Robot-Assisted Pelvic Dissection for Enlarged Lymph Nodes in Melanoma Improves Recovery with Equivalent Oncological Outcomes to Open Pelvic Dissection.

BACKGROUND: Robot-assisted pelvic lymph node dissection (rPLND) has been reported in heterogenous groups of patients with melanoma, including macroscopic or at-high-risk-for microscopic metastasis. With changing indications for surgery in melanoma, and availability of effective systemic therapies, pelvic dissection is now performed for clinically detected bulky lymph node metastasis followed by adjuvant drug therapy. rPLND has not been compared with open pelvic lymph node dissection (oPLND) for modern practice. METHODS: All patients undergoing pelvic node dissection for macroscopic melanoma at a single institution were reviewed as a cohort, observational study. RESULTS: Twenty-two pelvic lymph node dissections were identified (8 oPLND; 14 rPLND). The number of pelvic lymph nodes removed was similar (median oPLND 6.5 (interquartile range [IQR] 6.0-12.5] versus rPLND 6.0 [3.75-9.0]), with frequent matted nodes (11/22, 50.0%). Operative time (median oPLND 130 min [IQR 95.5-182] versus rPLND 126 min [IQR 97.8-160]) and complications (Clavien-Dindo scale) were similar. Length of hospital stay (median 5.34 days (IQR 3.77-6.94) versus 1.98 days (IQR 1.39-3.50) and time to postoperative adjuvant therapy (median 11.6 weeks [IQR 10.6-18.5] versus 7.71 weeks [IQR 6.29-10.4]) were shorter in the rPLND group. No differences in pelvic lymph node recurrence (p = 0.984), distant metastatic recurrence (p = 0.678), or melanoma-specific survival (p = 0.655) were seen (median follow-up 21.1 months [rPLND] and 25.7 months [oPLND]). CONCLUSIONS: rPLND is an effective way to remove bulky pelvic lymph nodes in melanoma, with a shorter recovery and reduced interval to initiating adjuvant therapy compared with oPLND. This group of patients may especially benefit from neoadjuvant systemic approaches to management.

Testicular cancer with small metastatic burden: optimal approach in 2024.

PURPOSE OF REVIEW: Recent advancements in the management of clinical stage II (CS II) testicular cancer have transformed it into a predominantly curable condition. This success in treatment advancements has markedly extended patient survival. However, these treatments carry risks and morbidities, which is important to consider given the disease's impact on young men and the emerging understanding of long-term treatment consequences. RECENT FINDINGS: Emerging data support primary retroperitoneal lymph node dissection (RPLND) for select CS II seminoma patients, with similar short-term outcomes to chemotherapy but less treatment intensity. Recent studies have also challenged the reflexive use of adjuvant chemotherapy for pathologic node-positive disease, as growing evidence shows low relapse rates regardless of nodal stage. Furthermore, novel biomarkers like circulating serum microRNA-371a-3p levels can help predict the presence of viable germ cell tumor at time of RPLND. SUMMARY: Advances in risk stratification and therapy enable personalized de-escalation approaches for oligometastatic testicular cancer, optimizing survivorship. Upfront RPLND, reassessing adjuvant systemic therapy for RPLND pN+ disease, and novel biomarkers will shape precision treatment to achieve high cure rates with excellent quality of life. Ongoing trials of reduced-intensity regimens, accurate prognostic models, improved surgical strategy, and emerging biomarkers represent the next frontier in tailored curative therapy.

Time to Flip the Approach: Retroperitoneoscopic Adrenalectomy.

INTRODUCTION: Retroperitoneoscopic adrenalectomy (RPA) has gained increasing popularity with its excellent perioperative outcomes and direct surgical access compared to other adrenalectomy approaches. We review perioperative outcomes of RPA by a specialized endocrine surgeon before and after expert intensive trainings (EITs), and to that of other laparoscopic adrenalectomy approaches at our center over a 9-year period, aiming to ascertain if RPA is worth the steep learning curve. MATERIAL AND METHODS: One hundred twenty one adrenalectomies were performed between January 2014 to June 2022. Patient demographic, tumor characteristics, and perioperative outcomes were retrospectively reviewed. The primary endpoints included procedure duration, complications, and length of stay. Part I of the study examined the effect of EITs on RPA's learning curve, and part II compared these outcomes with that of the alternative approach, transabdominal lateral adrenalectomy (TLA). RESULTS: Both procedure duration and days in hospital markedly decreased after the two EITs for RPA. RPA resulted in a shorter procedure duration and hospital stay compared to TLA, and had lesser and milder intraoperative and postoperative complications compared to TLA. CONCLUSIONS: RPA results in safe and excellent outcomes, and offers additional benefit of direct surgical access, feasibility in patients with previous abdominal surgery, high body mass index, and multiple comorbidities. The steep learning curve can be overcome and shortened by EITs, motivating centers with specialized endocrine surgery to integrate RPA training into its curriculum, given its foreseeable rewarding outcomes.

Prognostic Differences Between Surveillance and Active Treatment After Initial Orchiectomy in Patients With Stage I Mixed Germ Cell Tumors of the Testis: A Propensity Score Matching Analysis.

INTRODUCTION: The prognosis and optimal treatment approach for stage I mixed germ cell cancers of the testis are not well-established. This study aimed to assess contemporary treatment rates and their correlation with the cancer-specific mortality (CSM) and other-cause mortality (OCM) in patients with stage I testicular mixed germ cell tumors (TMGCT) who underwent orchiectomy, comparing surveillance with active treatment, including chemotherapy (CHT) and retroperitoneal lymph node dissection (RPLND). METHODS: Retrospective analysis of clinical data from stage I TMGCT patients who underwent orchiectomy was conducted using the Surveillance, Epidemiology, and End Results database from 2004 to 2019. The annual percentage change (APC) in the use of surveillance, postoperative CHT, and RPLND was examined. Propensity score matching (PSM) and cumulative incidence, analyses were employed to compare differences in CSM and OCM between surveillance and active treatment, as well as between CHT and RPLND. Multivariate competing-risks regression models were utilized to investigate independent factors affecting CSM and OCM among stage I TMGCT patients. RESULTS: The study included 5743 individuals with stage I TMGCT that underwent surveillance (61.6%), CHT(27.2%), or RPLND (11.2%). Among them, 82 deaths were attributed to TMGCT, and 82 deaths resulted from other causes. Surveillance rates increased over time (APC: 0.635%, P = 0.008), as did CHT rates (APC: 0.863%, P < 0.001), while RPLND rates declined (APC: -0.96%, P < 0.001). After PSM, multivariate competing-risks regression analysis showed that, active treatment, compared to surveillance, was not an independent factor for CSM and OCM. In contrast, when compared to CHT, RPLND was an independent factor associated with lower CSM (hazard ratio = 0.247, 95% confidence interval: 0.08-0.761; P = 0.015), but not OCM (hazard ratio = 0.946, 95% confidence interval: 0.377-2.37; P = 0.91). CONCLUSIONS: Surveillance and CHT rates have increased over time for patients with stage I TMGCT following initial orchiectomy, while RPLND utilization has decreased. There was no significant difference in CSM between surveillance and active treatment groups, but RPLND demonstrated significantly lower CSM than CHT in active treatment. Our findings suggest that the usage of RPLND in patients with stage I TMGCT should be reconsidered.

A novel mini-retractor for retroperitoneal laparoscopic partial nephrectomy.

BACKGROUND: Retroperitoneal partial nephrectomy (RLPN) is the premier treatment for localized renal tumors despite narrow operation space. Many efforts have been taken to facilitate the operation of RLPN, but the optimal resolution remains debatable. OBJECTIVE: To explore the feasibility of using Mini-lap to improve workspace and surgical vision in RLPN. DESIGN, SETTING, AND PARTICIPANTS: A multicenter retrospective review of 51 patients who underwent RLPN with Mini-lap from January 2018 to December 2020 was conducted. SURGICAL PROCEDURE: Standard RLPN under three poles was performed in all cases. We highlighted the usage of Mini-lap (Teleflex Minilap percutaneous Surgical System) as a novel retractor in RLPN. OUTCOME AND MEASUREMENTS AND STATICAL ANALYSIS: Demographics, preoperative, intraoperative, and postoperative outcomes were assessed. RESULTS AND LIMITATIONS: All 51 cases completed RLPN with three ports successfully and no conversion to open surgery. The mean diameter of tumors was (3.53 ± 1.05) cm, in which 62.7% (32/51) were located anteriorly. The operation time and warm ischemic time (WIT) were (86.7 ± 15.9) min and (25.6 ± 5) min respectively. Minor complications (Clavien grade 1-2) occurred in 6 cases. The limitations were small sample size, retrospective design, and absence of control. CONCLUSIONS: Mini-lap could be used as a mini-retractor in RLPN, sparing extra assistant ports, expanding workspace, and optimizing vision. PATIENT SUMMARY: With highlights of larger workspace and less instrument interference, mini-lap could be applied in retroperitoneal laparoscopic partial nephrectomy.

Lymph Node Dissection in Testicular Cancer: The State of the Art and Future Perspectives.

PURPOSE OF REVIEW: This narrative review provides a comprehensive overview of the evolving role of retroperitoneal lymph node dissection (RPLND) in the management of testicular cancer (TC). It explores the significance of RPLND as both a diagnostic and therapeutic tool, highlighting its contribution to accurate staging, its impact on oncological outcomes, and its influence on subsequent treatment decisions. RECENT FINDINGS: RPLND serves as an essential diagnostic procedure, aiding in the precise assessment of lymph node involvement and guiding personalized treatment strategies. It has demonstrated therapeutic value, particularly in patients with specific risk factors and disease stages, contributing to improved oncological outcomes and survival rates. Recent studies have emphasized the importance of meticulous patient selection and nerve-sparing techniques to mitigate complications while optimizing outcomes. Additionally, modern imaging and surgical approaches have expanded the potential applications of RPLND. In the context of TC management, RPLND remains a valuable and evolving tool. Its dual role in staging and therapy underscores its relevance in contemporary urological practice. This review highlights the critical role of RPLND in enhancing patient care and shaping treatment strategies, emphasizing the need for further research to refine patient selection and surgical techniques.

A prospective case series to evaluate subcostal nerve injury with high-resolution ultrasound in posterior retroperitoneoscopic adrenalectomy.

BACKGROUND: Posterior retroperitoneoscopic adrenalectomy has several advantages over transabdominal laparoscopic adrenalectomy regarding operating time, blood loss, postoperative pain, and recovery. However, postoperatively several patients report chronic pain or hypoesthesia. We hypothesized that these symptoms may be the result of damage to the subcostal nerve, because it passes the surgical area. METHODS: A prospective single-center case series was performed in adult patients without preoperative pain or numbness of the abdominal wall who underwent unilateral posterior retroperitoneoscopic adrenalectomy. Patients received pre- and postoperative questionnaires and a high-resolution ultrasound scan of the subcostal nerve and abdominal wall muscles was performed before and directly after surgery. Clinical evaluation at 6 weeks was performed with repeat questionnaires, physical examination, and high-resolution ultrasound. Long-term recovery was evaluated with questionnaires, and photographs from the patients were examined for abdominal wall asymmetry. RESULTS: A total of 25 patients were included in the study. There were no surgical complications. Preoperative visualization of the subcostal nerve was possible in all patients. At 6 weeks, ultrasound showed nerve damage in 15 patients, with no significant association between nerve damage and postsurgical pain. However, there was a significant association between nerve damage and hypoesthesia (p = 0.01), sensory (p < 0.001), and motor (p < 0.001) dysfunction on physical examination. After a median follow-up of 18 months, 5 patients still experienced either numbness or muscle weakness, and one patient experienced chronic postsurgical pain. CONCLUSION: In this exporatory case series the incidence of postoperative damage to the subcostal nerve, both clinically and radiologically, was 60% after posterior retroperitoneoscopic adrenalectomy. There was no association with pain, and the spontaneous recovery rate was high.

Long-term outcome of retroperitoneoscopic partial versus total adrenalectomy in patients with Cushing's syndrome.

BACKGROUND: We analyze the long-term outcome of surgery for Cushing's syndrome (CS) and the influence of the extent of surgical resection on the duration of postoperative cortisone substitution. METHODS: One-hundred forty-one patients (129 female, 12 males; mean age: 45.7 ± 12.8 years) operated between January 2000 to June 2020 were included in the analysis. Patients suffered from manifest (124) or subclinical (17) CS due to benign unilateral adrenal neoplasia. All tumors were removed by the posterior retroperitoneoscopic approach. 105 patients had total (TA) and 36 partial (PA) adrenalectomies. All patients were discharged with ongoing corticosteroid supplementation therapy. RESULTS: Follow-up data could be obtained for 83 patients. Twenty-four (1 male, 23 females; mean age 42.3 years) underwent PA and 59 TA (6 males, 53 females; mean age 44.6 years). Mean follow-up time was 107 ± 68 months (range: 6-243 months). The median duration of postoperative corticosteroid therapy was 9.5 months after PA and 11 months after TA (p = 0.1). Significantly, more patients after total adrenalectomy required corticosteroid therapy for more than 24 months (25% vs. 4%; p = 0.03). Recurrent ipsilateral disease occurred in one case after partial adrenalectomy and was treated by completion adrenalectomy. A case of contralateral recurrence associated with subclinical Cushing's syndrome was observed after total adrenalectomy. CONCLUSIONS: The risk of local recurrence after partial adrenalectomy in CS is low. Cortical-sparing surgery may shorten corticosteroid supplementation therapy after surgery.

A novel method of tunneling retroperitoneoscopic adrenalectomy: a prospective study.

BACKGROUND: To introduce the surgical technique and our team's extensive experience with tunnel method in laparoscopic adrenalectomy. METHODS: From July 2019 to June 2022, we independently designed and conducted 83 cases of " Tunnel Method Laparoscopic Adrenalectomy," a prospective study. There were 45 male and 38 female patients, ages ranged from 25 to 73 years(mean: 44.6 years).The cases included 59 adrenal cortical adenomas, 9 pheochromocytomas, 6 cysts, 4 myelolipomas, 1 ganglioneuroma, and 4 cases of adrenal cortical hyperplasia. In terms of anatomical location, there were 39 cases on the left side, 42 on the right side, and 2 bilateral cases. Tumor diameters ranged from 0.6 to 5.9 cm(mean: 2.9 cm). Utilizing ultrasound monitoring, percutaneous puncture was made either directly to the target organ or its vicinity, and the puncture path was manually marked. Then, under the direct view of a single-port single-channel laparoscope, the path to the target organ in the retroperitoneum or its vicinity was further delineated and separated. This approach allowed for the insertion of the laparoscope and surgical instruments through the affected adrenal gland, thereby separating the surface of the target organ to create sufficient operational space for the adrenalectomy. RESULTS: All 83 surgeries were successfully completed. A breakdown of the surgical approach reveals that 51 surgeries were done using one puncture hole, 25 with two puncture holes, and 7 with three puncture holes. The operation time ranged from 31 to 105 min (mean: 47 min), with a blood loss of 10 to 220mL (mean: 40 mL). Notably, there were no conversions to open surgery and no intraoperative complications. Postoperative follow-up ranged from 6 to 28 months, during which after re-examination using ultrasound, CT, and other imaging methods, there were no recurrences or other complications detected. CONCLUSIONS: The completion of the tunnel method laparoscopic adrenalectomy represents a breakthrough, transitioning from the traditional step-by-step separation of retroperitoneal tissues to reach the target organ in conventional retroperitoneoscopic surgery. This method directly accesses the target organ, substantially reducing the damage and complications associated with tissue separation in retroperitoneoscopic surgery, As a result, it provides a new option for minimally invasive surgery of retroperitoneal organs and introduces innovative concepts to retroperitoneoscopic surgery.

New technique of En bloc vertebral resection in the thoracolumbar region assisted by retroperitoneal laparoscopy in a single prone position: first results.

PURPOSE: To describe the technique and review the oncological and surgical results of the En Bloc resection assisted by retroperitoneal laparoscopy in a single prone position for tumors in the thoracolumbar region. METHODS: Monocentric retrospective case study. Procedure was performed in a single prone position by a dual team of spine and thoracovascular surgeons. An endoscopic balloon was inflated in the right retroperitoneal cavity. A plan was developed between the anterior spine and vena cava as well as abdominal aorta with segmental vessels ligation. Structures at risk were safely protected under endoscopy during horizontal or sagittal osteotomies. RESULTS: From 2021, seven patients aged a median 52 years old (range, 34-67) were included. Involved spinal segments went from T11 to L3. Surgery was aborted in one case due to massive bleeding and ventilating difficulties. There were two partial and four total vertebral resections. Median operating duration and estimated blood loss were 405 min (range, 360-540) and 2.1 L (range, 1.2-19), respectively. Postoperative complications consisted of 1 urinary infection; 1 transient urinary retention; 1 posterior wound infection; 1 pneumothorax; 1 persistent partial motor deficit; 1 transient confusion; 1 pulmonary embolism; 1 CSF leak; 1 subdural hematoma; 1 retroperitoneal lymphocele. All margins were uncontaminated. All patients were alive and ambulatory at last follow-up. CONCLUSION: Early results suggest En Bloc resection assisted by retroperitoneal videoscopy in tumors from T11 to L3/4 disk space is feasible, less invasive and safe. Careful surgical planning and experience in endoscopic vascular surgery are mandatory.

Successful laparoscopic resection of retroperitoneal ectopic pregnancy between the abdominal aorta and inferior vena cava: A case report.

Retroperitoneal ectopic pregnancies are extremely rare; only a few cases having been reported. Here, we report laparoscopic removal of an asymptomatic retroperitoneal ectopic pregnancy from a 29-year-old woman who was referred to our hospital for a suspected ectopic pregnancy. Transvaginal ultrasound did not reveal a gestational sac in the uterus or pelvic cavity. However, abdominal contrast-enhanced computer tomography showed a gestational sac between the abdominal aorta and inferior vena cava. On laparoscopy, the gestational sac was confirmed to be in this retroperitoneal location and successfully removed with minimal bleeding. Histopathologic examination revealed chorionic villi surrounded by lymphatic tissue, suggesting lymphatic spread of the retroperitoneal ectopic pregnancy. In summary, contrast-enhanced computer tomography is very useful for locating the site of pregnancy in women suspected of having a retroperitoneal ectopic pregnancy. Timely diagnosis of a retroperitoneal ectopic pregnancy before bleeding occurs can enable their safe laparoscopic removal.

vNOTES surgical staging for endometrial carcinoma in overweight patients: a case series.

OBJECTIVES: The purpose of this study is to show the feasibility and surgical outcome of vNOTES retroperitoneal dissection and isolation of sentinel lymph nodes in overweight and obese patients with endometrial cancer. MATERIALS AND METHODS: Four patients had undergone pelvic lymphadenectomy with a sentinel lymph node. Three patients were overweight, and one was obese with a BMI of 34.6 kg/m2. By using NMR mode sentinel lymph node was visualized, excised and marked separately for pathohistological analysis from the rest of the visualized lymph nodes that were then consecutively excised. RESULTS: The mean number of overall excised lymph nodes was 12.5, and the mean number on the right side was 5.75 and 6.25 on the left side. There were no metastases verified in the pathohistological evaluation. CONCLUSION: vNOTES retroperitoneal isolation of sentinel lymph nodes is good alternative and has its benefits, especially in overweight and obese patients with satisfying low intra- and postoperative complications.

Full-term pregnancy with retroperitoneal giant mucinous cyst: A case report and literature review.

RATIONALE: Retroperitoneal benign cysts during pregnancy are extremely rare and often remain asymptomatic until they attain a very large size. Diagnosis typically relies on a pathological tissue biopsy. The decision to pursue 1-step or 2-step surgical treatment should be tailored to each individual case rather than generalized. PATIENT CONCERNS: This case report presents the unique scenario of a pregnant woman with a confirmed pregnancy complicated by a large retroperitoneal cyst. The patient had a retroperitoneal cyst during her initial pregnancy, which went undetected during the first cesarean section. However, it was identified during her second pregnancy by which time it had grown to 13.0 cm × 15.0 cm × 25.0 cm, and extended from the liver margin to right ovarian pelvic infundibulopelvic ligament. Consequently, it was removed smoothly during her second cesarean section. DIAGNOSES: Postoperative pathology results indicated a massive retroperitoneal mucinous cystadenoma. INTERVENTIONS: The giant retroperitoneal cyst was smoothly excised during the second cesarean delivery for 1-step surgical treatment. OUTCOMES: Under the combined spinal and epidural anesthesia, a live female infant was delivered at 38 3/7 gestational weeks and the neonatal weight was 3200g. Under general anesthesia with endotracheal intubation, the giant retroperitoneal cyst was excised smoothly without complications. LESSONS: The findings of this case report contribute to the understanding of the diagnostic modalities, surgical approaches and postoperative considerations of giant retroperitoneal cysts associated with pregnancy.

Retroperitoneal Laparoscopic Debridement and Drainage for Pancreatic Abscess.

In patients with severe necrotizing pancreatitis, pancreatic necrosis and secondary infection of surrounding tissues can quickly spread to the whole retroperitoneal space. Treatment of pancreatic abscess complicating necrotizing pancreatitis is difficult and has a high mortality rate. The well-accepted treatment strategy is early debridement of necrotic tissues, drainage, and postoperative continuous retroperitoneal lavage. However, traditional open surgery has several disadvantages, such as severe trauma, interference with abdominal organs, a high rate of postoperative infection and adhesion, and hardness with repeated debridement. The retroperitoneal laparoscopic approach has the advantages of minimal invasion, a better drainage route, convenient repeated debridement, and avoidance of the spread of retroperitoneal infection to the abdominal cavity. In addition, retroperitoneal drainage leads to fewer drainage tube problems, including miscounting, displacement, or siphon. The debridement and drainage of pancreatic abscess tissue via the retroperitoneal laparoscopic approach plays an increasingly irreplaceable role in improving patient prognosis and saving healthcare resources and costs. The main procedures described here include laying the patient on the right side, raising the lumbar bridge and then arranging the trocar; establishing the pneumoperitoneum and cleaning the pararenal fat tissues; opening the lateral pyramidal fascia and the perirenal fascia outside the peritoneal reflections; opening the anterior renal fascia and entering the anterior pararenal space from the rear; clearing the necrotic tissue and accumulating fluid; and placing drainage tubes and performing postoperative continuous retroperitoneal lavage.

Single Port Modified Partial Nephrectomy: Novel Simultaneous Access to Peritoneal and Retroperitoneal Partial Nephrectomy, Initial Clinical Experience.

Introduction and Objective: Since its Food and Drug Administration (FDA) approval in 2018, Intuitive Surgical DaVinci single port (SP) robotic platform has been an effectively used technology for multiple urologic procedures. The purpose of this study is to share our early intraoperative and perioperative outcomes and potential benefits for performing a lower anterior access (LAA) incision for SP robot-assisted partial nephrectomy (SP-RAPN). The LAA incision enables performing a trans- or retroperitoneal (RP) approach through the same incision and eases the transition to a RP approach. Methods: This study is a prospective review of 78 SP-RAPN cases between March 2021 and January 2023 by an experienced robotic surgeon. A single 2-3 cm oblique incision parallel to the external oblique muscle, one-third of the distance between the iliac crest and umbilicus, was used to insert the multichannel port to perform the RAPN. We extracted intra- and perioperative data of these patients to share the outcomes of this approach. Results: SP-RAPN was effectively completed in 78 patients (38 females and 40 males) without conversion to open or laparoscopic techniques. The mean age was 61.2 ± 12.1 years. The mean tumor size was 3.0 ± 1.2 cm, 43 were right-sided masses, and 35 were left sided. The R.E.N.A.L Nephrometry score ranged from (4-11) with an average of 7.0 ± 1.9. Average operating room time was 90.5 ± 24.6 minutes, estimated blood loss was 88.3 ± 134 mL, and length of stay of 1.07 ± 0.7 days. Of the 78 cases, 40 required clamping of the renal artery with average warm ischemia time of 19.4 ± 6.7 minutes in patients who underwent clamping. No complications in all of 78 patients. Conclusions: This study demonstrates the feasibility and reproducibility of SP-RAPN using a LAA incision. This incision provides a standardized approach for surgeons to transition to the RP approach using the SP platform.

Modified versus three-level technique of retroperitoneal laparoscopic adrenalectomy for all patients with adrenal lesions ≤ 6cm: a retrospective, case-controlled study.

Objectives: The modified three-level technique for retroperitoneal laparoscopic adrenalectomy (RLA) has proven beneficial in the treatment of adrenal lesions in patients with BMI≥25 Kg/m2. This paper aims to summarize our institution's seven-year experience using this technique for all patients with Adrenal Lesions ≤ 6cm. Patients and methods: Between January 2016 and December 2022. The patients underwent laparoscopic adrenal surgery were categorized into Zhang's technique (ZT) (Three-level Technique) group and modified technique (MT) group. The fundamental characteristics and perioperative data were analyzed, with statistical significance set at p<0.05. Results: In total, 731 patients were stratified into two groups: ZT (n=448) and MT (n=283). Statistically significant distinctions were not detected between the two groups regarding sex, BMI, tumor location, tumor size, tumor type, or American Society of Anesthesiologists (ASA) score (p>0.05). The MT group demonstrated superior outcomes compared to the ZT group in terms of operative time, estimated blood loss, drainage volume, diet recovery time, complication rates, and postoperative hospitalization duration (p<0.05). 17 (4.34%) in the ZT group required unplanned adrenalectomy, while there was none in MT group (P<0.05). Conclusion: MT retroperitoneal laparoscopic adrenalectomy has demonstrated its benefits in the treatment of adrenal lesions across all patients with adrenal lesions ≤ 6cm, serving as a valuable point of reference for the surgical management of adrenal diseases. Patient summary: We have made modifications to the classic retroperitoneal laparoscopic adrenalectomy and achieved superior surgical outcomes, resulting in a procedure known as modified retroperitoneal laparoscopic adrenalectomy. This technique is suitable for both obese individuals and the general population with adrenal lesions ≤ 6cm.

Versatility of Single Port Retroperitoneal Low Anterior Access: Early Outcomes in Multiple Procedures.

Purpose: This study aimed to assess early outcomes of the single port (SP) robotic low anterior access (LAA) for all upper urinary tract surgeries. In addition, it aimed to explore the impact of clinical factors, notably Body Mass Index (BMI), on post-operative outcomes and length of hospital stay. Materials and Methods: Overall, 76 consecutive patients underwent SP robotic surgery with LAA involving all upper urinary tract pathologies, with data collected prospectively. Baseline characteristics, intra- and post-operative outcomes, pain levels, and opioid use were analyzed. Statistical methods, including logistic regression and locally weighted scatterplot smoothing analysis, were used to assess same-day discharge (SDD) predictors and the association between BMI and SDD probability. According to the Institutional Review Board (IRB) protocol, only data recorded in our electronic medical record system was included. Results: Ten different procedures were performed with LAA, with no need for conversion to open surgery and complication rates in line with the literature (30 days: 5%, 90 days: 6.6%). Notably, 77.6% of patients were discharged on the same day. A significant association was found between BMI and prolonged hospital stay, particularly in obese patients (BMI ≥30 kg/m2). Post-operative pain was generally low (median VAS: 4), with over 70% discharged without opioid prescriptions. Conclusions: The novel LAA is a versatile approach for various upper urinary tract surgeries, including in obese patients. While achieving satisfactory post-operative outcomes, increased BMI correlated with a reduced likelihood of SDD. Further studies, including larger cohorts and multicenter collaborations, are warranted to explore anesthesiologic management and validate these findings.