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Laparoscopic Management of Retroperitoneal Masses: Our Experience and Literature Review

                                  Table 3: Demographics, clinical presentation and imaging findings in literature
              Author      Gender  Age (years)  Presentation                      Symptomatic     Side     Size
                           (M/F)                                                   (Yes/No)  (L/R/Median)  (cm)
            Viani            F        49       Abdominal and flank pain              Yes          R         6
            Melvin           F        36       Abdominal pain                        Yes          R        2.5
            Kawabata         F        43       Incidental                            No           L        NA
                             M        68       Incidental                            No          NA        NA
            Nishio           F        41       Abdominal mass                        Yes          R         5
            Ohigashi         F        28       Incidental                            No           R         3
            Shalhav          F        58       Incidental                            No           L         3
                            NA        50       Incidental                            No           L         2
                            NA        62       Loin pain                             Yes          L         6
                            NA        62       Back pain                             Yes          R        NA
            Cadeddu          F        32       Abdominal pain                        Yes          R        12
                             F        45       Incidental                            No           L        20
                             F        35       Painful flank mass                    Yes          R        12
            Descazeaud       F        62       Incidental                            No           R         8
            Funamizu         M        55       Epigastric discomfort                 Yes          M         6
            Ishizuka         M        36       Incidental                            No           L         5
            Johna            F        37       Flank pain, lower limb sensory impairment  Yes     L        12
            Morrison         M        62       Incidental                            No          NA         7
            Akos             F        18       Incidental                            No           L         8
            Chung            M        46       Incidental                            No           L         3
            Dalpiaz          F        61       Incidental                            No           L        10
            Minei            M        39       Fever, suspect adrenal tumor          Yes          L        3.5
            Cho              F        27       Incidental                            No           M        10
            Tsukamoto        F        36       Abdominal and back pain               Yes          R        11
            Targarona        F        45       Abdominal pain                        Yes          L        12
            Celia            F        65       Abdominal pain                        Yes          R         7
            Trindade         M        28       Painful flank mass                    Yes          R         5

            Average (range)         (18-68)                                                               (2-20)
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            mass, fever, and epigastric discomfort were the presenting  group  and ourselves reported incisional biopsies whether all
            symptoms in 1 case each. In our series only one case presented  others report complete excisions of the specimen. Considering
            incidentally, and the most common cause of diagnosis was  that only few papers deal with malignant pathology it is to
            follow-up imaging for RCC (37.5% of cases). In found  expect that the rate of incisional biopsies is higher than reported.
            publications, average lesion size is reported to be 7.5 cm in its  Combining all reported cases (literature and our experience)
            largest diameter, ranging from 2 to 20 cm; malignant masses in  with malignant pathology we find 3 incisional biopsies and 8
            those reports are generally smaller (2-10 cm). On our experience  complete excisions. From another point of view, diagnostic
            malignant masses treated laparoscopically measured 2-5 cm  laparoscopy is likely to produce more incisional biopsies than
            indicating a cautious approach to laparoscopic indications.  reported considering this surgical intervention as the last
               Limitations of available preoperative imaging techniques  diagnostic tool available when non invasive techniques have
            and suboptimal feasibility of image-guided preoperative biopsy  failed.
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            account for the fact that only one group  reported performing  In the published papers malignant pathology is observed
            guided biopsies and in that setting its accuracy was quite low.  only in 6 out of 27 cases (22.2%) and in those cases radical
            In our series preoperative biopsy was carried out in 2 cases and  resection was performed in 4 cases whether in other 2 cases
            was accurate in diagnosis in one patient. Those findings  incisional biopsy was carried out in Table 4. No recurrences are
            emphasize the need of novel techniques to establish a more  reported in those papers; however this element is to be evaluated
            accurate diagnosis in such challenging cases as retroperitoneal  against a probable publishing bias. Moreover, in cases with
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            masses. An accurate preoperative diagnosis is essential to  malignant pathology only one group  stated the follow-up
            formulate an appropriate treatment plan.           period and reported the absence of recurrence at 12 months.
               Published papers report no conversions and this may be  We believe that laparoscopy is a viable and valid alternative
            due to extreme experience of the surgical team but publication  not only as a diagnostic tool but also as a treatment option in
            bias must be taken in consideration. It is understandable  retroperitoneal masses. Clearly, an accurate patient selection is
            however, that the growing experience in laparoscopic surgery  paramount, especially when one deals with possibly malignant
            increases its efficiency even in those delicate cases. Only one  finding. There is little question regarding the feasibility of

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