Patient hospital stay averaged 3.72 days (95% CI: 2.97-4.66); blood transfusion was required in 1.3% (95% CI: 0.30-8.88%). Conclusions: The feasibility and safety of LA for tumors exceeding 5 cm in size have notable implications for intraoperative and postoperative outcomes. Underreporting in the included studies may impact the generalizability of findings.

Comparison of Oncological Outcomes between Transperitoneal and Retroperitoneal Approaches in Laparoscopic Nephroureterectomies for Upper Tract Urothelial Carcinoma.

Background and Objectives: Our aim was to clarify the oncological outcomes of the two different approaches to laparoscopic nephroureterectomies (LNUs) in Japan, and to examine whether there were any significant differences between the transperitoneal approach and the retroperitoneal approach. Materials and Methods: We retrospectively evaluated patients who underwent an LNU for upper tract urothelial carcinoma (UTUC) from January 2013 to December 2022. We identified 52 patients who underwent a transperitoneal LNU (tLNU) and 93 who underwent a retroperitoneal LNU (rLNU). We adopted age, smoking, and pT-stage matching, and 43 patients were classified in each group. We investigated the time from surgery to recurrence (RFS: recurrence-free survival), the time to death (OS: overall survival), and the time to non-urothelial-tract recurrence-free survival (NUTRFS). A Cox regression analysis was performed to evaluate the risk factors that influenced recurrence. Results: There were no significant differences in the RFS, OS, and NUTRFS between the two matched groups. In the multivariate Cox regression analysis, the pT stage (pT3≥ vs. pT2≤) had an HR = 2.09 and a p = 0.01, and was an independent prognostic risk factor regarding cancer recurrence. Conclusions: There were no significant differences in the oncological outcomes between the tLNU and rLNU groups. It is suggested that the transperitoneal approach should be selected for LNUs.

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

INTRODUCTION: 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. METHODS: 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. RESULTS: 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]. CONCLUSIONS: 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.

Transperitoneal vs retroperitoneal laparoscopic radical nephrectomy: a double-arm, parallel-group randomized clinical trial.

OBJECTIVE: To compare the outcomes of patients undergoing Retroperitoneal laparoscopic Radical nephrectomy (RLRN) and Transperitoneal laparoscopic Radical nephrectomy (TLRN). METHODS: A total of 120 patients with localized renal cell carcinoma were randomized into either RLRN or TLRN group. Mainly by comparing the patient perioperative related data, surgical specimen integrity, pathological results and tumor results. RESULTS: Each group comprised 60 patients. The two group were equivalent in terms of perioperative and pathological outcomes. The mean integrity score was significantly lower in the RLRN group than TLRN group. With a median follow-up of 36.4 months after the operation, Kaplan-Meier survival analysis showed no significant difference between RLRN and TLRN in overall survival (89.8% vs. 88.5%; P = 0.898), recurrence-free survival (77.9% vs. 87.7%; P = 0.180), and cancer-specific survival (91.4% vs. 98.3%; P = 0.153). In clinical T2 subgroup, the recurrence rate and recurrence-free survival in the RLRN group was significantly worse than that in the TLRN group (43.2% vs. 76.7%, P = 0.046). Univariate and multivariate COX regression analysis showed that RLRN (HR: 3.35; 95%CI: 1.12-10.03; P = 0.030), male (HR: 4.01; 95%CI: 1.07-14.99; P = 0.039) and tumor size (HR: 1.23; 95%CI: 1.01-1.51; P = 0.042) were independent risk factor for recurrence-free survival. CONCLUSIONS: Our study showed that although RLRN versus TLRN had roughly similar efficacy, TLRN outperformed RLRN in terms of surgical specimen integrity. TLRN was also significantly better than RLRN in controlling tumor recurrence for clinical T2 and above cases. TRIAL REGISTRATION: Chinese Clinical Trial Registry ( https://www.chictr.org.cn/showproj.html?proj=24400 ), identifier: ChiCTR1800014431, date: 13/01/2018.

Transperitoneal vs. Retroperitoneal Approach in Laparoscopic Partial Nephrectomy for Posterior Renal Tumors: A Retrospective, Multi-Center, Comparative Study.

Purpose: The aim of our study is to compare the perioperative, functional, and oncological outcomes of laparoscopic transperitoneal partial nephrectomy (LTPN) and laparoscopic retroperitoneal partial nephrectomy (LRPN) for posterior cT1 renal tumors. Methods: We retrospectively collected data on all patients who consecutively underwent LTPN and LRPN for posterior cT1 renal tumors in three different centers from January 2015 to January 2023. Patients with a single, unilateral, cT1 renal mass, located in the posterior renal surface were included. Patients' data regarding perioperative, functional, and oncological outcomes were collected from medical records and statistically analyzed and compared. Results: A total of 128 patients was obtained, with 53 patients in the LPTN group and 75 patients in the LRPN group. Baseline characteristics were similar. Warm ischemia time (WIT) (18.8 vs. 22.6 min, p = 0.002) and immediate postoperative eGFR drop (-6.1 vs. -13.0 mL/min/1.73 m2, p = 0.047) were significantly lower in the LPTN group. Estimated blood loss (EBL) (100 vs. 150 mL, p = 0.043) was significantly lower in the LRPN group. All other perioperative and functional outcomes and complications were similar between the groups. The positive surgical margin (PSM) rate was lower in the LRPN group, although without statistical significance (7.2% vs. 13.5%, p = 0.258). Surgical success defined by Trifecta (WIT ≤ 25 min, no PSM, and no major postoperative complication) was similar between both approaches. Conclusions: LTPN has significantly shorter WIT and a significantly smaller drop in immediate eGFR when compared to LRPN for posterior renal tumors. On the other hand, LRPN has significantly less EBL than LTPN. LRPN demonstrated fewer PSMs than LTPN, albeit without statistical significance. In terms of overall surgical success, as defined by Trifecta, both approaches achieved similar results.

Image-guided percutaneous cholecystostomy: challenging the norms.

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

Clinical study of 3D laparoscopic radical prostatectomy by transperitoneal and extraperitoneal approaches.

OBJECTIVE: Comparison of the clinical effectiveness and safety of three-dimensional transperitoneal laparoscopic radical prostatectomy (3D TLRP) versus 3D extraperitoneal LRP (3D ELRP) for prostate cancer. MATERIALS AND METHODS: To retrospectively analyze the clinical and regular postoperative follow-up data of patients who underwent 3D LRP performed by the same attending surgeon at the Affiliated Hospital of Bengbu Medical College between 2017 and 2022. A total of 82 patients who met the criteria were included. They were divided into 3D TLRP (n = 39) and 3D ELRP groups (n = 43) according to the surgical approach. The preoperative, intraoperative, and postoperative data were compared. RESULTS: There were no statistically significant differences in preoperative characteristics between the two groups. There were also no statistically significant differences between the 3D TLRP and 3D ELRP groups in terms of intraoperative blood transfusion rate (12.82% vs. 2.33%), positive lymph node rate (11.11% vs. 2.38%), positive surgical margin rate (12.82% vs. 6.98%), pathological Gleason score, postoperative clinical stage, perioperative complication rate (10.26% vs. 4.65%), immediate urinary control rate (56.41% vs. 58.14%), 3-month postoperative urinary control rate (76.92% vs. 74.42%), 6-month postoperative urinary control rate (87.18% vs. 83.72%), 6-month postoperative biochemical recurrence rate (7.69% vs. 9.30%), or 6-month postoperative sexual function recovery rate (2.56% vs. 2.33%) (P > 0.05). Compared with the 3D ELRP group, the 3D TLRP group had a longer operative time (232.36 ± 48.52 min vs. 212.07 ± 41.76 min), more estimated blood loss (150.000 [100.0, 200.0] vs. 100.000 [100.0, 125.0]), longer recovery of gastrointestinal function (2.72 ± 0.89 vs. 2.26 ± 0.88), longer duration of drainage tube retention (5.69 ± 1.79 vs. 4.28 ± 2.68), and longer hospitalization time (12.54 ± 4.07 vs. 10.88 ± 2.97), with statistical significance (P < 0.05). CONCLUSION: 3D TLRP and 3D ELRP have similar oncologic and functional outcomes. Clinically, physicians can choose a reasonable procedure according to the patient's specific situation and their own surgical experience.

Laparoscopic Adrenalectomy: Tailoring Approaches for the Optimal Resection of Adrenal Tumors.

In this study, we investigated the outcomes of laparoscopic approaches for adrenal tumor resection in 67 patients from a single center with a median age of 51 (range 40-79). Predominantly comprising women, the majority of patients were overweight or obese. Adrenal tumors larger than 6 cm were mostly treated using the laparoscopic transperitoneal method (p < 0.001). Our results revealed that patients subjected to the retroperitoneal approach exhibited quicker recovery, as evidenced by faster resumption of oral intake and ambulation, along with reduced intraoperative blood loss and shorter hospitalization (p-value < 0.05). In contrast, patients subjected to the transperitoneal approach experienced minimal complications, though not statistically significant, despite the technique's intricacy and slower recovery. These findings emphasize the significance of tailoring the surgical approach to individual patient characteristics, with particular emphasis on the tumor size. The choice between the retroperitoneal and transperitoneal methods should be informed by patient-specific attributes to optimize surgical outcomes. This study underscores the need for a comprehensive evaluation of factors such as tumor characteristics and postoperative recovery when determining the most suitable laparoscopic approach for adrenal tumor resection. Ultimately, the pursuit of individualized treatment strategies will contribute to improved patient outcomes in adrenal tumor surgery.

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

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

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

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

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

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

Surgical techniques and oncological outcomes of pure transperitoneal laparoscopic radical nephroureterectomy for upper urinary tract urothelial carcinoma.

Background: Open radical nephroureterectomy (RNU) with bladder cuff excision is the standard treatment for upper urinary tract urothelial carcinoma (UTUC). Traditional laparoscopic radical nephroureterectomy (LSRNU) is not minimally invasive enough due to the complex surgical procedure. This study aims to discuss the clinical feasibility and oncological outcomes of pure transperitoneal LSRNU for UTUC. Methods: Between July 2010 and December 2020, 115 patients were admitted to the hospital with the diagnosis of UTUC treated with pure LSRNU by one surgeon. A special laparoscopic bulldog clamp was placed at the bladder cuff before cutting and suturing. The clinical and follow-up data were preoperatively collected and analyzed. Overall survival (OS) and cancer-specific survival (CSS) were estimated by the Kaplan-Meier method. Results: All surgeries were completed uneventfully in this cohort. The mean operative time was 145.69 minutes. The mean estimated blood loss was 56.61 mL. The mean removal time of the drain was 3.46 days. The mean time of having liquid diet was 1.32 days, and the ambulation time was 1.50 days. All surgeries were effectively completed, and no case required open conversion. According to the Clavien-Dindo classification system, postoperative complications occurred in two patients (II, III). The mean length of postoperative hospital stay was 5.78 days. The mean follow-up duration was 54.50 months. Recurrence in the bladder was 16.0% (15/94), compared with 4.6% (4/87) in the contralateral upper tract. The 5-year OS and CSS rates were 78.9% and 81.4%, respectively. Conclusions: Pure transperitoneal LSRNU is a safe and effective minimally invasive technology for the treatment of UTUC.

Comparison of extra-peritoneal cesarean section with conventional trans-peritoneal cesarean section: An open label randomized controlled trial.

Objective: To ascertain whether extra-peritoneal approach is superior to conventional trans-peritoneal approach of cesarean section in terms of fetus delivery time, intra-operative and postoperative outcomes, including return of bowel activity and pain. Study design: An open-label randomized controlled trial conducted over one year and six months at a tertiary care center in India. As per sample size calculation, 68 women enrolled in the study; 34 underwent extra-peritoneal, and another 34 underwent trans-peritoneal cesarean section after randomization. Statistical analysis was done with independent sample 't' test, chi-squared test, and fisher's exact test. Results: Baseline characteristics were comparable in both groups. Fetus delivery time was significantly higher in extra-peritoneal than trans-peritoneal cesarean section (14.26 ± 1.26 vs. 9.38 ± 1.83 min; p = <0.001). Total operation time was also higher in extra-peritoneal than trans-peritoneal approach (63.24 ± 12.74 vs. 57.41 ± 8.62 min; p = 0.027). Whereas average blood loss was comparable in both groups (733.82 ± 219.06 vs. 694.12 ± 351.57 ml; p = 0.063). Postoperatively, return of bowel activity was significantly earlier in extra-peritoneal than trans-peritoneal approach (4.59 ± 0.56 vs. 8.65 ± 1.23 h; p = <0.001). Mean time taken for passage of flatus was also significantly less in extra-peritoneal cesarean section (8.56 ± 0.99 vs. 12.76 ± 2.05 h; p = <0.001). Pain score at 6, 12, and 18 h was significantly lower in extra-peritoneal approach. No patient in extra-peritoneal approach had nausea, vomiting, and abdominal distension. Whereas 11.8 % of patients had nausea, 5.9 % had constipation, and 14.7 % had abdominal distension in trans-peritoneal cesarean section. Requirement of injectable antibiotics and analgesics, and hospital stay was less with extra-peritoneal approach. Conclusion: Extra-peritoneal cesarean section is associated with better postoperative outcomes with respect to return of bowel functions, pain, and requirement of injectable analgesics and antibiotics than the routine trans-peritoneal cesarean section. However, the significantly higher fetus delivery time questions its feasibility in patients with acute fetal distress. Additionally, it is technically difficult and has a longer learning curve.

Study of the predictive factors affecting outcomes of patients undergoing transperitoneal laparoscopic donor nephrectomy.

PURPOSE: We aim to study the preoperative and intraoperative factors and compare against specific outcomes in patients undergoing transperitoneal laparoscopic donor nephrectomy and see if we could find what were the predictive factors for these outcomes. METHODS: This is a prospective cohort study done in a single high-volume transplant center. 153 kidney donors were evaluated over a period of 1 year. The preoperative factors such as age, gender, smoking status, obesity, visceral obesity, perinephric fat thickness, number of vessels, anatomic abnormalities, comorbidities, and side of kidney and intraoperative factors such as lay of colon on the kidney, height of splenic or hepatic flexure of colon, loaded or unloaded colon, and sticky mesenteric fat were compared against specific outcomes such as duration of surgery, duration of hospital stay, postoperative paralytic ileus, and postoperative wound complications. RESULTS: Multivariate logistic regression models were used to study the variables of interest against the various outcomes. There were three positive risk factors for increased hospital stay, which were perinephric fat thickness and height of splenic or hepatic flexure of colon and smoking history. There was one positive risk factor for postoperative paralytic ileus which is lay of colon with relation to kidney and there was one positive risk factor for postoperative wound complication which was visceral fat area. CONCLUSION: The predictive factors for adverse postoperative outcomes after transperitoneal laparoscopic donor nephrectomy were perinephric fat thickness, height of splenic or hepatic flexure, smoking status, lay or redundancy of colon with relation to kidney and visceral fat area.

Risk factors for intraoperative complications, postoperative complications, and prolonged length of stay after laparoscopic adrenalectomy by transperitoneal lateral approach: a retrospective cohort study of 547 procedures.

BACKGROUND: Laparoscopic adrenalectomy (LA) is the gold standard for the resection of most adrenal lesions. A precise delineation of factors influencing its outcomes is lacking. The aim of this study was to assess factors associated with intraoperative complications, postoperative complications, and prolonged length of stay (LOS) after LA. METHODS: Patients who underwent LA from 1999 to 2021 in a single-academic-institution were included. Patient and disease-specific data, intraoperative complications, postoperative complications according to Dindo-Clavien (DC) scale, and LOS were recorded. Predictive factors of complications and prolonged LOS were determined by logistic regression. RESULTS: We identified 530 patients who underwent 547 LA. Intraoperative complications occurred in 33 patients (6.0%). Postoperative complications ≥  DC grade 2 occurred in 73 patients (13.35%); severe postoperative complications ≥ DC grade 3 in 14 patients (2.56%). Postoperative complications were positively associated with age ≥ 72 (OR 1.14 [95% CI 1.02-1.29]), intraoperative complications (OR 1.36 [95% CI 1.14-1.63]), and negatively associated with non functional adenomas (OR 0.88 [95% CI 0.7-0.99]), and right adrenalectomy (OR 0.91 [95% CI 0.86-0.97]). Severe postoperative complications were positively associated with chronic obstructive pulmonary disease (COPD, OR 1.08 [95% CI 1.00-1.17]), and negatively associated with right adrenalectomy (OR 0.97 [95% CI 0.92-0.99]). Prolonged LOS was associated with age ≥ 72 (OR 1.21 [95% CI 1.05-1.41]), and COPD (OR 1.20 [95% CI 1.01-1.44]). CONCLUSIONS: LA remains safe when performed by surgeons with expertise. Right adrenalectomy resulted in less postoperative overall and severe complications. The risk-benefit equation should be carefully assessed before left LA in older patients with COPD.

Atypical Recurrent Renal Cell Carcinoma of the Ipsilateral Ureter Showing Typical Symptoms of Upper Urinary Tract Urothelial Carcinoma: A Case Report and Literature Review.

BACKGROUND: Ureteral metastasis is a rare phenomenon. Synchronous recurrence in both the pelvis and ureter with symptoms that are typical of upper urinary tract urothelial carcinoma (UTUC) has not been reported previously. METHODS: We present a case of metastasis of clear cell renal cell carcinoma (ccRCC) to the ipsilateral pelvis and ureter in a 37-year-old man who underwent open partial nephrectomy (PN) after laparoscopic exploration 20 months after surgery. We suspected painless hematuria with clots and upper UTUC based on the imagological diagnosis. We performed complete transperitoneal laparoscopic nephroureterectomy in a single position. We also searched PubMed for studies with the keywords "renal cell carcinoma" and "ureteral metastasis" that had been published since 2000. RESULTS: Postoperative pathology demonstrated ccRCC in the left pelvis that had spread along the ureter. The patient was discharged 1 week after surgery, without a drainage tube, and free to eat and perform normal activities. We identified 10 cases from nine studies that had been published since 2000. Nephrectomy was performed in all 10 cases, and nine of the patients had hematuria. Open ureterectomy was performed on two patients who had ipsilateral ureteral metastasis. CONCLUSIONS: Recurrent ccRCC in the ureter is rare. Due to the difficulty in distinguishing it from ipsilateral upper UTUC, complete transperitoneal laparoscopic nephroureterectomy in a single position is a safe and feasible treatment option in this situation.

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.

An unusual presentation of cryptorchidism: A case report of Spigelian-cryptorchidism syndrome.

INTRODUCTION: Spigelian hernia is an uncommon hernia presenting as a protrusion of abdominal contents through the spigelian fascia, lateral to the rectus abdominis. In some rare cases, Spigelian hernia can occur alongside cryptorchidism, which forms a recognized syndrome found in male infants with Spigelian hernia. This is a relatively unreported syndrome with very limited literature available regarding it, none of which is reported in Pakistan in adults. PRESENTATION OF CASE: We report a case of a 65-year-old male with right sided obstructed spigelian hernia along with the rare finding of testis in the hernial sac. The patient was successfully managed by transperitoneal primary repair (herniotomy) with orchiectomy. The patient recovered uneventfully and was discharged 5 days after the surgery. DISCUSSION: The exact pathophysiology of this syndrome remains unclear. Three theories have been proposed to explain this syndrome, including the primary defect being Spigelian hernia leading to undescended testes (Al-Salem), testicular maldescent preceding the formation of the hernia (Raveenthiran), or the absence of the inguinal canal leading to the development of a rescue canal due to the undescended testes (Rushfeldt et al.). In this case, the absence of gubernaculum was confirmed suggesting the findings to be consistent with Rushfeldt's theory. The surgical team proceeded with hernial repair and orchiectomy. CONCLUSION: In conclusion, Spigelian-Cryptorchidism syndrome is a rare syndrome in adult male, with an unclear pathophysiology. Management of this condition involves repair of the hernia along with either orchiopexy or orchiectomy, depending upon the risk factors involved.