Objectives. To compare the efficacy of retroperitoneoscopic adrenalectomy by a posterior lumbar approach (RPA) with that obtained by a transperitoneal anterior approach (TAA) or retroperitoneal lateral flank approach (RLA). Methods. Fifty-one patients underwent endoscopic adrenalectomy by three approaches, including laparoscopic adrenalectomy by TAA in 33, retroperitoneoscopic adrenalectomy by RLA in 5, and retroperitoneoscopic adrenalectomy by RPA in 13. Results. The average adrenal tumor size was 27 mm (range 8 to 65). The average number of trocars required for RPA was 3.2, which was significantly less than that for TAA and for RLA (4.2 and 4.1, respectively). The conversion rate to open surgery was 9.1% by TAA, 0% by RLA, and 7.7% by RPA. The average operating time for TAA was 252 minutes, which was significantly shortened to 194 minutes by RLA and 142 minutes by RPA (P <0.02). The average blood loss was 101 mL for TAA and was negligible by RLA and RPA (22 and 32 mL, respectively). Conclusions. RPA allowed direct access to the main adrenal vascular supply before the gland was greatly manipulated. Endoscopic adrenalectomy by TAA or even by RLA required extra ports for retraction of liver, spleen, vena cava, or adrenal gland, with higher chance of vein avulsion. RPA was technically feasible and most effective for retroperitoneoscopic adrenalectomy in regard to the simplicity of vascular control. The operating time, perioperative morbidity, and cost were reduced with this approach.
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