Laparoscopic adrenalectomy (LA) continues to be considered the optimum approach to the surgical treatment of small benign adrenal tumours. The present study explores the correlation between the Mayo adhesive probability (MAP) score, derived from computed tomography images and delineating such perinephric fat characteristics as thickness and adhesiveness, and post-operative complications in patients undergoing LA.

Data of patients who underwent LA between 2013 and 2023 were subjected to a retrospective analysis, and MAP scores were calculated for all patients. Intraoperative and post-operative surgical outcomes, as well as any complications, were categorised using Modified Clavien-Dindo grading, and the relationship between their MAP scores and outcomes was analysed.

The mean body mass index, rate of overweight patients, Clavien-Dindo scores of II, III or IV, surgical time, hospitalisation duration, transfusion requirement and post-operative blood loss of the group of patients with MAP scores of 2-3 were significantly higher than those in the group with MAP scores in the 0-1 range (P < 0.05). Each one-point increase in MAP score led to a 2.559-times greater probability of a Clavien-Dindo Grade > I (95% confidence interval: 1.391-4.708, P < 0.05).

A high MAP score is associated with Grade II and higher Clavien-Dindo complications in LA.

Posterior retroperitoneal laparoscopic adrenalectomy (PRLA) has emerged as a revolutionary, minimally invasive technique for adrenal gland surgery, offering significant advantages over traditional open approaches. This narrative review aims to provide a comprehensive update on PRLA, focusing on its anatomical foundations, surgical technique, and clinical implications. We conducted an extensive review of the current literature and surgical practices to elucidate the key aspects of PRLA. The procedure leverages a unique "backdoor" approach, accessing the adrenal glands through the retroperitoneum, which necessitates a thorough understanding of the posterior abdominal wall and retroperitoneal anatomy. Proper patient selection, meticulous surgical planning, and adherence to key technical principles are paramount for successful outcomes. In this paper, the surgical technique is described step by step, emphasizing critical aspects such as patient positioning, trocar placement, and adrenal dissection. PRLA demonstrates reduced postoperative pain, shorter hospital stays, and faster recovery times compared to open surgery, while maintaining comparable oncological outcomes for appropriately selected cases. However, the technique presents unique challenges, including a confined working space and the need for surgeons to adapt to a posterior anatomical perspective. We conclude that PRLA, in the right clinical setting, offers a safe and effective alternative to traditional adrenalectomy approaches. Future research should focus on expanding indications and refining techniques to further improve patient outcomes.

This study aimed to compare the intraoperative and postoperative outcomes between robotic and laparoscopic transperitoneal adrenalectomies.

In this retrospective study, 93 patients underwent adrenalectomy using 2 surgical modalities: 45 patients underwent adrenalectomy using the da Vinci Xi system (robotic group), and 48 patients using laparoscopic devices (laparoscopic group). We compared the operation time, intraoperative bleeding, and hospital stay according to the surgical modality and tumor characteristics.

There were no significant differences in the operative time (P = 0.827), hospital stay (P = 0.177), and intraoperative bleeding (P = 0.174) between the groups. However, the robotic group showed a lower coefficient of variation in total operative time than that of the laparoscopic group (100.6 ± 23.3 minutes vs. 101.9±32.7 minutes, 0.230 vs. 0.321). When divided into 2 subgroups based on the tumor size (<3 cm and ≥3 cm), the robotic group with a tumor sized >3 cm had a shorter operative time than that of the laparoscopic group (P = 0.032). The robotic group also had fewer cases of intraoperative bleeding (P = 0.034).

Compared to the laparoscopic transperitoneal adrenalectomy, the robotic one achieved a lower deviation in total operative time and showed less bleeding and a shorter operative time, especially for tumors sized >3 cm.

Background: Laparoscopic adrenalectomy (LA) is the standard treatment for adrenal benign tumors, including primary aldosteronism (PA) or Cushing's syndrome (CS). Several obesity-related factors were associated with prolonged total operative time (OT), but perinephric fat characteristics were not assessed. We investigated whether the Mayo adhesive probability (MAP) score, which evaluates perinephric fat characteristics, was associated with OT for LA. Methods: This single-center, retrospective cohort study examined 141 consecutive patients who underwent LA for PA or CS. We reviewed patients' characteristics and OT. MAP scores were recorded using preoperative imaging. The correlation among characteristics data, MAP score, and OT was evaluated. Results: Overall, we assessed 82 women and 59 men. Adrenal tumors were found in 80 PA and 61 CS patients. There were 74 left-sided and 67 right-sided tumors. For all patients, the median age, body mass index, and tumor size were 56 years (interquartile range [IQR] 46-65), 24.1 kg/m² (IQR 21.7-26.8), and 19 mm (IQR 13-26), respectively. A total of 91 patients had MAP scores of 0, and 50 had MAP >0. The median OT was 183.5 minutes (IQR: 156-224 minutes) in the MAP >0 group and 162 minutes (IQR: 135-194 minutes) in the MAP = 0 group. In single variable analysis (unadjusted), MAP scores >0 and left-sided tumors were correlated with longer OT. Multivariable regression analysis revealed that this correlation was only significant for MAP scores >0. Conclusions: MAP score may be useful in preoperative planning for PA or CS patients undergoing LA.

Laparoscopic adrenalectomy is currently the standard of care for adrenal lesion. Minimal invasive laparoscopic surgery such as laparoendoscopic single site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) have been developed to improve cosmetic outcomes and reduce postoperative pain. However, there are still some problems related to instruments and port limitation during LESS surgery. Robot-assisted laparoscopic surgery may help to overcome these problems, and port platforms selection is an important issue.

Three cases received robot-assisted LESS adrenalectomy due to adrenal tumor were enrolled. Blood loss, hospital stay, and analgesia injection were compared.

Preoperative evaluations were done in a usual manner. Benign tumors were suspect for two patients, while metastatic tumor could not be excluded for the other patient with prior malignancy history. The pathology reports were all benign adrenal cortical adenoma after operation.

Three different port platforms, Da Vinci Single-Site Surgical Platform, GelPOINT, and homemade glove port were used. Trans-peritoneal approach was used for two patients, while the other one received trans-retroperitoneal approach. The advantage and disadvantage of different port platforms were discussed.

All patients underwent the operation smoothly without major complications or conversion to open surgery. Blood loss amount was small, hospital stay was short, and only one patient received one single dose of opioid analgesia injection after the surgery.

The main problems of LESS are the loss of a working triangle and the limitations of the instruments. Robot-assisted LESS may help surgeons overcome part of these problems. Many different port platforms are available, and based on our initial experience, we believe that the GelPoint may be a more suitable platform, for it maintains the endo-wrist function of the Da Vinci instruments, and allows the surgeon to design the position of ports freely to minimize external and internal collision.

Laparoendoscopic single-site surgery is a recently innovated urologic surgical procedure. Transumbilical laparoendoscopic single-site adrenalectomy (LESS-A) is technically safe and feasible in patients with benign adrenal tumors. To improve patient counseling and informed consent, we evaluated patient-reported postoperative pain, body image, and cosmetic satisfaction after transumbilical LESS-A.

We reviewed 24 patients who underwent transumbilical LESS-A and assessed their operative and esthetic outcomes and incisional pain. Incisional pain was evaluated using a 10-point visual analog scale, and the body image and cosmetic satisfaction were measured using a questionnaire that included a body image scale (range, 5-20 points) and a cosmetic scale (range, 3-24 points).

Pure LESS-A was performed on 10 patients using a multichannel port; an additional 5-mm trocar was used in two obese patients. Supplementary to the single-incision approach, one or two 3-mm ports were used in 12 patients. The mean operative time was 203 min; the mean blood loss was 41 mL. The mean pain visual analog scale scores on postoperative days 1, 3, and 7 were 3.5, 2.2 (P = 0.012), and 1.5 points (P = 0.018), respectively. The mean body image scale and cosmetic scale scores indicating wound satisfaction 1 month after the surgery were 20 and 22 points, respectively. Although one patient had liver injury during surgery, the postoperative course during the 3-month follow-up was uneventful.

Transumbilical LESS-A confers less postoperative pain and better cosmetic satisfaction than conventional laparoscopic adrenalectomy. Therefore, this procedure could potentially become a standard treatment option for benign adrenal tumors.

To report on a multi-institutional series of non-robotic urological laparoendoscopic single-site surgery in Japan.

Consecutive cases of laparoendoscopic single-site surgery carried out between February 2009 and December 2012 at nine academic institutions were included. We examined the surgical outcomes, including conversion and complications rates.

Four hundred and sixty-nine cases were included in the analysis. The most common procedure was adrenalectomy (n = 177) and the second most common procedure was radical nephrectomy (n = 143). The procedures also included nephroureterectomy (n = 40), living donor nephrectomy (n = 40), pyeloplasty (n = 30), urachal remnant excision (n = 9), simple nephrectomy (n = 7), radical prostatectomy (n = 6) and others (n = 17). The access sites included umbilicus (n = 248, 53%) and other sites (n = 221, 47%). A transperitoneal approach was used in 385 cases (82%), and retroperitoneal approach in 84 cases (18%). The median operation time of all procedures was 198 min. Conversion to reduced port surgery, conventional laparoscopy, or open surgery was noted in 27 cases (5.8%), 12 cases (2.6%), and two cases (0.4%), respectively, with an overall conversion rate of 8.7%. Intraoperative complications occurred in 10 cases (2.1%). Post-operative complications were noted in 29 cases (6.2%), including five major complications (1.1%). No mortality was recorded in this series.

Non-robotic laparoendoscopic single-site surgery is technically feasible and safe for various urologic diseases in Japan. Furthermore, urological laparoendoscopic single-site surgery is a promising minimally invasive surgical option that is feasible for experienced urological surgeons in intermediate-volume centers as well as high-volume centers.

We studied the construct validity of the LapMentor, a virtual reality laparoscopic surgical simulator, and the correlation between the data collected on the LapMentor and the results of video assessment of real laparoscopic surgeries.

Ninety-two urologists were tested on basic skill tasks No. 3 (SK3) to No. 8 (SK8) on the LapMentor. They were divided into three groups: Group A (n=25) had no experience with laparoscopic surgeries as a chief surgeon; group B (n=33) had <35 experiences; and group C (n=34) had ≥35 experiences. Group scores on the accuracy, efficacy, and time of the tasks were compared. Forty physicians with ≥20 experiences supplied unedited videotapes showing a laparoscopic nephrectomy or an adrenalectomy in its entirety, and the videos were assessed in a blinded fashion by expert referees. Correlations between the videotape score (VS) and the performances on the LapMentor were analyzed.

Group C showed significantly better outcomes than group A in the accuracy (SK5) (P=0.013), efficacy (SK8) (P=0.014), or speed (SKs 3 and 8) (P=0.009 and P=0.002, respectively) of the performances of LapMentor. Group B showed significantly better outcomes than group A in the speed and efficacy of the performances in SK8 (P=0.011 and P=0.029, respectively). Analyses of motion analysis data of LapMentor demonstrated that smooth and ideal movement of instruments is more important than speed of the movement of instruments to achieve accurate performances in each task. Multiple linear regression analysis indicated that the average score of the accuracy in SK4, 5, and 8 had significant positive correlation with VS (P=0.01).

This study demonstrated the construct and predictive validity of the LapMentor basic skill tasks, supporting their possible usefulness for the preclinical evaluation of laparoscopic skills.

A 74-year-old woman presented with symptoms consistent with hyperadrenocorticism and hyperca-techolaminism. She had a cushingoid appearance and her cortisol level was elevated. Her serum dopamine and noradrenalin levels were also elevated. Computed tomography detected a left adrenal mass measuring 3.5 cm multiply 3.0 cm in diameter. Metaiodobenzylguanidine scintigraphy was negative. Unexpectedly, the serum Serum carcinoembryonic antigen (CEA) level was elevated. Fluorodeoxyglucose positron emission tomography showed increased uptake in the adrenal tumor only, with a maximum standardized uptake value of 2.8. Selective venography and blood sampling revealed that the concentrations of cortisol, catecholamines and CEA were significantly elevated in the vein draining the tumor. A diagnosis of CEA-producing benign adenoma was made. After preoperative management, we performed a combined lateral and anterior transperitoneal laparoscopic adrenectomy. Her vital signs remained stable during surgery. Histopathological examination revealed a benign adenoma. Her cortisol, catecholamine and CEA levels normalized immediately after surgery. We present, to the best of our knowledge, the first case of CEA-producing adrenal adenoma, along with a review of the relevant literature, and discuss our laparoscopic surgery techniques.

To determine the feasibility and safety of laparoscopic adrenalectomy for large adrenal pheochromocytomas as although the safety and efficacy for small pheochromocytomas is relatively well documented its use for large pheochromocytomas is controversial because of a perceived increased risk of malignancy.

All pheochromocytomas (>8 cm) managed prospectively using a laparoscopic approach between January 2002 and April 2006 were included. Blood loss, operative duration, complications, and hospital stay were assessed.

In all, 11 consecutive patients underwent laparoscopic adrenalectomy for large pheochromocytomas. The adrenal sizes were 8-15 cm. The mean blood loss was <100 mL, the mean operative duration was 145 min and the mean postoperative stay was 3.6 days. Only one patient had an intraoperative hypertensive crisis, and recovery was uneventful in all.

Laparoscopic transperitoneal, lateral adrenalectomy is safe and efficient means of resecting large (>8 cm) adrenal pheochromocytomas. Although intraoperative catecholamine surges are a cause of major concern, early clipping and dividing of the adrenal vein helps to avoid a catecholamine-induced hypertensive crisis.

We examined the clinical outcomes and the learning curve for a laparoscopic adrenalectomy (LA) in 103 consecutive cases performed by three surgeons at our institute, according to the type of adrenal disorder.

One hundred and three patients with adrenal tumors, including 38 cases of primary aldosteronism, 33 cases of Cushing syndrome (including preclinical Cushing syndrome), 15 cases of pheochromocytoma, and nine cases of non-functioning adenoma were evaluated, while focusing on the approaches, intraoperative and postoperative data, and the learning curve of LA, according the type of adrenal disorder.

There was no significant difference in the operation time, estimated blood loss, incidence of conversion to open surgery and blood transfusion, or postoperative recovery among the patients treated by LA for aldosteronoma, Cushing adenoma, pheochromocytoma, and non-functioning adenoma. In the cases of aldosteronoma and Cushing adenoma, the learning curve for the operation time and blood loss in each operator tended to decrease as the number of operations increased. On the other hand, in the cases treated by LA for pheochromocytoma, no trends in either the operation time or blood loss were observed. However, there has been neither any conversion to open surgery nor blood transfusion in cases treated by LA since 1998 (our 42nd case), even after the changes in the operators.

Our results clearly indicate that LA is becoming safer than before, probably due to improvements in the technique, education, and training of surgeons, in addition to the increased number of cases now treated by LA.

Laparoscopic adrenalectomy is generally performed with carbon dioxide insufflation of the cavity and requires multiple trocars. This study reports the outcomes of retroperitoneoscopic adrenalectomy (RA) for adrenal tumors via a single port using a large cylinder without carbon dioxide insufflation.

Fifty-four patients with adrenal tumors were treated using RA via a single large port. The average tumor size was 2.6 cm. For surgery, patients were placed in the lateral decubitus position with slight flexion, and a 4.5-cm skin incision was performed below the 12th rib in the midaxillary line. The retroperitoneal space was dissected using index fingers and a balloon dilator. A rectoscope tube with a 4-cm diameter was inserted, and the adrenal glands were removed endoscopically via the single large port without carbon dioxide insufflation.

This procedure was completed in 53 patients (98.1%). The average duration of surgery was 203 minutes, and the mean estimated blood loss was 252 mL. Four patients (7.4%) required blood transfusion. Postoperative major complications, including fulminant hepatitis and pulmonary thrombosis, were observed in two patients (3.7%), and the patient with hepatic disease died on the 14th postoperative day. The mortality rate after surgery thus was 1.9%. However, no local tumor recurrence or hormonal relapse has occurred at a median follow-up of 34 months.

This procedure appears to be effective and relatively minimally invasive. However, it is limited by the narrow working space and restriction of the manipulation of instruments.

In order to evaluate the indication and usefulness of laparoscopic adrenalectomy, clinical outcomes of laparoscopic adrenalectomy for patients with adrenal tumors were examined. Whether tumor size affects surgical outcome was analysed, along with the long-term clinical outcome for these patients.

A total of 63 patients with adrenal tumor underwent laparoscopic adrenalectomy in our institute between 1999 and 2003. A laparoscopic transperitoneal approach was used in all cases. Underlying pathologies comprised Cushing syndrome (n = 12), pheochromocytoma (n = 13), primary aldosteronism (n = 21), non-functioning adenoma (n = 12) and others (n = 5).

No open conversion was performed. Mean operative duration was 239 min, and mean estimated blood loss was 134 mL. Tumor diameter was significantly smaller for primary aldosteronism than for Cushing syndrome, which in turn was significantly smaller than for adrenocorticotropic hormone-independent macronodular hyperplasia (AIMAH). No significant differences in surgical outcome and postoperative recovery were noted between large (>or=5 cm) and small (<5 cm) tumors. Long-term clinical outcome was better for patients with pheochromocytoma or primary aldosteronism than for patients with Cushing syndrome.

Laparoscopic adrenalectomy for benign tumor offers excellent surgical outcomes and convalescence. This is true for both small and large tumors.

Laparoscopic adrenalectomy is unanimously recognized as the gold standard for the treatment of adrenal tumors, but it is not indicated for tumors of any size when invasion of the surrounding tissues is clearly detected by preoperative imaging. Although laparoscopic adrenalectomy for metastatic adrenal malignancy is a feasible procedure, in the case of primary adrenal malignancy, it should be done very carefully. When laparoscopic surgery is performed for adrenal tumors >6 cm or for tumors that are considered potentially malignant after preoperative imaging or endocrine studies, the operation should be performed only by a highly skilled laparoscopic surgeon. It is also important to inform the patient and family that the tumors may be malignant and that conversion to open surgery could be necessary. The surgeon must create a sufficiently wide working space, remove the tumor and surrounding fat en bloc, and never grasp the tumor or adrenal tissue. The ultrasonically activated scalpel or ultrasonic endoaspirator should be carefully handled so that it does not touch the tumor surface because this will create a risk of tumor-cell dissemination. It also is essential not to persist unreasonably with laparoscopic procedures but to switch immediately to open surgery when laparoscopic surgery becomes difficult.

Laparoscopic adrenalectomy has become the standard treatment for benign adrenal tumors, providing minimal invasiveness and early recovery. In the case of pheochromocytomas, special attention should be paid perioperatively to prevent excessive hypertension or hypotension. The protocol should include sufficient preoperative medication with alpha 1 blockers, early ligation of the adrenal vein, and minimal handling of the tumor itself. A literature review of 227 laparoscopic adrenalectomies for pheochromocytomas revealed that the perioperative data, including the operative time, blood loss, and hemodynamic status, were similar or slightly better in the laparoscopic procedures as compared to the open procedures, although the convalescence period was significantly shorter in the laparoscopic surgery. The majority of surgeons prefer the transperitoneal approach for pheochromocytomas, although some authors use the retroperitoneal approach successfully. A comparison of the perioperative data from laparoscopic surgeries for pheochromocytomas versus those for other adrenal tumors showed that the former had slightly higher demands to complete the procedure safely. In the treatment of familial pheochromocytoma due to multiple endocrine neoplasia type 2 or von Hippel-Lindau disease, a cortical-sparing adrenalectomy can be safely performed laparoscopically. In conclusion, laparoscopic adrenalectomy is the standard for small pheochromocytomas, with a high success rate when the procedure is performed by experienced surgeons.

A decade has elapsed since laparoscopic adrenalectomy was first performed in 1992. Accumulated experiences of laparoscopic adrenalectomy have shown superior results to treat small functional benign tumors and make the indication expand to large tumors, pheochromocytomas and localized malignant tumors. Following the initially established transperitoneal approach, which includes anterior and lateral approaches, the retroperitoneal lateral flank and posterior lumber approaches have been performed. Each approach has advantages and disadvantages. The transperitoneal approach supplies a large operative field, many anatomical landmarks and easy handling. But it causes post-operative irritability and it is very difficult to perform after previous upper abdominal surgery. The retroperitoneal approach can be performed even after previous abdominal surgery and patients may be more comfortable after the operation. However, the narrow working space and the lack of anatomical landmarks may increase the rate of intra-operative complications and the rate of conversion to open surgery. Although there is no clear preference between transperitoneal and retroperitoneal approaches, the transperitoneal approach is commonly employed and the transperitoneal anterior approach seems to be the easiest one for right adrenal tumors and the transperitoneal lateral approach for left adrenal tumors. The shorter convalescence with laparoscopic adrenalectomy as compared with open adrenalectomy has been accepted and lower morbidity from laparoscopic adrenalectomy has been achieved. The operative time has been shortened to the level of open adrenalectomy. Less blood loss, less pain and better cosmesis are absolute advantages for the patients. Laparoscopic adrenalectomy is now the gold standard for the treatment of adrenal tumors.

This paper outlines the indications and techniques of laparoscopic surgery for malignant adrenal tumors. Laparoscopic surgery is not indicated for adrenal tumors of any size when invasion of the surrounding tissues is clearly detected by preoperative imaging. When laparoscopic surgery is performed for a tumor without invasion that has a maximum diameter of more than 6 cm or a tumor that is considered potentially malignant from preoperative imaging or endocrine studies, it is important to inform the patient and family that the tumor may be malignant and that conversion to open surgery may be necessary. The transperitoneal approach is appropriate for primary adrenal malignancies. For metastatic cancer, the transperitoneal approach is suitable for radical surgery and the extraperitoneal approach for histological diagnosis by partial resection or tumor biopsy. In either case, it is important for the surgeon to have a sufficiently wide working space, to remove the tumor and surrounding fat en bloc, to never grasp the tumor or adrenal tissue, and to carefully handle the ultrasonically activated scalpel or ultrasonic aspirator so that it does not touch the tumor surface due to the risk of tumor cell dissemination. It is also essential not to unreasonably persist with laparoscopic procedures, but to immediately switch to open surgery when laparoscopic surgery becomes difficult.

The objective of this study was to present the clinical outcomes of 26 patients who underwent laparoscopic radical prostatectomy at our institution.

We performed laparoscopic prostatectomy on patients who were clinical stage T1 or T2. The mean age was 70 years old (range: 52-76). The mean level of pre-treatment prostate-specific antigen (PSA) was 8.7 ng/mL (range: 3.3-45). The Gleason score of the needle biopsy was < 7 in 21 patients and > or = 7 in five patients. Clinical stage was T1c in 17 patients, T2a in 6 patients and T2b in 3 patients. Operative techniques followed those of the French groups. Five trocars were introduced into the peritoneal cavity. The vas deferens and seminal vesicles were dissected to reach the posterior wall of the prostate and the retroperitoneal space was dissected around the urinary bladder. Incision of endopelvic fascia and dorsal vein complex (DVC) ligation were performed. The bladder neck and prostate were divided, then the distal urethra was cut. The lateral pedicles of the prostate were cut and the entire prostate was removed. Vesico-urethral anastomosis was performed at eight points.

Mean operation time was 7 h 30 min. Mean bleeding volume (including urine volume) was 850 mL (range: 32-3135). All patients underwent autologous blood transfusion. Only one patient required further blood transfusion. Gleason scores of resected specimens were < 7 in 10 patients, and > or = 7 in 16 patients. Pathological stage was T0 in 1 patient, T2a in 6 patients, T2b in 13 patients, T3a in 5 patients and T3b in 1 patient. The PSA value was undetectable in all patients one month after surgery. Ten patients who survived for 6 months after surgery had complete urinary continence without a pad. In 7 of the 12 patients who were potent before surgery, neurovascular bundles were preserved, and 5 of them (71%) achieved complete or incomplete erection 3 months after surgery. However, only one patient (14%) could have sexual intercourse.

Although longer follow-up is necessary to evaluate this surgical technique, laparoscopic prostatectomy seems to be a reasonable option in the treatment of organ-confined prostate cancer.

We report our experience with laparoscopic adrenalectomy in nine patients with pheochromocytoma and compare the morbidity with that of laparoscopic adrenalectomy for tumors of other pathology.

Between January 1997 and November 1999, nine patients underwent laparoscopic surgery for pheochromocytoma via a transperitoneal approach. Of the patients, eight had solitary tumors, and one presented with bilateral pheochromocytomas. The mean size of the tumors was 5.4 cm. The surgical outcomes of the 9 patients were compared with those of 28 patients with adrenal tumors of other pathology (primary aldosteronism in 15 patients, Cushing syndrome in 6, and nonfunctioning adenoma in 7) who underwent transperitoneal laparoscopic adrenalectomy during the same period. The mean size of the adrenal tumors of other pathology was 2.4 cm.

In eight of the nine patients with pheochromocytoma, laparoscopic adrenalectomy was successful. The procedure was converted to open surgery in the patient with bilateral tumors because of uncontrollable hemorrhage. A hypertensive crisis with the systolic blood pressure >200 mm Hg occurred in 6 patients (67%), but the episode could be controlled by temporary discontinuation of tumor manipulation, administration of drugs, or both. In adrenalectomy for pheochromocytoma, the mean operative time was longer (199 v 177 minutes) and the mean estimated blood loss was greater (360 v 54 mL) than for tumors of other pathology. Blood transfusion was given to two patients with pheochromocytoma but to no patient with tumors of other pathology. The patients with adrenal tumors of other pathology could resume normal activity earlier (mean 18 v 26 days) than those with pheochromocytoma.

The operation is more difficult and the morbidity is higher in laparoscopic adrenalectomy for pheochromocytoma than that for tumors of other pathology. An experienced team of surgeons with advanced laparoscopic skills and anesthesiologists is mandatory. In large tumors, great caution should be taken for intraoperative complications. Nevertheless, laparoscopic adrenalectomy is not contraindicated for pheochromocytoma and can be performed safely.

Laparoscopic prostatectomy has become an established treatment option for localized prostate cancer in France, where open prostatectomy is now the gold standard. The main purposes of treatment for prostate cancer are cancer control and preservation of urinary continence and sexual function. To become a standard treatment option for organ-confined prostate cancer, laparoscopic prostatectomy has to show equal or better clinical outcome in these areas than its open counterpart. Many institutes in other countries are now trying to perform this surgery. There are, however, some negative reports, mainly because of the difficulty of the procedure. In Japan, more than 250 patients have undergone this surgery. It seems that satisfactory results in terms of positive surgical margin rate, bleeding volume, recovery from surgery, and urinary continence have been obtained so far. We need longer follow-up to assess recurrence rate and sexual function. The main obstacles for this surgery are the long operative time and the difficulty of the procedures. Although it will take time until laparoscopic prostatectomy becomes an approved treatment modality, we are gradually conquering these problems. In this paper, we review the current situation facing laparoscopic prostatectomy in Japan.

Endoscopic adrenalectomy represents the "New Golden Standard" in the surgical treatment of benign adrenal lesions up to 6 cm. Open adrenalectomy is recommended for patients with suspected malignant disease and tumors larger than 6 cm.

The surgical technique of trans- and retroperitoneal adrenalectomy is described. Reviewing literature the importance of the endoscopic approach and its role in the surgical treatment of adrenal lesions is analyzed.

As in open adrenalectomy different endoscopic approaches to the adrenals were developed: adrenal tumors can be removed endoscopically using a transperitoneal (patient in a supine or lateral decubitus position) or extraperitoneal route (patient in a lateral decubitus or prone position). Reviewing literature the endoscopic transperitoneal adrenalectomy is documented in 1425 patients. 4.6% (66 patients) had to be converted to an open procedure. Five hundred and forty-four tumors were removed by an extraperitoneal access. The conversion rate was 4.4% (24 patients).

The basis of excellent results are careful patient selection, evaluation and preoperative preparation in a center with experience in the open techniques and at least 20 endoscopic adrenalectomies per year.

To clarify the characteristics of surgical approaches to laparoscopic adrenalectomy we performed background matched analysis of clinical outcomes of the 3 approaches.

From February 1992 to July 2000 we performed 118 laparoscopic adrenalectomies in 115 patients with adrenal tumors. For these operations we used the anterior transperitoneal approach in 46 patients, the lateral transperitoneal approach in 32 and the lateral retroperitoneal approach in 40.

To exclude the learning curve effect we eliminated our initial 20 patients treated with the anterior transperitoneal approach. To allow background matching of the 3 groups we also excluded 14 patients with tumors more than 5 cm., 6 who underwent conversion to open surgery and 1 patient who required 5 days of bed rest for retroperitoneal hematoma caused by bleeding from a trocar port. The final analysis included 16, 25 and 36 cases managed via the anterior transperitoneal, lateral transperitoneal and lateral retroperitoneal approach, respectively. Average operative time was significantly shorter for the lateral transperitoneal approach. Postoperative recovery was not significantly different in the lateral transperitoneal and lateral retroperitoneal groups. Postoperative complications included mild paralytic ileus in 2 patients and shoulder tip pain, probably peritoneal irritation due to carbon dioxide insufflation and bowel preparation, in 4 in the transperitoneal groups. Our results imply that the easiest procedure is the lateral transperitoneal approach but the lateral retroperitoneal approach is slightly less invasive.

Although it is important to remember that this study was not a prospective randomized trial and, thus, had from certain biases, we believe that if a tumor is more than 5 cm. and/or the surgeon is not yet skilled in laparoscopic adrenalectomy, the lateral transperitoneal approach is the most suitable method. If the surgeon has performed at least 20 operations, the adrenal tumor is unilateral and the lesion is less than 5 cm., the lateral retroperitoneal approach seems to be more suitable because of its minimally invasive nature. The lateral retroperitoneal approach is also preferred in patients with a history of upper abdominal surgery. With improvements in technique and new instruments the time required for the lateral retroperitoneal approach has been significantly decreased.

The most important procedure in retroperitoneoscopic adrenalectomy is en bloc dissection of the perinephric fat, including the upper pole of the kidney and the adrenal gland, from the surrounding muscles (transversus abdominalis, psoas, and diaphragm) just inside Gerota's fascia. It is not recommended that the surgeon directly identify the adrenal gland at the start of the operation. After dividing the perinephric fat between the adrenal gland and kidney, the upper pole of the kidney is exposed, and dissection proceeds along the renal surface. The lateral retroperitoneoscopic approach promises to be a safer and less invasive treatment for patients with small unilateral adrenal tumors. In all cases, careful patient selection and correct choice of the surgical approach based on tumor size, the patient's condition, and the surgeon's skill are vital to avoid complications during laparoscopic adrenalectomy.

The early diagnosis and safe treatment of pheochromocytoma have become possible due to advances in preoperative imaging techniques and endocrine tests, as well as improvements in the control of blood pressure and hemodynamics before and during the operation using various drugs. This article outlines the use of meticulous surgical technique via various approaches for open surgery and gives a step-by-step description of the methods for laparoscopic surgery. Such techniques have made the excision of pheochromocytoma safe and easy, allowing hypertension to be surgically cured in these patients. Thus, pheochromocytoma is less likely to be fatal than before. However. it is necessary to follow these patients for a long period postoperatively because it is often difficult to distinguish benign from malignant tumors and recurrence has been reported even more than ten years postoperatively.

To compare the efficacy of laparoscopic adrenalectomy for pheochromocytoma with that of conventional open adrenalectomy for pheochromocytoma and laparoscopic surgery for other adrenal tumors.

Fifty-four patients with adrenal tumors, including 10 cases of pheochromocytoma, 18 cases of Cushing's syndrome, 20 cases of primary aldosteronism, and 6 cases of nonfunctioning tumors, were evaluated. A historical group of 7 consecutive patients who underwent conventional open adrenalectomy for pheochromocytoma was also studied.

Laparoscopic adrenalectomy for pheochromocytoma was successful in 9 of the 10 patients. There was no difference in tumor size, operation time, estimated blood loss, or occurrence of hypertensive episodes during surgery between patients treated with laparoscopic procedures and those treated with open surgery. However, the number of days to first postoperative oral feeding and first ambulation, length of hospitalization, and number of patients requiring parenteral analgesics were significantly smaller after laparoscopic surgery than after open surgery. There was no significant difference in operation time, estimated blood loss, incidence of intraoperative complications, or postoperative recovery between patients who underwent laparoscopic adrenalectomy for pheochromocytoma and those who underwent laparoscopic surgery for other adrenal lesions.

Laparoscopic adrenalectomy does not increase the specific risks associated with surgery for pheochromocytoma. It is a minimally invasive alternative to conventional open adrenalectomy.

To compare the results between transperitoneal and retroperitoneal approaches.

Between 17 January 1992 and 31 December 1997, 76 patients (31 men and 45 women, 37 right and 37 left, mean 46.7 years old) with adrenal tumors including 37 primary aldosteronism. 19 Cushing's syndrome, 15 non-functioning adrenal tumors, and five pheochromocytomas, underwent laparoscopic removal operations in one hospital. Fifty-seven open adrenalectomies were also included.

Fifty-two patients by transperitoneal laparoscopic approach, and the other 24 patients by retroperitoneal laparoscopic approach were compared.

Mean operative time, operative blood loss, time to oral intake, and ambulation of transperitoneal approach were 203 min, 115.6 mL, 1.9 days, and 1.4 days. In patients operated on by the retroperitoneal approach, these factors were 257 min, 141.6 mL, 1.1 days, and 1.4 days. There was no significant difference in any item between the two groups. In patients operated on by open procedure, these factors were 143 min, 214 mL, 2.5 days, and 2.4 days. Operating time of the open surgery group was significantly shorter than either of the other two groups, and all of the other three items of open surgery group were significantly greater than either of the other two groups. Open surgery was required in two of 76 patients treated by endoscopic procedure due to inadvertent injury of the anomalous adrenal vein during the transperitoneal approach, and pancreatic injury during the retroperitoneal approach. During and after the operation, no significant complication was observed.

Both transperitoneal and retroperitoneal laparoscopic adrenalectomies are feasible for adrenal tumors.

Four laparoscopic methods have been developed to approach the adrenal gland: anterior or lateral transperitoneal approaches, and lateral or posterior retroperitoneal approaches. The advantages and disadvantages of these methods were reviewed during a workshop held by the Japanese Society of Endourology and ESWL in 1997. The transperitoneal anterior approach, when combined with a lateral approach for the left side, is the easiest for small adrenal tumors, and discloses the adrenal vein early in the procedure. For large tumors over 5 cm in diameter, the transperitoneal lateral approach is the most feasible bilaterally. Regardless of the methods of approach, laparoscopic adrenalectomy has already become the standard procedure for adrenal tumors, because it minimizes the operative morbidity and postoperative hospital stay.

A total of 370 laparoscopic adrenalectomies, including 311 transperitoneal (TP) and 59 retroperitoneal (RP) approaches, were performed in nine urologic centers, where the laparoscopic adrenalectomy was first begun independently in Japan, and their affiliated hospitals between January 1992 and September 1996. The clinical diagnoses of those 370 adrenal diseases were primary aldosteronism in 155 patients, Cushing's syndrome in 61. preclinical Cushing's syndrome in 21. pheochromocytoma in 16, nonfunctioning adenoma in 87, complicated cyst in ten, myelolipoma in nine, adrenal cancer in four and other diagnoses in eight (table 1). There was no mortality in this series. Intraoperative complication rate was 33/370 (9%) in total: 26/311(8%) in the TP procedures and 7/59 (12%) in the RP procedures (table 11). Postoperative complication rate was 24/370 (6%) in total: 22/311 (7%) in the TP procedures and 2/59 (3%) in the RP ones (table 111). Conversion rates to open surgery in total, in the TP and in the RP procedures were 13/370 (3.5%), 10/311 (3.2%) and 3/59 (5.1 %). respectively (table IV). Although the RP procedure has a lower morbidity rate compared to the TP procedure, more skill is required to overcome the drawback of the narrow working space and fewer anatomical landmarks.

We report the first patient who had bilateral pheochromocytoma associated with multiple endocrine neoplasia type 2a syndrome (MEN 2a) and underwent unilateral laparoscopic adrenalectomy followed by contralateral retroperitoneoscopic partial adrenalectomy 2 years later. The postoperative course was uneventful both times, and the patient was cured of hypertension without any need for steroid replacement. Endoscopic partial adrenalectomy is a minimally invasive procedure for pheochromocytoma with mild symptoms. We believe that this procedure has considerable potential for treating bilateral pheochromocytoma, which is frequently observed in patients with MEN 2a.

To evaluate the efficacy of laparoscopic radical nephrectomy for patients with small renal cell carcinoma by comparing the clinical results of patients treated laparoscopically with those of patients treated with traditional open radical nephrectomy.

Of 100 patients with localized, small (less than 5 cm in diameter) renal cell carcinoma treated by the same surgical team between 1992 and 1998, 60 patients underwent laparoscopic radical nephrectomy and 40 underwent open radical nephrectomy. Of the 60 laparoscopically treated patients, the first 11 and the most recent 34 patients were operated on transperitoneally and the other 15 retroperitoneally.

The mean operative time of the laparoscopically treated patients was longer than that of the open nephrectomy patients (5.2 versus 3.3 hours, P<0.001). The mean blood loss of the laparoscopically treated patients was less than that of the open nephrectomy patients (255 versus 512 mL, P<0.001). One laparoscopically treated patient needed conversion to open surgery. The time to full convalescence of the laparoscopically treated patients was shorter than that of the open nephrectomy patients (23 versus 57 days, P<0.001). Two of the 59 laparoscopically treated patients and 1 of the 40 open nephrectomy patients had metastatic disease. The former 2 are alive with stable disease and the latter died of progressive disease 11 months after surgery. The 5-year disease-free rate was 95.5% in laparoscopy patients and 97.5% in open nephrectomy patients (P = NS).

Laparoscopic radical nephrectomy is a less invasive alternative to open surgery for patients with localized small renal cell carcinoma.

Between July 1992 and October 1996, 100 transperitoneal laparoscopic adrenalectomies were performed on 99 patients at our hospital and affiliated hospitals. The clinical diagnoses were primary aldosteronism (41 patients), Cushing's syndrome (15), pre-Cushing's syndrome (6), pheochromocytoma (7; 8 adrenal glands), adrenal cancer (2), nonfunctioning adenoma (22), myelolipoma (3), and complicated adrenal cyst (3). Ninety-seven glands were removed laparoscopically. The mean operative time was 240 +/- 76 (SD) minutes and the mean blood loss 68 +/- 80 mL for the series. The mean blood was 77 +/- 113 mL when the three operations that were converted to open surgery are included. The mean times for the return to a normal diet and unassisted ambulation were 1.3 +/- 0.6 and 1.4 +/- 0.8 days, respectively. The mean duration of the use of analgesics was 1.5 +/- 1.3 days, including the day of surgery. In contrast, in the latest 10 open adrenalectomies done at Kyoto University Hospital, the mean operative time was 186 +/- 53 minutes and the mean blood loss 220 +/- 170 mL. The mean times for return to a normal diet and for unassisted ambulation and the mean duration of the use of analgesics were 1.9 +/- 0.3, 2.9 +/- 1.1, and 2.9 +/- 1.7 days, respectively. Thirty-six operations, excluding one converted to open surgery, performed at Kyoto University Hospital were selected to look at the learning curve for transperitoneal laparoscopic adrenalectomy and evaluated for operative time and blood loss. The mean operative time and mean blood loss in the first 10 procedures performed at Kyoto University Hospital were 256 +/- 63 minutes and 89 +/- 57 mL; however, these values were reduced to 177 +/- 39 minutes and 48 +/- 32 mL in the next 10 procedures at the same hospital. Laparoscopic adrenalectomy via the transperitoneal anterior approach can be equivalent to open adrenalectomy in efficiency with a shorter convalescence.

One hundred consecutive laparoscopic adrenal procedures for a variety of endocrine disorders were reviewed. There was no mortality, morbidity was 12%, and conversions was 3%. During follow-up, none had recurrence of hormonal excess. Laparoscopic adrenalectomy is the procedure of choice for adrenal removal except in carcinoma or masses > 15 cm.

The authors evaluate the effectiveness of laparoscopic adrenalectomy for a variety of endocrine disorders.

Since the first laparoscopic adrenalectomy was performed in 1992, this approach quickly has been adopted, and increasing numbers are being reported. However, the follow-up period has been too short to evaluate the completeness of these operations.

One hundred consecutive laparoscopic adrenal procedures from January 1992 until November 1996 were reviewed and followed for adequacy of resection.

Eighty-eight patients underwent 97 adrenalectomies and biopsies. The mean age was 46 years (range, 17-84 years). Indications were pheochromocytomas (n = 25), aldosterone-producing adenomas (n = 21), nonfunctional adenomas (n = 20), cortisol-producing adenomas (n = 13), Cushing's disease (n = 8), and others (n = 13). Fifty-five patients had previous abdominal surgery. Mean operative time was 123 minutes (range, 80-360 minutes), and estimated blood loss was 70 mL (range, 20-1300 mL). There was no mortality, and morbidity was encountered in 12% of patients, including three patients in whom venous thrombosis developed with two sustaining pulmonary emboli. During pheochromocytoma removal, hypertension occurred in 56% of patients and hypotension in 52%. There were three conversions to open surgery. The average length of stay has decreased from 3 days (range, 2-19 days) in the first 3 years to 2.4 days (range, 1-6 days) over the past 16 months. During follow-up (range, 1-44 months), two patients had renovascular hypertension and none had recurrence of hormonal excess.

Laparoscopic adrenalectomy is safe, effective, and decreases hospital stay and wound complications. Prior abdominal surgery is not a contraindication. Pheochromocytomas can be resected safely laparoscopically despite blood pressure variations. Venous thrombosis prophylaxis is mandatory. The laparoscopic approach is the procedure of choice for adrenalectomy except in the case of invasive carcinoma or masses > 15 cm.