BACKGROUND: Kidneys are a retroperitoneal organ but the widely practiced laparoscopic approach to renal surgery is transperitoneal due to the advantages of greater working space at the cost of entering the peritoneal cavity, risk of injury to intraperitoneal organs, and the increased risk of postoperative bowel complications. The classic open approach to kidney procedures has been the flank approach without violating the peritoneal cavity instead of the retroperitoneal approach to renal surgery with the advantages of direct access to the renal hilum, especially the renal artery. Being a technically challenging procedure, the retroperitoneoscopic approach is less practiced and needs an experienced surgical team. Through this study, we have tried to unveil the myths and illustrate the exact position of ports, which is the decisive initial step in retroperitoneoscopic surgery.
METHODS: This retrospective study was conducted at a developing tertiary center in northern India with novice staff mainly to determine the technical and anatomical caveats pertaining to the retroperitoneoscopic approach for renal surgeries, the challenges faced, and their resolutions. The decision for the site of incision for primary or camera port was taken only after a proper anatomical study of the cadavers and ongoing retroperitoneal surgical experience while treating various patients suffering from renal diseases. The study comprised eight patients, during the period from June 2023 to March 2024. Various parameters, such as demographic variables, diagnosis, mean operative time, estimated blood loss, technical difficulties encountered and their resolution, complications, and reasons for conversion were studied. A total of 15 cadavers were dissected during the above time period to study finer anatomical details of port positioning and other details.
RESULTS: After an elaborate study of 15 cadavers and thereafter performing surgery on eight patients during the above time period, surgery was successfully performed on six patients, and two patients needed conversion to open procedure due to dense adhesions and non-progression while complications occurred in two patients (peritoneal rent and renal vein injury), which were managed laparoscopically.
CONCLUSIONS:  Nonetheless, restrictions of surgical space make retroperitoneoscopic space a challenging procedure but with elaborate experience, which we gained through cadaveric study, and surgical results obtained during the initial few cases such as the exact site of the primary port and technical intricacies, and handling of complications if and when faced, we hope our study will certainly make retroperitoneal space more amicable to urologists.

Retroperitoneal abscess as a sequela of penetrating trauma can pose a difficult clinical scenario for surgeons and literature to inform decision making is sparse. It is logical to follow a \"step-up\" approach applied to other etiologies of infected retroperitoneal fluid collections, such as infected pancreatic necrosis and perinephric abscess. Video-assisted retroperitoneal debridement (VARD) is a well-established approach in infected pancreatic necrosis when surgical debridement is warranted. Minimally invasive retroperitoneal approaches have emerged in a broadening range of etiologies and specialties. We describe our experience utilizing VARDs in two patients that developed retroperitoneal abscesses following gunshot injuries to bowel and proximal urinary system. Both failed a conservative approach including antibiotic and percutaneous drains. Rapid improvement and subsequent discharge were observed within days of VARD procedure. We believe VARD to be a viable approach to post-trauma retroperitoneal abscesses when surgical drainage is indicated, and anatomy is favorable.

Aims: Retroperitoneoscopic simple nondismembered pyeloplasty (SNDP) with da Vinci Si assistance was developed because of a possible risk for alignment shift after retroperitoneoscopic diamond-shaped bypass pyeloplasty (Diamond-Bypass; DP). Outcomes of SNDP and DP were compared. Materials and Methods: For SNDP, a small longitudinal incision is made on the border of the dilated pelvis and narrowed ureter at the ureteropelvic junction (UPJ). Extending this incision toward the pelvis allows identification of mucosa while maintaining the integrity of surrounding tissues that are so thin and fragile that they will not influence lumen alignment. Data for DP were obtained from a previously published article. Results: For SNDP (n = 3), mean age at surgery was 2.67 years (range: 1-4), mean operative time was 176 minutes. Mean postoperative Society of Fetal Urology (SFU) grades for hydronephrosis were 1.2, 0.7, and 0.6, 1, 2, and 3 months after stent removal, respectively. Postoperative diethylenetriaminepentaacetic acid (DTPA) was normal (n = 3). For DP (n = 5) mean age at surgery was 4.3 years (range: 1-14), mean operative time was 189 minutes. Mean postoperative SFU grades were 2.8, 2.2, and 1.6, respectively. Postoperative DTPA was normal (n = 4) and delayed (n = 1). All SNDP and DP were asymptomatic by 3 months after stent removal. Conclusion: Both SNDP and DP have favorable outcomes. If the UPJ is located at the lowest end of the renal pelvis, SNDP may improve hydronephrosis more quickly.

Laparoscopic total adrenalectomy has become the standard treatment for adrenal mass. Meanwhile, there has been a growing trend toward laparoscopic adrenal-sparing surgery worldwide to avoid the risk and potential complications of adrenal insufficiency. The objectives of this study were to describe a retroperitoneoscopic adrenal tumor enucleation technique, to assess the clinical outcomes of this technique in the treatment of 20-40 mm nonsecreting adrenal tumor (NAT) with low potential of malignancy, and to provide a feasible choice for patients who have preference on resection. This study was a retrospective analysis of 61 patients with low potential of malignancy in 20-40 mm NAT identified at the first imaging examination or during follow-up. All patients were scheduled for planned enucleation adrenalectomy by a single surgeon between July 2016 and December 2020 in Xuanwu Hospital, Beijing, China. In all patients, retroperitoneoscopic surgery was performed via a retroperitoneoscopic process for all the patients. The crucial techniques of enucleation are presented in the video. Safety and feasibility factors of enucleation technique were measured for this study. No blood transfusion or organ injury was registered during the operation. The median operation time was 75 min, and the median blood loss was 35 mL. All operations were successfully performed without open conversion. A total of 58 patients received successful enucleation surgery. Three cases were converted to retroperitoneoscopic total adrenalectomy. In this study, surgical outcomes of retroperitoneoscopic enucleation adrenalectomy as a method to remove adrenal tumors were assessed. This procedure is a feasible and safe technique with the added benefit of preserving the remaining functional adrenal tissue.

BACKGROUND: Surgical approaches to the equine rectum and perirectal area are described in the literature. However, surgeries in this region can be challenging.
OBJECTIVE: To describe the surgical anatomy of the presacral space and to evaluate its access using a retroperitoneoscopic approach.
METHODS: Ex vivo experiment.
METHODS: Preliminary dissections were performed in two cadavers to define the boundaries of the presacral space and to determine portal locations for the surgical approach. After that, nine cadavers were used for experimental presacral retroperitoneoscopic procedure in a standing position. Following retroperitoneoscopy, cadavers were dissected to confirm the anatomical structures observed during the endoscopic procedures, to control the location of each portal and to record iatrogenic trauma.
RESULTS: The presacral space was bordered by the vertebral column from the ventral aspect of lumbosacral promontorium to the first coccygeal vertebra dorsally and by the presacral fascia and peritoneum ventrally. Lateral limits were composed of the sacrosciatic ligament and transversalis fascia. Cranial and caudal borders were composed of the peritoneum and coccygeal and levator ani muscles respectively. Retroperitoneoscopic portals were placed between the external anal sphincter and semimembranosus muscles and between the base of the tail and the external anal sphincter muscle through the anococcygeal fascia to enter the space by its caudal border. The retroperitoneal space was reached in all cases and the dorsal and lateral aspects of the rectum were visualised after creation of a working space.
CONCLUSIONS: Use of cadaver specimens do not permit to evaluate the tolerance in living animals and the surgical complications such as rectal damage, haemorrhage and infection.
CONCLUSIONS: This study provides an anatomical description and surgical access of the presacral space with a minimal invasive approach. Retroperitoneoscopy allows access to the rectum and the dorsal aspect of the pelvis.
UNASSIGNED: In der Literatur werden chirurgische Zugänge zum Rektum und zum perirektalen Bereich des Pferdes beschrieben. Operationen in dieser Region können jedoch eine Herausforderung darstellen.
UNASSIGNED: Beschreibung der chirurgischen Anatomie des präsakralen Raums und Bewertung seines Zugangs mittels retroperitoneoskopischem Ansatz.
METHODS: Ex‐vivo‐Experimentelle Studie.
METHODS: Vorab wurden an zwei Kadavern Sektionen durchgeführt, um die Grenzen des präsakralen Raums zu definieren und die Portalstandorte für den chirurgischen Zugang zu bestimmen. Anschließend wurden neun Kadaver für den experimentellen retroperitoneoskopischen Eingriff in stehender Position verwendet. Nach der Retroperitoneoskopie wurden die Kadaver seziert, um die während der endoskopischen Verfahren beobachteten anatomischen Strukturen zu bestätigen, die Lage jedes Portals zu kontrollieren und iatrogene Verletzungen zu dokumentieren.
RESULTS: Der präsakrale Raum war dorsal begrenzt von der Wirbelsäule (ventraler Aspekt des lumbosakralen Promotoriums bis zum ersten coccygealen Wirbelkörper) und ventral von der präsakralen Faszie und des Peritoneums. Die lateralen Grenzen bestanden aus dem sakrosciatischen Ligament und der transversalen Faszie. Die kranialen und kaudalen Begrenzungen waren durch das Peritoneum sowie durch die Steißbein‐ und Levator‐ani‐Muskeln gebildet. Die retroperitoneoskopischen Portale wurden zwischen dem äußeren Schließmuskel des Afters und den Semimembranosus‐Muskeln sowie zwischen der Basis des Schweifes und dem äußeren Schließmuskel des Afters durch die anococcygeale Faszie platziert, um den Raum durch seine kaudale Grenze zu erreichen. Der retroperitoneale Raum wurde in allen Fällen erreicht, und die dorsalen und lateralen Aspekte des Rektums wurden nach Schaffung eines Arbeitsraums visualisiert. WICHTIGSTE EINSCHRÄNKUNGEN: Die Verwendung von Kadaverpräparaten erlaubt keine Bewertung der Verträglichkeit bei lebenden Tieren sowie chirurgischer Komplikationen wie Rektumschäden, Blutungen und Infektionen.
UNASSIGNED: Diese Studie liefert eine anatomische Beschreibung und chirurgischen Zugang zum präsakralen Raum mittels minimal‐invasivem Ansatz. Die Retroperitoneoskopie ermöglicht den Zugang zum Rektum und zum dorsalen Aspekt des Beckens.

UNASSIGNED: We present our experience with retroperitoneoscopic pyeloplasty with simultaneous pyelolithotomy using a flexible cystoscope in patients with ureteropelvic junction obstruction(UPJO) complicated with kidney stones.
UNASSIGNED: The records of 37 patients who underwent retroperitoneoscopic pyeloplasty with simultaneous pyelolithotomy using a flexible cystoscope to manage UPJO complicated with kidney stones from July 2015 to December 2020 were retrospectively reviewed. All patients underwent one-stage retroperitoneoscopic pyeloplasty combined with flexible cystoscopic pyelolithotomy. The operative time, blood volume, stone clearance rate, length of hospital stay, complications and follow-up events were recorded.
UNASSIGNED: The operation went smoothly in all 37 patients. The mean operative time was 148.4 ± 24.2 min. The mean intraoperative blood loss volume was 54.3 ± 20.5 ml. The mean hospitalization time was 10.6 ± 3.7 days. The stone clearance rate was 81.08%. The mean follow-up period was 23.5 months (range 12-53 months). Hydronephrosis was significantly decreased in 33 of the 37 cases. The success rate of the operation was 89.19%. Stones recurred in 9 patients during follow-up, for a recurrence rate of 24.32%.
UNASSIGNED: Retroperitoneoscopic pyeloplasty with simultaneous pyelolithotomy using a flexible cystoscope in patients with UPJO complicated with kidney stones is safe, effective and worthy of promotion.

Bilateral adrenalectomy is the reference treatment for Cushing\'s syndrome related to adrenocorticotropic hormone-independent macronodular adrenal hyperplasia (AIMAH). We report a case of AIMAH managed by sequential retroperitoneoscopic adrenalectomy and review the literature of the same.

Today, adrenalectomy can be performed by a variety of laparoscopic and retroperitoneoscopic approaches. Of particular importance are the lateral transperitoneal and the posterior retroperitoneoscopic access routes. Comparative studies of transperitoneal and retroperitoneal procedures still demonstrate heterogeneous results. Nevertheless, retroperitoneal access techniques seem to enable less postoperative pain and a faster recovery. Robotic procedures are gaining in popularity but the final importance cannot yet be determined. All minimally invasive techniques are considered to be so safe and reliable that open approaches are only justified in exceptional cases.
UNASSIGNED: In der Nebennierenchirurgie stehen heute laparoskopische und retroperitoneoskopische Operationsverfahren in zahlreichen Varianten zur Verfügung. Besondere Bedeutung haben inzwischen der laterale transperitoneal Zugang und der posteriore retroperitoneoskopische Zugang gewonnen. Die Ergebnisse vergleichender Studien zwischen transperitonealen und retroperitonealen Verfahren sind nach wie vor heterogen. Immerhin scheint der retroperitoneale Zugang eine geringere postoperative Schmerzbelastung und schnellere Rekonvaleszenz zu ermöglichen. Robotische Verfahren erfreuen sich zunehmender Beliebtheit, ihre finale Bedeutung kann heute noch nicht festgelegt werden. Alle minimal-invasiven Verfahren gelten als so sicher und zuverlässig, dass die offenen Methoden nur noch ausnahmsweise berechtigt sind.

Introduction: Cerebral and renal regional oxygen saturation (C-rSO2 and R-rSO2, respectively) were monitored using near-infrared spectroscopy in pediatric patients (range: 0.3-14.3 years) during minimally invasive surgery (MIS) taking at least 3 hours performed by laparoscopy (Lap), thoracoscopy (Tho), or retroperitoneoscopy (Ret) from January 2019 to December 2021. Materials and Methods: Criteria compared were operative time, preoperative/intraoperative hemoglobin, blood loss, mean arterial pressure, arterial partial pressure of carbon dioxide (PaCO2), peripheral oxygen saturation (SpO2), C-rSO2, and R-rSO2. Pathological desaturation (PD) was defined as >20% decrease from baseline, and statistical significance as P < .05. Results: Subjects (n = 79) were similar for gender, age, and body mass index. MIS procedures were: Lap = 45, Tho = 20, Ret = 14; one Lap case required conversion for severe adhesions, not PD. Intraoperative PaCO2 (mmHg) was significantly higher in Tho (maximum: 59.5 ± 17.0, minimum: 39.9 ± 7.5) versus Lap (maximum: 39.9 ± 5.1, minimum: 34.6 ± 3.9) and Ret (maximum: 37.8 ± 4.2, minimum: 35.0 ± 3.3); P < .0001 (maximum), P = .0013 (minimum). Minimum intraoperative SpO2 was significantly lower in Tho (P < .0001). Mean operative times were significantly shorter in Tho (259 ± 114 minutes) versus Lap (433 ± 154 minutes) and Ret (342 ± 100 minutes); P < .0001, respectively. PD was absent during Ret (C-rSO2: 0/14 = 0% and R-rSO2: 0/14 = 0%). Differences in PD for Lap (C-rSO2: 7/45 = 15.6% and R-rSO2: 10/45 = 22.2%) and Tho (C-rSO2: 9/20 = 45.0%, and R-rSO2: 7/20 = 35.0%) were significant; P = .0028 for C-rSO2 and P = .0497 for R-rSO2. Hemoglobin and blood loss were similar. Conclusions: PD was absent during Ret, despite longer operative times. If Ret is indicated for a procedure, neurodevelopmental sequelae of MIS could be minimized.

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