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.

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.

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.

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.

The same parastomal hernia repairs rate in the different approaches to colostomy.

PURPOSE: This study aimed to compare the parastomal hernia repairs rate in the different approaches to colostomy and investigate the risk factors for parastomal hernia formation in patients with permanent colostomies. METHODS: Consecutive rectal cancer patients who underwent abdominoperineal resection from June 2014 to July 2020 in West China Hospital were divided into two groups according to their surgical approach for permanent colostomies. The impact of different approaches to colostomy on parastomal hernia repairs was determined by comparing a group of patients receiving an extraperitoneal route to colostomy with a group receiving transperitoneal. Potential variables were evaluated first with univariate and then multivariate analyses to identify the risk factors for the formation of parastomal hernia. RESULTS: Two hundred two subjects in the transperitoneal group and 103 in the extraperitoneal group attended the follow-up visit with a median follow-up period of 33 (25th-75th percentiles, 17-46) months. Clinically and radiologically detectable parastomal hernias were present in 76 of 202 (37.6%) and 14 of 103 (13.6%) subjects in the transperitoneal and extraperitoneal groups during the follow-up period (p＜0.01). Besides, 10 of 76 (13.1%) subjects in the transperitoneal group and 2 of 14 (14.3%) subjects in the extraperitoneal group underwent a parastomal hernia operation during the follow-up (p = 0.82). In addition, the transperitoneal approach of colostomy (p = 0.002), older age (p＜0.001), and higher body mass index (p = 0.013) were identified as independent risk factors for the occurrence of parastomal hernia. CONCLUSIONS: Extraperitoneal colostomy decreased the detectable parastomal hernias but did not reduce the surgical repair rate of parastomal hernias.

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.

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.

Is transperitoneal laparoscopic adrenalectomy for pheochromocytoma really more challenging? A propensity score-matched analysis.

PURPOSE: Minimally invasive surgery is the gold standard treatment for adrenal masses, but it may be a challenging procedure in the case of pheochromocytoma (PHEO). The aim of the present study is to report the results of transperitoneal laparoscopic adrenalectomy (TLA) in cases of PHEO in comparison to other types of adrenal lesions. METHODS: From 1994 to 2021, 629 patients underwent adrenalectomy. Twenty-two and thirty-five patients, respectively, were excluded because they underwent bilateral and open adrenalectomy, leaving 572 patients for inclusion. Of these, 114 patients had PHEO (Group A), and 458 had other types of lesions (Group B). To adjust for potential baseline confounders, a propensity score matching (PSM) analysis was conducted. RESULTS: After PSM, 114 matched pairs of patients were identified from each group. Statistically significant differences were not observed when comparing the median operative time (85 and 90 min in Groups A and B, respectively, p = 0.627), conversion rate [6 (5.3%) in each group, p = 1.000], transfusion rate [4 (3.5%) and 3 (2.6%) in Groups A and B, respectively, p = 1.000], complication rate [7 (6.1%) and 9 (7.9%) in Groups A and B, respectively, p = 0.796), median postoperative hospital stay (3.9 and 3.6 days in Groups A and B, respectively, p = 0.110), and mortality rate [1 (0.9%) in each group, p = 1.000]. CONCLUSIONS: Based on this analysis, the results of TLA for PHEO are equivalent to those of TLA for other types of adrenal lesions, but the fundamental requirements are multidisciplinary patient management and adequate surgeon experience. Further prospective studies are required to draw definitive conclusions.

De Garengeot's hernia patients entirely treated laparoscopically: a safe and feasible alternative-a systematic review.

PURPOSE: Less than 450 cases of femoral hernias containing the vermiform appendix have been published since De Garengeot's first description. A laparoscopic treatment option opened 15 years ago seems reliable and safe. A literature review of all the patients who have benefited from this new therapeutic alternative is presented. METHODS: A systematic review using the German Society of Surgery's recommendations was performed for De Garengeot's hernias totally treated laparoscopically. Keywords searched included "De Garengeot hernia" OR "femoral hernia appendix" OR "crural hernia appendix." RESULTS: Only 29 out of 225 De Garengeot hernia's manuscripts were identified describing patients entirely treated laparoscopically: 25 patients by a transabdominal preperitoneal hernia repair (TAPP) and 4 patients by a total extraperitoneal (TEP) procedure; 85.1% were females. The mean age was 71 years. Twenty-two patients had pre-operative imaging tests, sonography (2), computed tomography (14), or both (6). Nevertheless, only 56% had a preoperative diagnosis. Twenty-one cases required urgent treatment, while programmed surgery was possible in 7 instances. An appendix-sparing procedure could be done in 16% of the TAPPs. No postoperative complications occurred. The median hospital stay was 2.5 days. CONCLUSIONS: The best surgical approach for a De Garengeot's hernia is not defined, and many critical questions remain unanswered. A better understanding of the diagnosis and treatment of this peculiar hernia will supply guidelines for clinicians who may encounter it hereafter. A fully laparoscopic approach seems perfectly safe and feasible for this entity, and it could be considered the first-line alternative if enough expertise is available.

Perioperative and oncologic outcomes of transperitoneal versus retroperitoneal laparoscopic radical nephrectomy for large-volume renal carcinoma (> 7 cm): a systematic review and pooled analysis of comparative outcomes.

BACKGROUND: Recently, there has been a significant amount of debate concerning the question of whether laparoscopic surgery should be performed transperitoneally or retroperitoneally for treating large renal tumors. AIM: The purpose of this research is to conduct a comprehensive review and meta-analysis of the previous research on the safety and efficacy of transperitoneal laparoscopic radical nephrectomy (TLRN) and retroperitoneal laparoscopic radical nephrectomy (RLRN) in the treatment of large-volume renal malignancies. METHODS: An extensive search of the scientific literature was carried out utilizing PubMed, Scopus, Embase, SinoMed, and Google Scholar in order to locate randomized controlled trials (RCTs) and prospective and retrospective studies that compared the effectiveness of RLRN versus TLRN in the treatment of for large renal malignancies. For the purpose of comparing the oncologic and perioperative outcomes of the two techniques, data were taken from the research studies that were included and pooled together. RESULTS: A total of 14 studies (five RCTs and nine retrospective studies) were incorporated into this meta-analysis. The overall RLRN had an association with significantly shorter operating time (OT) (MD [mean difference]: - 26.57; 95% CI [confidence interval]: - 33.39 to - 19.75; p < 0.00001); less estimated blood loss (EBL) (MD: - 20.55; CI: - 32.86 to - 8.23; p = 0.001); faster postoperative intestinal exhaust (MD: - 0.65; CI: - 0.95 to - 0.36; p < 0.00001). The terms of length of stay (LOS) (p = 0.26), blood transfusion (p = 0.26), conversion rate (p = 0.26), intraoperative complications (p = 0.5), postoperative complications (p = 0.18), local recurrence rate (p = 0.56), positive surgical margin (PSM) (p = 0.45), and distant recurrence rate (p = 0.7) did not show any differences. CONCLUSIONS: RLRN provides surgical and oncologic results similar to TLRN, with potential advantages regarding shorter OT, EBL, and postoperative intestinal exhaust. Due to the high heterogeneity among the studies, long-term randomized clinical trials are required to obtain more definitive results.

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.

BACKGROUND: The 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. METHODS: A 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. RESULT: Six 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. CONCLUSION: TLNU 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 REGISTRATION: www.crd.york.ac.uk/prospero/ , identifier CRD42023388554.

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.

Comparison of Transperitoneal and Retroperitoneal Laparoscopic Ureterolithotomy: A Meta-Analysis.

PURPOSE: The aim of this study was to evaluate the efficacy and safety of transperitoneal and retroperitoneal laparoscopic ureterolithotomy (TLU and RLU). MATERIALS AND METHODS: We undertook a literature search PubMed, Embase, and the Cochrane Library. Search date will range from inception to January 1, 2020. The final article results will be analyzed using StataSE 12 software. This meta-analysis was reported according to PRISMA guidelines, and a protocol was registered in PROSPERO (CRD42020160906). RESULTS: Eleven articles eventually met the requirements, involving a total of 609 patients. The final result shows the operative time (Std. Mean Difference [SMD] = 0.58; 95% CI 0.36-0.80; p < 0.01), hospital stay (SMD = 0.26; 95% CI 0.02-0.49; p = 0.031), and the complication of paralytic ileus (risk difference = 0.11; 95% CI 0.05-0.17; p < 0.01) are significant difference between TLU and RLU, and TLU are higher or longer. CONCLUSIONS: Our meta-analysis suggests that if there are no other constraints, it is better to choose RLU. And more clinical trial data are needed to confirm this conclusion.

Initial experience with 161 extraperitoneal laparoscopic radical cystectomy procedures: Comparison with transabdominal laparoscopic radical cystectomy.

OBJECTIVES: There is substantial concern about traditional transperitoneal laparoscopic radical cystectomy (TLRC) due to multiple postoperative complications. In contrast, extraperitoneal laparoscopic radical cystectomy (ELRC) appears to cause a lower rate of morbidity. The present study aimed to compare the efficacy of ELRC and TLRC for bladder cancer (BCa). METHODS: The clinical data of patients undergoing laparoscopic radical cystectomy for BCa from April 2018 to October 2021 were retrospectively analyzed, as ELRC and TLRC groups. The postoperative follow-up data of 275 patients were collected and the incidence of postoperative complications and other perioperative outcomes were compared between the two groups. RESULTS: Surgery was successfully completed in all patients without conversion to open surgery. There was no significant difference in the duration of cystectomy surgery (67.32 ± 23.53 vs 72.17 ± 25.72 min, p = 0.106), intraoperative blood loss (178.06 ± 110.4 vs. 174.56 ± 127.40 ml, p = 0.413), or the number of lymph node dissection (15.1 ± 5.7 vs. 14.5 ± 5.1, p = 0.380) between the two groups. The length of stay (11.6 ± 3.8 vs 14.7 ± 5.6 d, p < 0.001), time to resume food intake after surgery (2.3 ± 0.9 vs 3.0 ± 1.3 d, p < 0.001), and the incidence of ileus (p < 0.001) in the ELRC group were significantly lower than in the TLRC group. CONCLUSIONS: ELRC is a safe procedure that can reduce the incidence of postoperative complications, shorten postoperative hospital stay, reduce the duration of recovery of patients, and, therefore, should be promoted.

Laparoscopic placement of left renal vein extravascular stenting in treatment of nutcracker syndrome: Techniques and long-term outcomes.

OBJECTIVES: We aimed to assess the feasibility and efficacy of laparoscopic extravascular stent in treatment of nutcracker syndrome by transperitoneal or retroperitoneal approach. METHODS: Seventy-six patients with nutcracker syndrome were retrospectively enrolled from a tertiary referral center, and underwent transperitoneal (63 patients) or retroperitoneal (13 patients) laparoscopic extravascular stent from March 2011 to December 2020. Surgical parameters, complications, imaging and clinical outcomes were collected and analyzed. RESULTS: All procedures were successfully carried out without open conversion. The median operation time, estimated blood loss, and postoperative hospital day were 120 (interquartile range [IQR]: 90-144) min, 20 (IQR: 10-30) ml, and 7 (IQR: 6-9) days. At a median follow-up of 52 (range: 9-127) months, 60 (79%) patients had complete symptom resolution, 14 (18%) patients had significant symptom improvement, and 2 (3%) patients reported no symptom improvement. Ninety-four percent (50/53) of hematuria, 91% (30/33) of proteinuria, and 89% (25/28) of flank/abdominal pain resolved after extravascular LRV stenting. No significant differences were detected in surgery parameters and recovery rates of clinical symptoms between two approaches (each p > 0.05). However, patients with transperitoneal approach need longer to achieve complete recovery compared with retroperitoneal approach (8.7 vs. 1.5 months, p = 0.016). CONCLUSIONS: Laparoscopic extravascular stent performed either transperitoneally or retroperitoneally is a feasible and effective option in treatment of nutcracker syndrome. Retroperitoneal laparoscopic extravascular stent required shorter time to achieve complete recovery, which should be considered whenever possible in surgical decision-making.

A retroperitoneal operative approach is associated with improved perioperative outcomes compared with a transperitoneal approach in open repair of complex abdominal aortic aneurysms.

OBJECTIVE: Several studies have demonstrated the advantages of a retroperitoneal (RP) vs a transperitoneal (TP) approach during open repair of infrarenal abdominal aortic aneurysms (AAAs). We compared the outcomes after open repair of complex AAAs (cAAAs) using an RP vs a TP approach and evaluated the relative use of these approaches over time. METHODS: We identified all patients who had undergone open intact cAAA repair in the Vascular Quality Initiative from 2003 to -2019 and created 1:1-propensity score-matched cohorts stratified by the operative approach (RP vs TP). The primary outcome was perioperative mortality. The secondary outcomes included perioperative complications and approach usage over time. To create 1:1 propensity score-matched cohorts, the patients were matched for demographics, comorbidities, and anatomic and/or intraoperative characteristics, including proximal clamp site and renal revascularization. The approach usage over time was determined by plotting the proportion of RP usage over time for the overall open cAAA cohort and subgroups of repairs using a supraceliac cross clamp, repair with concomitant renal revascularization, and repairs performed at high-volume centers (highest quintile, >11 cases annually). RESULTS: Of a total of 4613 patients, 2843 (62%) had undergone open cAAA repair using the TP approach and 1770 (38%) using the RP approach. Of the 1256 matched pairs, the RP approach was associated with lower risk of perioperative mortality compared with the TP approach (3.9% vs 6.8%; relative risk [RR], 0.57; 95% confidence interval [CI], 0.41-0.80; P = .001). Furthermore, the RP approach was associated with a lower risk of cardiac complications (7.2% vs 9.6%; RR, 0.75; 95% CI, 0.58-0.98), bowel ischemia (3.1% vs 5.4%; RR, 0.56; 95% CI, 0.39-0.84), and postoperative dialysis (3.3% vs 5.5%; RR, 0.59; 95% CI, 0.41-0.87). Overall, the proportion of patients who had undergone repair via an RP approach became lower over time (-1.0%/y; 95% CI, -1.5 to -0.5; P < .001). A similar trend in the decrease was found for the patients who had undergone repair with a supraceliac clamp (-2.3%/y; 95% CI, -3.6 to -1.0; P < .001) and in the high-volume hospitals (-2.1%/y; 95% CI, -3.4 to -0.8; P = .001), although no statistically significant decrease in RP usage was found for the patients who had undergone concomitant renal revascularization (-0.9%/y; 95% CI, -2.6 to 0.8; P = .28). CONCLUSIONS: For open cAAA repair, an RP approach was associated with lower perioperative mortality and complications compared with a TP approach. However, the relative usage of the RP approach has been decreasing over time. An increased adoption of the RP approach, when appropriate, might lead to improved outcomes with open cAAA repair.

Retroperitoneal versus Transperitoneal Approach for Open Repair of Complex Abdominal Aortic Aneurysms.

OBJECTIVE: Several studies have demonstrated advantages of the retroperitoneal approach (RP) over the transperitoneal approach (TP) for infrarenal abdominal aortic aneurysm (AAA) repair. A retrospective analysis was performed comparing the outcomes of a TP vs. RP surgical approach for open complex AAA (cAAA) repair and evaluated their relative use over time. METHODS: Patients undergoing open repair for intact cAAA (juxtarenal, suprarenal, or type IV thoraco-abdominal aortic aneurysms) between 2011 and 2019 were identified in the National Surgical Quality Improvement Program. The primary outcome was peri-operative death. Secondary outcomes included peri-operative complications and approach use over time. Multivariable adjustment was performed by creating propensity scores and using inverse probability weighted logistic regression. RESULTS: Among 1 195 patients identified, 729 (61%) underwent cAAA repair via a TP approach and 466 (39%) via an RP approach. Compared with a TP approach, RP patients more frequently had a supracoeliac clamp position (32% vs. 20%, p < .001) and concomitant renal revascularisation (30% vs. 18%, p < .001). After adjustment, an RP approach was associated with lower odds of peri-operative death (4.0% vs. 7.2%; odds ratio [OR] 0.54; 95% confidence interval [CI] 0.32 - 0.91; p = .022). Furthermore, an RP approach was associated with lower odds of any major complication (24% vs. 30%; OR 0.73; 95% CI 0.56 - 0.94), cardiac complications (4.9% vs. 8.2%; OR 0.60; 95% CI 0.37 - 0.96), wound complications (2.1% vs. 6.0%; OR 0.34; 95% CI 0.17 - 0.64), and post-operative sepsis (0.8% vs. 2.4%; OR 0.37; 95% CI 0.12 - 0.99). The proportion of repairs using an RP approach decreased between 2011 - 2015 and 2016 - 2019 (42% vs. 35%, p = .020), particularly for suprarenal and type IV thoraco-abdominal aneurysms (49% vs. 37%, p = .023). CONCLUSION: In open cAAA repair, the RP approach may be associated with lower peri-operative mortality and morbidity rates compared with the TP approach. However, it was found that the relative use of the RP approach is decreasing over time, even in suprarenal/type IV thoraco-abdominal aneurysms, and repairs using a supracoeliac clamp. Increased use of the RP approach, when appropriate, may lead to improved outcomes following open cAAA repair.

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

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

Extraperitoneal colostomy after laparoscopic abdominoperineal resection using a cannula for tunnel creation through a trocar port.

BACKGROUND: Extraperitoneal colostomy (EPC) after laparoscopic abdominoperineal resection (APR) remains a challenge for surgeons. This study aims to summarize our laparoscopic EPC method and assess its effects versus a transperitoneal colostomy (TPC) for patients with rectal tumors. METHODS: A total of 133 patients with rectal cancer treated with laparoscopic APR between May 2009 and May 2020 were retrospectively reviewed. The clinical data, including demographics, comorbidities, tumor stage, colostomy duration, and complications were compared between the EPC group and the TPC group. RESULTS: The EPC group included 83 patients whose extraperitoneal tunnels were created using a cannula through a trocar port, and the TPC group included 50 patients whose stomata were formed traditionally. There were no differences in colostomy time [(23.1 ± 6) min vs. (21.4 ± 4) min, P = 0.078], number of parastomal dermatitis patients (5 vs. 2, P = 0.916), or number of stomal stenoses (1 vs. 1, P = 0.715) between the EPC and TPC groups. No cases of parastomal hernia developed in the EPC group, whereas 4 patients were diagnosed with a parastomal hernia; the difference between the two groups was statistically significant (P = 0.036). CONCLUSIONS: Laparoscopic EPC have a lower incidence of parastomal hernia than TPC. It is easy and inexpensive to create an extraperitoneal tunnel using a cannula through a trocar port.

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

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