title: Midline extraperitoneal approach to upper urinary tract surgery: anatomical basis of surgical technique.
abstract: To overcome the disadvantages inherent in the standard surgical approach to the kidney, we introduced a novel surgical technique via a midline extraperitoneal approach. The surgical technique is not substantially different from that of the standard midline transperitoneal approach, except no entry is made into the peritoneal cavity. Although the peritoneum itself is extremely thin and fragile, the peritoneum together with underlying subperitoneal fascia can be dissected readily as a substantial layer, if the proper plane is dissected. Further medial mobilization of the peritoneal sac en bloc by pursuing the fusion fascia plane allows full exposure of the kidney, ureter and great vessels. This approach was adopted for consecutive 51 patients during a 10-month period in 2003. All operations, including 33 radical nephrectomies and 11 nephroureterectomies were completed successfully without significant technical difficulties and differences in operation time and estimated blood loss compared to the transperitoneal approach. No intra- or perioperative complication occurred. All patients did seem to have a much more comfortable postoperative period with minor pain and few abdominal complaint, and the clinical impression was that they resumed the physical activity and oral intake earlier than those after the transperitoneal approach (P = 0.056). There are no operation-related problems such as intra-abdominal adhesion or abdominal muscle weakness resulting in some deformity at 2-year or more follow up. This approach combines the advantages of the transperitoneal midline and extraperitoneal flank approach. Its use will undoubtedly reduce the complications inherent in the transperitoneal approach or the flank approach.
authors.affiliation: Department of Urology, Senseki Hospital, Higashi-matsushima and Sendai Shakaihoken Hospital, Sendai, Japan. drsroom@senseki.gr.jp
authors.forename: Seiichi
authors.initials: S
authors.lastname: Orikasa
authors.forename: Koichi
authors.initials: K
authors.lastname: Kanbe
authors.forename: Shuichi
authors.initials: S
authors.lastname: Shirai
authors.forename: Naomasa
authors.initials: N
authors.lastname: Iorotani
authors.forename: Masataka
authors.initials: M
authors.lastname: Aizawa
authors.forename: Akira
authors.initials: A
authors.lastname: Takeuchi
authors.forename: Shinichi
authors.initials: S
authors.lastname: Yamashita
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000075202:Contraindications; D005205:Fascia / Q000033:anatomy & histology; D006801:Humans; D007431:Intraoperative Complications / Q000517:prevention & control; D010535:Laparoscopy; D008875:Middle Aged; D010529:Peritoneal Cavity / Q000033:anatomy & histology; D014551:Urinary Tract / Q000033:anatomy & histology*; D013520:Urologic Surgical Procedures / Q000379:methods*