The active development of minimally invasive procedures on retroperitoneal organs using endoscopic technology raises the question of the most rational approach. The studies dedicated to the ...comparison of transperitoneal and retroperitoneoscopic approach are analyzed in the article. The advantages and the most common complications, as well as the factors limiting the widespread use of retroperitoneoscopic approach, are reviewed.
Abstract Objective To assess if FDG PET combined with diagnostic CT improves diagnostic CT accuracy to detect lymph node (LN) metastasis in advanced cervical cancer. Methods A prospective HIPAA ...compliant ACRIN/GOG multicenter trial was conducted. Patients underwent concurrent diagnostic contrast-enhanced CT (DCT) and PET and pelvic/abdominal lymphadenectomy. Seven independent blinded readers reviewed PET-DCT and DCT one-month apart. Reference standard was surgically removed LN pathology. Accuracy values were calculated at participant level, correlating abdominal (right and left para-aortic/common iliac) and pelvic (right and left external iliac/obturator) LN regions with pathology, respecting laterality. Reader average sensitivities/specificities of PET-DCT vs. DCT were compared with generalized linear mixed models, and AUCs with Obuchowski's method. Results One hundred fifty-three patients had PET-DCT and pathology. Forty-three of 153 patients had metastasis to abdominal LNs. Sample size calculation required review of the first 40 abdominal positive and 40 randomly selected abdominal negative studies. Patients were 24 to 74 years (48.9 ± 10.6) old. Mean sensitivities of PET-DCT/DCT for detection of LN metastasis in abdomen were 0.50 (CI: 0.44, 0.56) and 0.42 (CI: 0.36, 0.48) ( p = 0.052) and in pelvis 0.83 (CI: 0.78, 0.87) and 0.79 (CI: 0.73, 0.83) ( p = 0.15). Corresponding specificities were 0.85 (CI: 0.80, 0.89) and 0.89 (CI: 0.84, 0.92) ( p = 0.21) and 0.63 (CI: 0.54, 0.70) and 0.62 (CI: 0.53, 0.69) ( p = 0.83). Mean AUC values were 0.70 (CI: 0.61, 0.79) and 0.68 (CI: 0.59, 0.77) ( p = 0.43) and 0.80 (CI: 0.71, 0.88) and 0.76 (CI: 0.67, 0.85) ( p = 0.21) respectively. Conclusion Addition of PET to DCT resulted in statistically borderline increase in sensitivity to detect LN metastasis in abdomen in advanced cervical cancer.
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.
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.
Postoperative pathology results indicated a massive retroperitoneal mucinous cystadenoma.
The giant retroperitoneal cyst was smoothly excised during the second cesarean delivery for 1-step surgical treatment.
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.
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.
Background
Surgical approaches to the kidneys and perirenal structures are uncommonly performed in horses and several complications have been described with the current procedures.
Objective
To ...describe the anatomy of the retroperitoneal perirenal space and investigate a retroperitoneal minimally invasive approach to access the kidney and perirenal structures in horses.
Study design
Descriptive, cadaveric study.
Methods
Anatomical description of the retroperitoneal space was performed on three equine cadavers and the surgical approach was developed based on these dissections. Ten cadaveric horses underwent a retroperitoneoscopy. Five horses were placed in a right lateral recumbency position to explore the left retroperitoneal space and five horses were placed in a standing position to explore both left and right sides. Anatomical landmarks, working space and access to the renal hilus and perirenal structures were evaluated.
Results
Dissections revealed that kidneys are surrounded by a renal fascia which delimits two spaces: a perirenal space between the kidney and the renal fascia, and a pararenal space between the renal fascia and psoas muscles or peritoneum. The retroperitoneoscopic portal was placed at the level of the dorsal aspect of the tuber coxae, 3 cm caudal to the last rib for the left side and 2 cm caudal to the last rib for the right side. Retroperitoneal access and working space were successfully established in all horses. The standing position allowed an easier dissection than lateral recumbency. Division of the perirenal fat allowed access to the kidney and adrenal glands as well as individualisation of renal vessels and ureter in the renal hilus.
Main limitations
Study of cadavers precluded appreciation of haemorrhage or use the pulsating vessels as landmarks.
Conclusions
This study provides a description of the retroperitoneal perirenal space and describes a new surgical approach to access kidneys and perirenal structures in horses.
Résumé
Introduction/Contexte
Les approches chirurgicales pour accéder aux reins et aux structures péri‐rénales sont réalisées de façon peu fréquente chez le cheval. Plusieurs complications ont été rapportées avec l’utilisation des techniques déjà décrites.
Objectifs
Décrire l’anatomie de l’espace péri‐rénal rétropéritonéal et investiguer une approche rétropéritonéale minimalement invasive afin d’accéder aux reins et aux structures péri‐rénales chez le cheval.
Type d’étude
Descriptive, étude cadavérique.
Méthodes
La description anatomique de l’espace rétropéritonéal a été effectué en utilisant 3 cadavres équins et l’approche chirurgicale a été développée à partir de ces dissections. Dix cadavres équins ont été soumis à la rétropéritonéoscopie. Cinq chevaux ont été placés en décubitus latéral droit afin d’explorer l’espace rétropéritonéal gauche et cinq chevaux ont été positionnés debout pour pouvoir visualiser à la fois les espaces droit et gauche. Les repères anatomiques, l’espace de travail disponible ainsi que l’accès à l’hile rénal et aux structures péri‐rénales ont été évalués.
Résultats
Les dissections ont permis de visualiser les reins entourés d’un fascia rénal séparant l’espace en deux parts : l’espace péri‐rénal entre le rein et le fascia rénal ainsi que l’espace para‐rénal entre le fascia rénal et les muscles psoas ou le péritoine. La porte rétropéritonéoscopique a été positionnée dorsalement au niveau du tuber coxae, 3 cm caudalement à la dernière côte du côté gauche et 2 cm caudalement à la dernière côte à droite. L’accès rétropéritonéal et à l’espace de travail ont été établis avec succès chez le cheval. La position dorsale permet une meilleure dissection comparativement au décubitus latéral. La séparation du gras péri‐rénal permet l’accès au rein et glandes surrénales de même que l’individualisation des vaisseaux rénaux et de l’uretère au sein du hile rénal.
Limites principales
L’étude cadavérique n’a pas permis l’évaluation du degré d’hémorragie ou la visualisation du pouls sanguin comme repère.
Conclusions
Cette étude offre une description de l’espace péri‐rénal rétropéritonéal et décrit une nouvelle approche chirurgicale pour accéder au rein et aux structures péri‐rénales chez le cheval.
Resumo
Introdução
As abordagens cirúrgicas dos rins e das estruturas perirenais são incomuns em equinos e muitas complicações foram descritas com os procedimentos praticados atualmente.
Objetivo
Descrever a anatomia do espaço perirenal retroperitoneal e investigar uma abordagem retroperitoneal minimamente invasiva para acessar os rins e as estruturas perirenais no cavalo.
Delineamento experimental
Estudo descritivo em cadáveres.
Métodos
A descrição anatômica do espaço retroperitoneal foi realizada em três cadáveres equinos e a abordagem cirúrgica foi desenvolvida com base nestas dissecações. Dez cadáveres equinos foram submetidos à retroperitoneoscopia. Cinco cavalos foram posicionados em decúbito lateral direito para a exploração do espaço retroperitoneal esquerdo e cinco cavalos foram posicionados em pé para a exploração dos lados esquerdo e direito. As referências anatômicas, o espaço de trabalho e o acesso ao hilo renal e às estruturas perirenais foram avaliados.
Resultados
As dissecações revelaram que os rins são envoltos por uma fáscia renal que delimita dois espaços: um espaço perirenal entre os rins e a fáscia renal e um espaço pararenal entre a fáscia renal e os músculos psoas ou peritôneo. O acesso retroperitoneoscópico foi posicionado ao nível da face dorsal da tuberosidade coxal, 3 cm caudal à última costela para o lado esquerdo e 2 cm caudal à última costela para o lado direito. O acesso retroperitoneal e o espaço de trabalho foram estabelecidos com sucesso em todos os cavalos. A posição quadrupedal permitiu uma dissecação mais fácil do que o decúbito lateral. A separação da gordura perirenal permitiu o acesso aos rins e às glândulas adrenais, bem como a individualização dos vasos renais e ureter no hilo renal.
Principais limitações
O estudo em cadáveres impediu a avaliação de hemorragia ou o uso de vasos pulsáteis como referências anatômicas.
Conclusões
Este estudo fornece uma descrição do espaço perirenal retroperitoneal e descreve uma nova abordagem cirúrgica para o acesso aoss rins e às estruturas perirenais em cavalos.
Renal angiomyolipoma (AML) is a common benign tumor of the kidney. The main complication of AML is retroperitoneal hemorrhage caused by AML rupture, which can be severe and life threatening. The risk ...of AML rupture used to be determined by tumor size. However, these criteria have been challenged by series of clinical studies and case reports, suggesting prediction AML rupture based on tumor size is not always reliable.
The authors searched PubMed using "angiomyolipoma," "AML," and "rupture" and reviewed relevant studies. The authors investigated the risk factors of AML rupture using the retrieved literature. The authors also summarized current modalities to evaluate and manage AML.
It is established that risk of AML rupture is associated with lesion size. However, genetic abnormality, aneurysm formation, and pregnancy are also risk factors for tumor rupture. Thus, the prediction of AML rupture should be based on a more comprehensive risk assessment system. The management of renal AML and tumor rupture was also discussed in the present paper.
The risk of AML rupture is associated with but not exclusive to lesion size. Any decision to intervene AML must be based on multiple factors including risk, symptoms, and auxiliary findings.
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.
Graphical Abstract
Primary retroperitoneal neoplasms are a rare but diverse group of benign and malignant tumors that arise within the retroperitoneal space but outside the major organs in this space. Although computed ...tomography and magnetic resonance imaging can demonstrate important characteristics of these tumors, diagnosis is often challenging for radiologists. Diagnostic challenges include precise localization of the lesion, determination of the extent of invasion, and characterization of the specific pathologic type. The first step is to determine whether the tumor is located within the retroperitoneal space. Displacement of normal anatomic structures of the retroperitoneum is helpful in this regard. For tumors that are located within the retroperitoneum, the next step is to identify the organ of origin. Specific signs, including the "beak sign," the "embedded organ sign," and the "phantom (invisible) organ sign," are useful for this purpose. When there is no definite sign that suggests the organ of origin, the diagnosis of a primary retroperitoneal tumor becomes likely. Awareness of specific patterns of spread, specific tumor components, and tumor vascularity help in further narrowing the differential diagnosis. Attention to these diagnostic clues is essential in making an accurate radiologic diagnosis of primary retroperitoneal tumors and in obtaining clinically significant information.
To explore the feasibility and safety of retroperitoneal laparoscopic resection of paraganglioma (RLPG) in a large study population.
In a six-year period, 49 patients with primary retroperitoneal ...paragangliomas (PG) underwent retroperitoneal laparoscopic surgery in a single center. Medical records were reviewed, and collected the following data, which were clinical characteristics, perioperative data (operative time, estimated blood loss, intraoperative hemodynamic changes, intraoperative and postoperative complications, and open conversions), and follow-up data (recurrence or distant metastases).
All PGs were removed with negative tumor margin confirmed by postoperative histopathology. The operative time of RLPG was 101.59±31.12 minutes, and the estimated blood loss was 169.78±176.70ml. Intraoperative hypertensive and hypotensive episodes occurred in 25 cases and 27 cases, respectively. Two open conversions occurred. Two intraoperative complications occurred but were successfully managed endoscopically. Postoperative complications were minor and unremarkable. No local recurrence or distant metastasis were observed during the follow-up period.
Our experience indicates the feasibility and safety of resection of PGs in a relatively large study population.
There is a broad spectrum of neurogenic tumors that involve the abdomen. These tumors can be classified as those of (a) ganglion cell origin (ganglioneuromas, ganglioneuroblastomas, neuroblastomas), ...(b) paraganglionic system origin (pheochromocytomas, paragangliomas), and (c) nerve sheath origin (neurilemmomas, neurofibromas, neurofibromatosis, malignant nerve sheath tumors). Abdominal neurogenic tumors are most commonly located in the retroperitoneum, especially in the paraspinal areas and adrenal glands. All of these tumors except neuroblastomas and ganglioneuroblastomas are seen in adult patients. Abdominal neurogenic tumor commonly manifests radiologically as a well-defined, smooth or lobulated mass. Calcification may be seen in all types of neurogenic tumors. The diagnosis of abdominal neurogenic tumor is suggested by the imaging appearance of the lesion, including its location, shape, and internal architecture. Benign and malignant neurogenic tumors are difficult to differentiate unless distant metastatic foci are seen. For malignant tumors, imaging modalities other than computed tomography (CT) and magnetic resonance (MR) imaging may be necessary for staging. However, because most neurogenic tumors in adults are benign, CT and MR imaging can be used to develop a differential diagnosis and help determine the immediate local extent of tumor.
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