Search

Purpose: A midline extraperitoneal approach for retroperitoneal lymph node dissection (EP-RPLND) has been associated with decreased morbidity compared to the transperitoneal approach. We aimed to review our 11-year experience in patients with germ cell tumors (GCTs) who underwent EP-RPLND at a single institution. Materials and Methods: All patients with GCT who underwent EP-RPLND between 2010 and 2021 were reviewed. Surgical, perioperative, and oncologic outcomes were reported. A logistic regression model was developed to evaluate variables predictive of early discharge. Oncologic outcomes included 2-year recurrence-free survival (RFS) and recurrence patterns, which were analyzed according to pathology. Results: Overall, 237 patients underwent EP-RPLND, of which 72% were administered in the postchemotherapy (PC) setting. Median follow-up was 16.7 months (interquartile range [IQR] 3.9-39.6). Median size of retroperitoneal disease was 2.8 cm (IQR 1.8-5.4), of which 16 cases were ≥ 10 cm. There were no cases of postoperative ileus or readmission due to small-bowel obstruction. Median hospital stay was 2 days (IQR 1-3). From 2020 to 2021, 74% of patients were discharged on postoperative day 1 and 89% by postoperative day 2. Thirty-one complications occurred, including 4% grade III to IV complications. In the primary setting, 2-year RFS for seminoma and nonseminomatous GCT was 0.93 (95% CI 0.84-1.00) and 0.85 (95% CI 0.72-1.00), respectively. In the PC setting, 2-year RFS for seminoma and nonseminomatous GCT was 0.88 (95% CI 0.74-1.00) and 0.88 (95% CI 0.81-0.95), respectively. Overall, only 7 patients had in-field recurrence. Conclusions: Midline EP-RPLND is safe and associated with rapid gastrointestinal recovery, short hospital stay, and low complication rates. It also demonstrates acceptable oncologic outcomes in the primary and PC settings, with low rates of in-field relapse. [ABSTRACT FROM AUTHOR]

The extraperitoneal approach has been successfully employed by general surgeons, urologists, and orthopedic surgeons. In obstetrics and gynecology, this approach has been utilized for cesarean section, pelvic lymph node dissection, and drainage of extraperitoneal fluid collection including pelvic abscess, hematoma, and lymphocysts. With advancements in the use of antibiotics, imaging and image-guided drainage techniques the frequency of this approach has been reduced. However, it remains a valuable option in specific clinical situations related to gynecological surgery. This article provided a detailed description of the extraperitoneal technique, encompassing relevant anatomy and surgical considerations that are further illustrated in the accompanying cadaveric video dissection. As demonstrated in the reported cases, this technique can be performed on either the right or left and can be extended superiorly or inferiorly as needed. Potential advantages of the extraperitoneal technique compared with intraperitoneal approaches included reduced morbidity. [ABSTRACT FROM AUTHOR]

Purpose: The extended totally extraperitoneal technique (eTEP) is a relatively new laparoscopic approach to address ventral hernias. Since this technique is not widely used yet, the literature regarding its efficacy and safety is limited, especially when compared to more established surgical techniques like intraperitoneal onlay mesh (IPOM). This study aimed at contributing to the expanding body of evidence for eTEP, by comparing the early outcomes of eTEP and IPOM surgeries for ventral hernias. Methods: This monocentric, retrospective cohort study compared patients with ventral hernias that were treated with eTEP or IPOM from 2019 to 2023. Results: A total of 123 patients were analysed. 92 underwent eTEP and 31 IPOM respectively. Both groups were overall comparable. The IPOM group had a higher proportion of incisional hernias (61,29% vs. 21,74%, p < 0,001). This was taken into account for in a subgroup analysis of only primary hernias. The IPOM group had a significantly longer admission time (eTEP: 3 days, IPOM: 4 days, p < 0,001). The subgroup analysis revealed a statistically significant shorter surgery time in IPOM (median of 66,5 min vs. 106,5 min; p = 0,043) and a lower rate of postoperative complications in eTEP (eTEP: 4,17%, IPOM: 25%. p = 0,009). The eTEP group reported lower postoperative pain, yet without statistical significance. Conclusion: eTEP for ventral hernia repair appears to be non-inferior to IPOM. Compared to IPOM it leads to shorter postoperative hospital stay and a potentially lower complication rate, despite a longer operation time. [ABSTRACT FROM AUTHOR]

Background and Objectives: To prove the feasibility of continuous spinal extraperitoneal robot-assisted laparoscopic radical prostatectomy (cseRALP) in order to expand the pool of eligible patients. Materials and Methods: According to IDEAL guidelines, a consecutive cohort of patients who underwent cseRALP was enrolled. Pre-, intra-, and post-operative data were collected, with particular focus on safety and oncological outcomes. Results: A total of three patients underwent this technique, with no intra- or post-operative medical complications. Only a grade 1 Clavien–Dindo complication was reported, small urinary leakage treated with an indwelling catheter. Oncological and functional results at month 3 were satisfactory, with no recurrence and no stress incontinence. Conclusions: cseRALP seems to be feasible and safe; further trials are mandatory. [ABSTRACT FROM AUTHOR]

Bladder ruptures are uncommon but potentially life-threatening conditions, that necessitates prompt medical intervention. Urological trauma guidelines differentiate between intraperitoneal and extraperitoneal bladder ruptures. Intraperitoneal bladder ruptures typically require surgical repair, while extraperitoneal bladder ruptures are often treated conservatively. This case report presents a 25-year-old male patient with a significant intraperitoneal bladder rupture, successfully treated through conservative management. This case highlights the potential for nonoperative treatment in selected patients with intraperitoneal bladder injury, contributing to the evolving discussion on the management of urological trauma.

Background and objective: The role of pelvic lymph node dissection (PLND) for prostate cancer is still controversial. This study aims to compare the outcomes of PLND between extraperitoneal single-port (SP eRARP) and transperitoneal multiport (MP tRARP) robotic-assisted radical prostatectomy. Methods: This was a retrospective analysis from our single-center database for patients who underwent SP eRARP or MP tRARP with PLND between 2015 and 2023. The primary endpoint was to analyze and compare specific data related to PLND between the two populations by the detection of pN+ patients, the total number of lymph nodes removed, and the number of positive lymph nodes removed. The secondary endpoints included comparing major complications, lymphoceles, and biochemical recurrence between the two cohorts of the study. Key findings and limitations: A total of 293 patients were included, with 85 (29%) undergoing SP eRARP and 208 (71%) undergoing MP tRARP. SP eRARP showed significant differences in PLND extension from MP tRARP, while MP tRARP yielded more lymph nodes (p

Purpose: Transabdominal preperitoneal (TAPP) ventral hernia repair requires incising the peritoneum from within the abdominal cavity, developing a flap, and placing a reinforcing mesh after fascial closure from the preperitoneal space. We present a novel adaptation to this technique that allows placement of preperitoneal mesh without entering the abdominal cavity. The robotic totally extra- and preperitoneal (R-PeTEP) access for ventral hernia repair is best suited for small to moderate sized ventral hernias with concomitant diastasis recti. Methods: Our study is a retrospective review of all patients who underwent R-PeTEP from December 2022 to November 2023. A comprehensive description of the surgical technique is included. Patient demographics, hernia characteristics, as well as clinical outcomes are described. Results: A total of 25 patients underwent R-PeTEP for ventral hernia repair with diastasis recti plication. The median age was 55 years (IQR 43.5–63) and 92% (n = 23) were male. The median ASA score was 2 (IQR 1–2) and the median BMI was 30.4 (IQR 29.3–32.8) with 64% (n = 16) percent having a BMI ≥ 30. Median hernia width was 3 cm (IQR 3–4), with a median diastasis recti width of 4 cm (IQR 2.6–4) and length of 15 cm (IQR 11.8–16). The median operative time was 120 min (IQR 116–134). All repairs were reinforced with permanent mesh. Sixty-eight percent of the patients (n = 17) were discharged on the same day. With a median follow-up of 30 days (IQR 16–107), 8% (n = 2) seromas, 16% (n = 4) developed clinically insignificant hematomas, and one patient (4%) developed ileus that was managed conservatively. Conclusion: This study establishes the feasibility and safety of R-PeTEP, which provides direct access to the preperitoneal space, avoiding disruption to the posterior rectus sheath, possibly reducing neurovascular bundle injuries, and omitting entry to the abdominal cavity. R-PeTEP facilitates wide flap creation for prosthetic overlap and allows for posterior plication of diastasis recti with little to no mesh fixation with overall excellent preliminary clinical outcomes. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Hydatid cyst is a sly disease that can manifest with a spectrum of symptoms in almost every part of the human body, so it is crucial to be familiar with different scenarios that a patient may present. The echinococcus granulosus parasite causes hydatid disease and is common in areas with animal husbandry and agriculture. Here, we report a middle age woman who presented with abdominal pain that further investigation revealed a cyst in subdiaphragmatic area. [ABSTRACT FROM AUTHOR]

The article discusses the early experience of a novel single-port extraperitoneal robotic kidney transplantation technique. The study aimed to demonstrate the safety and feasibility of the surgery, with successful completion of the transplant procedure without any major complications. The procedure showed reduced morbidity and decreased hospitalization times, with no detrimental impact on graft function post-surgery. The technique offers potential benefits in terms of enhanced recovery and decreased morbidity compared to traditional approaches. [Extracted from the article]

Aim: A minimally invasive surgery (MIS) extraperitoneal (XP) approach to left‐sided colorectal resection utilizing the laparoscopic approach has recently been shown to be safe and feasible and to have potential advantages over the transperitoneal approach, especially in high‐risk surgical patients. The aim of this article is to provide a first cadaveric demonstration of the use of a single‐port robotic platform in performing XP low anterior resection by MIS. Method: A single‐port robotic platform (DaVinci®SP™) was used to perform XP single‐port low anterior resection in two cadavers with body mass indexes (BMIs) of 19 and 40 kg/m2. Results: The single‐port robotic platform with versatile arms was successfully used to perform a complete low anterior resection with splenic flexure mobilization and total mesorectal excision through a single port. Conclusions: A single‐port robotic platform enhances complete XP dissection in the supine patient in extreme BMI ranges. Clinical studies are necessary to confirm these findings. [ABSTRACT FROM AUTHOR]

Background and Objectives: To prove the feasibility of continuous spinal extraperitoneal robot-assisted laparoscopic radical prostatectomy (cseRALP) in order to expand the pool of eligible patients. Materials and Methods: According to IDEAL guidelines, a consecutive cohort of patients who underwent cseRALP was enrolled. Pre-, intra-, and post-operative data were collected, with particular focus on safety and oncological outcomes. Results: A total of three patients underwent this technique, with no intra- or post-operative medical complications. Only a grade 1 Clavien–Dindo complication was reported, small urinary leakage treated with an indwelling catheter. Oncological and functional results at month 3 were satisfactory, with no recurrence and no stress incontinence. Conclusions: cseRALP seems to be feasible and safe; further trials are mandatory.

Introduction and objectives: There are various approaches available for surgical management of large prostatic adenomas – open, laparoscopic as well as laser enucleation – but there are no available clear cut consensus or guidelines. We present our experience in Extraperitoneal Laparoscopic Simple Prostatectomy on 14 patients with large prostatic adenoma (>100 g). Materials and methods: This is a retrospective analysis on 14 patients with large prostatic adenoma who underwent extraperitoneal laparoscopic prostatectomy (LSP) over a period of 2 years (2021–2023). All selected patients underwent extraperitoneal LSP. The case records were retrospectively reviewed and data were collected regarding age, clinical presentation, prostate size, median surgical time, intra-operative and post-operative events, pre-operative and post-operative assessment of IPSS score, Uroflowmetry and PVR values and duration of hospital stay. Results: A total of 14 patients underwent LSP. The median age was 64.2 years and the median prostatic size was 123.25 g. Median operative time was 150 min. None of the patients required blood transfusion; mean Post-operative day (POD) for drain removal was 2.5 days. The mean duration of hospital stay was 3.5 days. Only one patient had urinary leak and vesico-cutaneous fistula which was managed conservatively by prolonged catheterisation. At 3 months follow-up, there was significant improvement in IPSS Score (mean 7.8 vs 21.3 pre-operatively), uroflow values (mean Qmax of 27.3 vs 6.8 pre-operatively) and PVR (mean 30.5 vs 350 ml pre-operatively). Conclusion: Laparoscopic Simple Prostatectomy is a safe and feasible approach for large prostatic adenomas with lesser morbidity and complications and satisfactory outcome. [ABSTRACT FROM AUTHOR]

Abstract Objectives To describe a technique to improve exposure of prostate during extraperitoneal robot-assisted radical prostatectomy (EP-RARP). Material and methods From March 2020 to June 2022, a total of 41 patients with prior intra-abdominal surgery underwent EP-RARP. Twenty-three patients improved exposure by traction of prostate through urinary catheter. The catheter traction prostatectomy (CTP) group was compared with the standard prostatectomy (SP) group using three robotic arms (18 patients) in terms of estimated blood loss (EBL), operative time, positive surgical margin rate, the recovery rate of urinary continence, Gleason score and postoperative hospital stays. Differences were considered significant when P

Introduction: Newer extraperitoneal techniques of laparoscopic ventral/incisional hernia repair (LVIHR) have been continually introduced since the popularity of the laparoscopic intraperitoneal onlay mesh technique began in 1993. One of which is the extended totally extraperitoneal (eTEP) approach allowing wide mesh augmentation, concurrent repair of diastasis recti, and performance of transversus abdominis release (TAR) for large/complex hernias. However, minimally invasive/laparoendoscopic ventral hernia repair is not yet widely adopted in the Philippines. We aim to share our preliminary experience with LVIHR using the eTEP approach. Methods: This was a retrospective review of all consecutive eTEP repairs for ventral hernia between January 2019 and September 2023. The clinical profiles of all patients were gathered. Hernia characteristics, operative profile, and postoperative outcomes were reported. Results: Thirty‐five patients were included in the study with a mean age of 54.7; 60% were incisional hernias, and the most common hernia location was the umbilical area. A defect size between 4 and 10 cm was reported in 54.3%. eTEP‐TAR was necessary in 12 patients. At a median follow‐up of 16 months, two patients developed seroma, one hematoma, and two surgical site infections. All were successfully managed conservatively. Only one patient developed recurrence. Conclusion: eTEP approach is safe and feasible for repairing ventral hernias. Our preliminary experience showed acceptable outcomes similar to the published literature. Surgeons interested in this technique should be familiar with the abdominal wall anatomy, carefully select patients during preoperative planning, and undergo mentorship with hernia surgeons experienced with the technique to shorten the learning curve. [ABSTRACT FROM AUTHOR]

This case report describes a 69-year-old male patient who underwent laparoscopic inguinal hernia repair using a total extraperitoneal approach. Complications during the procedure were hypercarbia, surgical emphysema, and pneumothorax. Immediate interventions were necessary to address the rising end-tidal CO2 levels, hypercarbia, and acidosis. The incidence of these complications may be higher than previously reported, particularly in extraperitoneal laparoscopic procedures, underscoring the importance of increased awareness among anaesthesiologists. This case report emphasises the significance of monitoring CO2 inflation pressure, assessing subcutaneous CO2 accumulation, and adjusting ventilation to enhance patient safety and promote the reporting of such complications in the future. [ABSTRACT FROM AUTHOR]

Purpose: The Hugo™ RAS system is a novel robotic platform with innovative features. However, there are currently no available data on extraperitoneal robot-assisted radical prostatectomy (RARP) performed using this system. The objective of this study is to describe the surgical setup and assess the safety and feasibility of the extraperitoneal approach in robotic radical prostatectomy with the Hugo™ RAS system. Methods: Sixteen consecutive patients diagnosed with localized prostate cancer underwent extraperitoneal RARP ± lymph node dissection at our institution, between March and May 2023. All RARP procedures were performed extraperitoneal with a modular four-arm configuration. The focus was to describe the operative room setup, trocar placement, tilt and docking angles and evaluate the safety and feasibility of this approach with this robotic platform. Secondary outcomes recorded included, total operative time, console time, estimated bleeding, intra- and postoperative complications, and length of stay after surgery. A descriptive analysis was conducted. Results: We report on the first sixteen cases of extraperitoneal robot-assisted radical prostatectomy performed with the new Hugo™ RAS system. All procedures were completed, without the need for conversion or placement of additional ports. No intraoperative complications or major technical failures that would prevent the completion of surgery were recorded. The median operative time was 211 min (IQR 180–277), and the median console time was 152 min (IQR 119–196). The mean docking time was 4.6 min (IQR 4.1–5.2). The median estimated blood loss and the median time to remove the vesical catheter were 200 mL (IQR 150–400) and 8 days (IQR 7–8), respectively. The median length of stay was 2 days (IQR 2–2). Only one minor complication was registered in the first 30 days. Conclusion: This study provides evidence of the safety and feasibility of the extraperitoneal approach in RARP with the Hugo™ RAS system. The description of the surgical setup in terms of trocar placement, arm-cart disposition, tilt and docking angles offers valuable information for surgeons interested in adopting this surgical approach with the Hugo™ RAS platform. [ABSTRACT FROM AUTHOR]

Background: The Dextile Anatomical mesh (Medtronic) is a polypropylene heavyweight mesh and has a 3D patented anatomical shape which adapts to the contours of the extra-peritoneal inguinal region without the need for fixation, potentially reducing the risk of hernia recurrence and chronic post-operative pain. This retrospective study will be the first study to assess the outcomes of the Dextile Anatomical mesh compared to another three-dimensional mesh, the 3DMax mesh (Bard). Methods: Between 2019 and 2022, all patients who underwent an elective unilateral inguinal hernia repair were assessed. 416 patients in the Dextile Anatomical mesh group and 540 patients in the 3DMax mesh group were included. Outcomes were intra- and post-operative complications, inguinal hernia recurrence and chronic post-operative inguinal pain. Results: No significant differences were found between the two groups regarding intra- and post-operative complications including wound infection, antibiotic use, hematoma, seroma, urinary retention and delayed wound healing. 1-year recurrence rate was comparable for the Dextile Anatomical mesh group and the 3DMax mesh group, respectively, 3.8% and 3.0%, P = 0.45. Chronic post-operative inguinal pain was similar for the Dextile Anatomical mesh (3.4%) and the 3DMax mesh (3.0%), P = 0.72. Conclusion: This retrospective study comparing the relatively new Dextile Anatomical mesh (Medtronic) with the 3D Max mesh (Bard) in unilateral inguinal hernia repair showed that both meshes are safe and effective to use. There were no significant differences in intra-operative outcomes, recurrence rates and chronic post-operative inguinal pain. [ABSTRACT FROM AUTHOR]

To conduct a comparative analysis of outcomes from 2 different surgical approaches, transperitoneal radical prostatectomy (TP-RP) and extraperitoneal radical prostatectomy (EP-RP) in minimally invasive surgery. A comprehensive search was conducted up to September 2022 using 5 online databases, namely PubMed, Cochrane, Scopus, EMBASE, and Science Direct. Studies were screened per the eligibility criteria, and outcomes included operative duration, estimated blood loss (EBL), hospital stay, operative complication, and positive surgical margin. Total of 13 studies compiled of 2387 patients were selected, with TP-RP and EP-RP performed on 1117 (46.79%) and 1270 (53.21%) patients, respectively. Six laparoscopy radical prostatectomy (LRP) studies and 7 robotassisted radical prostatectomy (RARP) studies with 1140 and 1247 patients, respectively, were also included. The EP-RP demonstrated a marked advantage in terms of operative complications (Risk Ratio [RR] = 0.78, 95% CI = 0.62, 0.98; P = .04), but no significant difference concluded for operative duration, EBL, hospital stay, and surgical margin. In the RARP group, there was a significant difference in operative duration for EP-RARP and TP-RARP (Mean difference [MD] = 17.27, 95% CI = 26.89, -7.65; P = .0004), hospital stay (MD = -0.54, 95% CI = -0.94, -0.14; P = .008), and operative complications (RR = 0.7, 95% CI = 0.49, 0.99; P = .04). There were no noteworthy variations identified in EBL and surgical margin. Furthermore, the LRP group did not show any significant differences. This study shows that regardless of the techniques used, EP-RP has a lower risk of operative complications than TP-RP, with no significant difference in other outcomes. [ABSTRACT FROM AUTHOR]

In 2018, the da Vinci Single Port (SP) robotic system was approved by the US Food and Drug Administration for urologic procedures. Available studies for the application of SP to prostate cancer surgery are limited. The aim of our study is to summarize the current evidence on the techniques and outcomes of SP robot-assisted radical prostatectomy (SP-RARLP) procedures. A narrative review of the literature was performed in January 2023. Preliminary results suggest that SP-RALP is safe and feasible, and it can offer comparable outcomes to the standard multiport RALP. Extraperitoneal and transvesical SP-RALP appear to be the two most promising approaches, as they offer decreased invasiveness, potentially shorter length of stay, and better pain control. Long-term, high-quality data are missing and further validation with prospective studies across different sites is required.

Pediatric inguinal hernia is a common surgical problem in boys. Open hernia repair surgery (OH) has been traditionally used to treat this condition, but it leads to complications, such as testicular complications. Laparoscopic hernia repair by using the extraperitoneal method (LHE) is performed through the percutaneous insertion of sutures and extracorporeal closure of patent vaginalis processus; thus, injury to spermatic cord structures is avoided. However, a meta-analysis comparing LHE and OH is lacking. PubMed, EMBASE, and Cochrane Library databases were searched for relevant studies. A meta-analysis of the retrieved studies was performed, and a random-effects model was used to calculate the pooled effect size. The primary outcome was testicular complications, including ascending testis, hydrocele, and testicular atrophy. The secondary outcomes were surgical metachronous contralateral inguinal hernia (MCIH), ipsilateral hernia recurrence, and operation time. In total, 6 randomized controlled trials (RCTs) and 20 non-RCTs involving 17,555 boys were included. The incidence of ascending testis (risk ratio [RR]: 0.38, 95% confidence interval [CI]: 0.18–0.78; p = 0.008) and MCIH (RR: 0.17, 95% CI: 0.07–0.43; p = 0.0002) was significantly lower in LHE than in OH. The incidence of hydrocele, testicular atrophy, and ipsilateral hernia recurrence did not differ between LHE and OH. Compared with OH, LHE led to fewer or equivalent testicular complications without increasing ipsilateral hernia recurrence. Moreover, MCIH incidence was lower in LHE than in OH. Hence, LHE could be a feasible choice with less invasiveness for inguinal hernia repair in boys. Treatment study, LEVEL III. [ABSTRACT FROM AUTHOR]

Objective: The goal of this research was to investigate the feasibility, safety, and short-term clinical outcome of pure extraperitoneal sacrocolpopexy with transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) for treating central pelvic defects. Material and Methods: A total of 9 patients with central pelvic prolapse underwent extraperitoneal sacrocolpopexy with V-NOTES, at the Chengdu Women's and Children's Central Hospital, Chengdu, Sichuan, China, between December 2020 and June 2022. The patients' demographic characteristics, perioperative parameters, and clinical outcomes were analyzed retrospectively. Each patient had the following major surgical procedures: (1) Establishing a platform for an extraperitoneal approach with V-NOTES; (2) separating the extraperitoneal path to the sacral promontory region; (3) suturing the long arm of the mesh to the anterior longitudinal ligament S1; and (4) suturing and fixating the short arm of the mesh at the top of the vagina. Results: The median patient age was 55, the median operative time was 145 minutes, and the median intraoperative blood loss was 150 mL. The operations were successful for all 9 cases, with a median preoperative Pelvic Organ Prolapse–Quantification score of C: +4, and a 3-months postoperative score of C: −6. There were no recurrences during a follow-up of 3–11 months, and no complications occurred, such as mesh erosion, exposure, and infection. Conclusion: As a new surgical approach, extraperitoneal sacrocolpopexy with V-NOTES is safe and feasible. (J GYNECOL SURG 39:108) [ABSTRACT FROM AUTHOR]

Bladder perforation is a potentially life-threatening condition, typically occurring after genitourinary trauma. The vast majority of cases are secondary to blunt abdominal trauma resulting in pelvic fractures, with motor vehicle accidents the commonest cause. There are however a wide range of underlying causes, including iatrogenic injuries and spontaneous perforations. This case series of 4 unusual cases of bladder perforations presenting to a single center under the same consultant within a 3-month period aims to highlight the diverse nature of patients who can present with bladder perforations and the different management options available.

Departments of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, Japan A peritoneal loose body (PLB) is tissue completely separated from other intraperitoneal organs. It is rare and usually found incidentally during laparotomy, examination, or autopsy. PLBs are usually located free in the peritoneal cavity and not in the extraperitoneal space. They are thought to originate when epiploic appendices are released into the abdominal cavity after ischemic necrosis. We report a case of a giant PLB outside the peritoneal cavity, adjacent to the rectovesical excavation, that was identified preoperatively in an asymptomatic 83-year-old man undergoing evaluation for cholecystolithiasis. Computed tomography revealed a mass with well-defined margins in the rectovesical excavation. The mass (diameter, 60 mm) consisted of a calcified core and peripheral soft tissue and did not appear to invade adjacent organs. Although there were no symptoms or tumor growth over time, we scheduled a laparoscopic extraction for definitive diagnosis. On laparoscopic exploration, a white ovoid mass was found in the rectovesical excavation; there was no invasion of adjacent organs. We diagnosed a giant PLB. Postoperative recovery was uneventful. Most PLBs are asymptomatic and do not require surgery, except when symptoms are present, when the PLB is large, or when malignancy is suspected. PLB is rarely extraperitoneal and is usually freely mobile; however, in our patient, it was fixed and outside the abdominal cavity, near the rectovesical fossa. Although it could not be diagnosed preoperatively as being extraperitoneal, imaging findings were typical of PLB; thus, it was possible to remove the mass laparoscopically without bowel resection. [ABSTRACT FROM AUTHOR]

In 2018, the da Vinci Single Port (SP) robotic system was approved by the US Food and Drug Administration for urologic procedures. Available studies for the application of SP to prostate cancer surgery are limited. The aim of our study is to summarize the current evidence on the techniques and outcomes of SP robot-assisted radical prostatectomy (SP-RARLP) procedures. A narrative review of the literature was performed in January 2023. Preliminary results suggest that SP-RALP is safe and feasible, and it can offer comparable outcomes to the standard multiport RALP. Extraperitoneal and transvesical SP-RALP appear to be the two most promising approaches, as they offer decreased invasiveness, potentially shorter length of stay, and better pain control. Long-term, high-quality data are missing and further validation with prospective studies across different sites is required. [ABSTRACT FROM AUTHOR]

Technical challenges during laparoscopic and robotic anterior resection include identification of key retroperitoneal structures and obtaining clear views of the inferior mesenteric artery (IMA) pedicle and total mesorectal excision (TME) plane. Steep head-down position improves surgical exposure but is associated with cerebral oedema, high intrapulmonary pressures, and rare neurological complications. In this article we describe the key steps of an anterior resection performed via the extra-peritoneal (XP) space in the supine position. The technique of same-side lateral-to-medial XP dissection has been developed and refined in serial cadaveric workshops. A standard periumbilical port is inserted for initial laparoscopic exploration. Dissection is then performed in the left XP space via a 5 cm skin incision (later used as the extraction site) to allow for insertion of four (latterly three) working ports. The colon is mobilized along its lateral attachments, reflecting retroperitoneal structures down and away. The IMA pedicle is taken proximally, next to the duodenum. If required, TME dissection can be continued in the same plane. A short intraperitoneal phase is then required to complete the procedure. Eight cadavers were studied (seven males; median 78 y). Four operations were performed laparoscopically and four robotically. Excellent views of the key retroperitoneal structures were achieved early in the procedure. Anatomical identification was performed sequentially for left-sided structures–psoas tendon, gonadal vessel, ureter, common iliac artery, IMA, and duodenum before ligation of the IMA pedicle. High ligation of IMA on the aorta and splenic flexure mobilization were performed in all eight procedures. This novel study shows it is feasible to perform the key steps of an anterior resection using the XP space in the supine position. This will reduce the need for steep head-down positioning which may have meaningful clinical benefits. Prospective clinical studies are required to validate the technique within a patient population. [ABSTRACT FROM AUTHOR]

• Standard transperitoneal procedure is associated with high complication rates. • Indications: elderly, frail, high risk patients. • Second primary in the bladder with solitary functioning kidney. • Complete avoidance of general anesthesia, minimal cardiopulmonary complications. • Retrograde dissection posteriorly: caudal to cranial in the rectovesical space. • End cutaneous ureterostomy for drainage of urine. Radical cystectomy with urinary diversion is the gold standard treatment for bladder cancer (high-risk/muscle invasive). The transperitoneal approach is associated with significant gastrointestinal complications like ileus. In the elderly and frail with a single functional kidney, we describe an extraperitoneal technique of radical cystectomy, with a ureterostomy, to be performed without general anesthesia. The elderly, frail, and high-risk candidates for general anesthesia, with a prior history of nephroureterectomy with a second primary muscle-invasive bladder cancer, were chosen. All patients underwent the described procedure under combined spinal and epidural anesthesia. The posterior dissection was retrograde, caudal to cranial, with the peritoneum being opened only for resection of the dome. A cutaneous ureterostomy was fashioned on the side of the functional kidney. Peri-operative parameters were assessed for early recovery in this high-risk group. The mean age was 82 years (range: 73–91), with Charleson Comorbidity Index 5, and were all deemed unfit for neoadjuvant chemotherapy. With a median duration of 127.5 minutes, an average blood loss of 225ml, and no patient requiring general anesthesia; early ambulation, early return of bowel function, and a lesser hospital stay (7 days) with minimal morbidity were achieved. Negative surgical margins were achieved in all cases, with a mean harvest of 29 lymph nodes. Only 1 patient developed stomal stenosis. The cause-specific survival (CSS) is 100% at 2 years. The highlighting features are the early return of bowel function (flatus passage on day 1) and the avoidance of the cardio-pulmonary complications of general anesthesia. The extraperitoneal cystectomy offers a promising alternative in this select group and warrants further studies to extrapolate this technique for bilateral urinary drainage. [ABSTRACT FROM AUTHOR]

The rise of frail patients in the worldwide population poses a challenge in the prostate cancer surgical care. In this light, we aimed to compare perioperative and early surgical outcomes of Extraperitoneal Single Port (SP)- vs Transperitoneal Multiport (MP) - Robot Assisted Radical Prostatectomy (RALP) in different frailty settings. Clinical and surgical data of all consecutive patients treated with RALP between March 2014 and October 2023 were gathered. Propensity score matching was performed to adjust for potential baseline pre-operative confounders. The 5-miFI score was calculated for each patient and then five risk categories were identified (5-mFI score = 0, 1,2,3 and ≥ 4). A total of 549 patients were assessed in the unmatched analysis. After the propensity score, 126 patients for each treatment group were matched. When stratified in different frailty-groups, 30-days postoperative complications occurred significantly more frequently in case of 5-mFI score=3 and >4 (p = 0.001). Moreover, higher rate of both overall (52 vs 23 %, p = 0.01) and major (19.6 vs 8.2 %, p = 0.02) postoperative complications was found in these patients in case of transperitoneal MP RARP as compared to the extraperitoneal SP procedures. Exploring predictors of postoperative early complications in patients with 5-mFI score = 3 and 4, extraperitoneal SP robotic approach showed a significant protective role on both overall (OR 0.21, p = 0.001) and major (OR 0.33, p = 0.001) complications occurrence. In a matched cohort of patients treated with Robot Assisted Radical Prostatectomy, extraperitoneal Single Port approach significantly reduced the overall and major early complications rate in frail patients. • Extraperitoneal Single Port Robot Assisted Radical Prostatectomy (RARP) reduced the surgical burden on frail patients. • The 5 items modified Frailty index successfully predicted the occurrence of perioperative complication in patients treated with RARP. • Preoperative frailty assessment should be routinely performed in patients with localized prostate cancer to optimize the patient care pathway. [ABSTRACT FROM AUTHOR]

Abstract Background Bladder cancer is one of the most common genitourinary cancers. Traditional transperitoneal radical cystectomy is the gold standard treatment for muscle-invasive bladder cancer. Our study was to compare the perioperative and oncological outcomes of extraperitoneal laparoscopic radical cystectomy (ELRC) with intracorporeal neobladder versus transperitoneal urinary diversion for bladder cancer. Method A total of 113 patients who underwent laparoscopic radical cystectomy performed at our center were included in this retrospective study. The perioperative data of the extraperitoneal laparoscopic radical cystectomy (ELRC) with intracorporeal urinary diversion (ICUD) and transperitoneal laparoscopic radical cystectomy (TLRC) with ICUD groups were compared. The demographic, perioperative, oncological, and complication data were collected and analyzed. Results In total, 113 patients were enrolled for the final analysis. The median follow-up period was 22 months. The ELRC group had shorter interval to flatus (p < 0.001), solid food (p < 0.001), shorter length of hospital stay (p < 0.01), and fewer early gastrointestinal complications (p < 0.05). Furthermore, urinary continence, recurrence-free, cancer-specific, and overall survival rates and recurrence patterns did not significantly differ. Conclusions Surgical technique of ELRC with ICUD can achieve the established oncologic criteria of TLRC, and such technique can improve perioperative and early postoperative outcomes.

Abstract 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, I 2 = 0%) and stomatal prolapse (RR, 0.27; 95% CI, 0.08–0.95, P = 0.04, I 2 = 0%), but a higher rate of defecation sensation (RR, 3.51; 95% CI, 2.47–5.0, P

IntroductionThe role of robot-assisted radical prostatectomy (RARP) in high-risk prostate cancer (PCa) has been debated over the years, but it appears safe and effective in selected patients. While the outcomes of transperitoneal RARP for high-risk PCa have been already widely investigated, data on the extraperitoneal approach are scarcely available. The primary aim of this study is to evaluate intra- and postoperative complications in a series of patients with high-risk PCa treated by extraperitoneal RARP (eRARP) and pelvic lymph node dissection. The secondary aim is to report oncological and functional outcomes.MethodsData of patients who underwent eRARP for high-risk PCa were prospectively collected from January 2013 to September 2021. Intraoperative and postoperative complications were recorded, as also perioperative, functional, and oncological outcomes. Intraoperative and postoperative complications were classified by employing Intraoperative Adverse Incident Classification by the European Association of Urology and the Clavien–Dindo classification, respectively. Univariate and multivariate analyses were performed to evaluate a potential association between clinical and pathological features and the risk of complications.ResultsA total of 108 patients were included. The mean operative time and estimated blood loss were 183.5 ± 44 min and 115.2 ± 72.4 mL, respectively. Only two intraoperative complications were recorded, both grade 3. Early complications were recorded in 15 patients, of which 14 were of minor grade, and 1 was grade IIIa. Late complications were diagnosed in four patients, all of grade III. Body mass index (BMI) > 30 kg/m2, Prostate-Specific Antigen (PSA) > 20 ng/mL, PSA density >0.15 ng/mL2, and pN1 significantly correlated with a higher rate of overall postoperative complications. Moreover, BMI >30 kg/m2, PSA >20 ng/mL, and pN1 significantly correlated with a higher rate of early complications, while PSA >20 ng/mL, prostate volume 20 ng/mL significantly correlated with overall postoperative complications, while PSA > 20 and pN1 correlated with early complications. Urinary continence and sexual potency were restored in 49.1%, 66.7%, and 79.6% of patients and in 19.1%, 29.9%, and 36.2% of patients at 3, 6, and 12 months, respectively.ConclusionseRARP with pelvic lymph node dissection in patients with high-risk PCa is a feasible and safe technique, resulting in only a few intra- and postoperative complications, mostly of low grade.

Case: We present a case of spontaneous extra-peritoneal rupture of an acquired diverticulum an elderly male with symptoms of bladder outlet obstruction who presented in emergency with acute abdomen. Outcome: The acute phase was managed conservatively with bladder drainage and intravenous antibiotics. He recently underwent Transurethral Resection of Prostate. He is asymptomatic on follow-up. Conclusions: Acquired bladder diverticulum are rare in adults and are mostly seen in patients with high pressure bladder due to bladder outlet obstruction. Atraumatic extraperitoneal ruptures of diverticulum are uncommonly reported. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: To explore the extraperitoneal laparoscopic urachal mass excision technique and its safety and efficacy in treating urachal mass. Methods: Baseline characteristics were collected from patients who underwent surgery to diagnose a urachal cyst or abscess in our hospital between January 2020 and August 2021. The full-length of the urachus and part of the top bladder wall were completely removed through the extraperitoneal approach. Patient outcomes were collected to evaluate surgical safety and efficacy, including operation time, intraoperative blood loss, drainage tube removal time, length of stay (LOS), and postoperative complications. Results: All 20 surgeries were successfully performed laparoscopically, and no case was converted to open surgery. The mean body mass index of the patients was 24.6 ± 2.2. The mean patient age was 49.3 ± 8.7 years. The mean size of the cysts was 3.0 ± 0.4 cm. The mean operation time was 56.3 ± 12.0 min. The mean intraoperative blood loss was 28.0 ± 6.4 mL. The mean drainage tube removal time was 3.0 ± 0.5 days. The mean LOS was 5.2 ± 0.4 days. The mean follow-up was 13.4 ± 2.1 months. No postoperative complications were observed during the follow-up period. The short-term follow-up and small patient cohort limited our outcome evaluation. Conclusion: Our results indicated that the extraperitoneal laparoscopic approach was a safe and effective method to treat urachal mass. Given the limitations of the study, further multiple and larger sample-sized trials are required to confirm our findings. [ABSTRACT FROM AUTHOR]

This study was concerned with the examination of patients who underwent surgery for subcutaneous endometriosis in our clinic and the relationship between subcutaneous endometriosis and inflammatory markers. Patient demographics and information on history and duration of previous surgery, lesion size, number of lesions, location, recurrence, symptoms, type and number of deliveries, recurrence status, and imaging method were recorded. Laboratory analysis recorded TSH, blood count (Hb), WBC, mean platelet volume (MPV), neutrophil/lymphocyte ratio (NLR), monocyte/platelet ratio (MPR), lymphocyte/monocyte ratio (LMR), platelet/lymphocyte ratio (PLR) and CA -125 values of patients. The study included 28 patients and it was found that the mean age of the patients was 32.67±5.56 years. Five (17.9%) and 18 (64.3%) of the patients complained of a palpable mass and cyclic pain, respectively. Five patients (17.9%) were asymptomatic. Endometriosis associated with the scar line was localized in 18 (64.3%) of the patients. In three (10.7%) of the patients, the endometriosis was localized in the perineal line and in 7 (25%) of the patients in the rectus abdominis. No significant difference was found in the patients' routine laboratory results and inflammatory markers. In the present study, there was no significant association between the levels of inflammatory markers in patients who underwent surgery for subcutaneous endometriosis at different sites and with different symptoms. [ABSTRACT FROM AUTHOR]

Abstract Background Removing more inframesenteric nodes is not only significantly increases the likelihood of finding metastasis for endometrial cancer, but also can add survival advantage. As most patients diagnosed with endometrial cancer are overweight or obesity, a high efficiency approach is important. Aim of this study was to compare the surgical outcomes of extraperitoneal laparoscopic, transperitoneal laparoscopic, and laparotomic para-aortic lymphadenectomy in endometrial carcinoma staging. Methods We retrospectively reviewed data of all patients diagnosed with primary endometrial carcinoma who were treated at the Department of Gynecologic Oncology, Fudan University Shanghai Cancer Center from 1 January 2017 to 31 December 2019. The numbers of para-aortic lymph nodes, surgical time, complications, blood loss and hospital stay were compared. The patients’ medical records and pathological reports were carefully reviewed. Statistical significance was defined as p < 0.05. Results We retrospectively compared patients who underwent extraperitoneal laparoscopy (Group E, n = 20), transperitoneal laparoscopy (group T, n = 21), and laparotomy (group L, n = 135). The median number of para-aortic lymph nodes was significantly higher in group E than in groups T and L (9.5, 5, and 6, respectively; p = 0.004 and 0.0004, respectively). All patients in group E underwent successfully dissection to the renal vessel level. The median operation time was significantly shorter in group L than in groups T and E (94, 174, and 233 min, respectively; p < 0.0001). The median estimated blood loss volume was higher in group L than in groups T and E (200, 100, and 142.5 ml, respectively; all comparisons p < 0.001), and the length of hospital stay was significantly longer in group L than in Groups T and E (6, 5, and 6 days, respectively; all comparisons p < 0.001). Conclusion The extraperitoneal laparoscopic approach for staging endometrial carcinoma harvested higher numbers of para-aortic lymph nodes which could be considered for endometrial carcinoma staging, especially for para-aortic lymph node harvest.

Stercoral ulcers are localized areas of loss of colonic mucosal integrity. They result from pressure necrosis of the colonic mucosa, secondary to chronic constipation and fecal inspissation. These ulcers are rare and, are associated with serious complications, including bleeding and perforation. We present the case of a 50-year-old woman who presented with small bowel evisceration through the anal canal secondary to extraperitoneal perforation of the rectum. The patient underwent emergent exploratory laparotomy with reduction of the bowel, followed by second look laparotomy in 24 hours. A full thickness defect in the rectum was identified and Hartmann's procedure was performed. The patient's postoperative course was uneventful. Extraperitoneal perforation and evisceration of bowel is a rare clinical entity. These cases are diagnosed early due to the obvious clinical presentation and however may be misdiagnosed as prolapse. They necessitate urgent and careful surgical planning, to ensure preservation of bowel and complete recovery. [ABSTRACT FROM AUTHOR]

Objective: The novel single-port (SP) platform offers an alternative way to perform robot-assisted radical prostatectomy (RARP). The SP platform allows operating in small anatomical spaces. Using this benefit, we adopted the extraperitoneal approach to RARP. Herein, we aim to describe our technique to perform SP extraperitoneal RARP.Patients and Surgical Procedure: We demonstrate the video of a 55-year-old man with a PSA of 4.4 ng/ml. Biopsy showed 5/13 cores positive for Gleason 3+3 prostate cancer. Preoperative prostate MRI showed a 43 g prostate and a right to midline anterior 1.8 cm PI-RADS 5 lesion, with possible extracapsular extension. We performed an extraperitoneal SP RARP and bilateral pelvic lymph node dissection.Results: The case was completed in 3 hours and 11 minutes. Estimated blood loss was 100 ml. Patient was discharged 8 hours after surgery. Pathology revealed pT2N0 stage and Gleason 3+4 prostate cancer. At 3 months follow up, PSA was undetectable and patient was continent. We performed 212 cases using this approach. Surgery was successfully completed in all patients without any need for additional port placement. Median length of stay was 4 hours, and 62 patients were admitted for observation. 50.5% of patients did not require opioid analgesics after discharge. Among patients with available one year follow data, 92.2% were continent and 85.9% had undetectable PSA.Conclusion: Extraperitoneal SP RARP can be safely performed using the novel SP surgical platform.

Splenic injury is a common result of blunt trauma, and bleeding occurs mainly inside the splenic capsule and may leak into the peritoneal space. Herein, we report a case where active bleeding occurred in the splenic artery and only leaked into the extraperitoneal space. This is the first case of this phenomenon in a trauma patient in the English-language literature. Bleeding passed through the peritoneum, leaked into the anterior pararenal space, and continued along the extraperitoneal space to the prevesical space of the pelvis. Therefore, on the initial computed tomography (CT) scan, the bleeding appeared to be in the left paracolic gutter, so we suspected mesenteric bleeding. However, after the CT series was fully reconstructed, we accurately read the scans and confirmed splenic injury with active bleeding. If there had been a suspicion of bowel or mesenteric injury, surgery would have been required, but fortunately surgery could be avoided in this case. The patient was successfully treated with angioembolization.

Objectives: To investigate the safety profile and short-term outcome of super-veil nerve-sparing extraperitoneal single-port robotic-assisted radical prostatectomy (espRARP) on da Vinci Si platform. Methods: From December 2018 to March 2021, 106 consecutive patients with treatment-naive prostate cancer were prospectively included. espRARP was performed on da Vinci Si surgical platform. Operative time, estimated blood loss, Clavien–Dindo complication classification, continence, potency recovery, quality-of-life scores, and postoperative prostate-specific antigen (PSA) were documented. Results: Patients aged 52–79 years (mean ± SD, 64.8 ± 6.15 yrs), with a median PSA of 9.2 ng/ml (IQR: 6.70, 16.83) and median prostate volume of 31.9 ml (IQR: 30.01, 38.54). 95.28% (101/106) were clinically localized. All patients underwent espRARP successfully with no open conversions. Operative time was 94.2 ± 30.26 min with an estimated blood loss of 68.5 ml (range, 50–120 ml). No Grade III complications or above were documented. Positive surgical margin was 17.9% (19/106). Median pain score at discharge was 0 (IQR: 0, 1.75) without use of opioid narcotics. Postoperative length of stay was 3 days (IQR: 1, 3), in which 28 patients were discharged within 24 h. Instant, 1-, 3-, and 6 month continence recovery was 18.9, 45.3, 79.2, 93.4, and 96.4%, respectively. Of the 43 patients who received nerve-sparing procedures, 13 (30.23%) resumed potency 6 months postoperatively. 12 month biochemical recurrence-free survival was 92.77% (77/83). Conclusions: Extraperitoneal single-port robotic-assisted radical prostatectomy is a safe and feasible technique. Combined with super-veil nerve-sparing procedures, it may provide satisfactory outcome in short-term functional recovery. [ABSTRACT FROM AUTHOR]