Abstract
Introduction: The aim of this study was to determine the incidence and risk factors for postoperative flank bulging and associated physiologic/psychologic consequences as well as to establish a clinical flank bulge classification system after open retroperitoneal surgery. Methods: In this retrospective study, a postal patient survey was sent to 240 patients who underwent open retroperitoneal surgery between 2007 and 2017. Patients, who reported a flank bulge, were invited for further evaluation, which included a clinical examination and standardized photo documentation. Results: Forty-three of 120 patients (35.8%) reported a flank bulging after retroperitoneal surgery. During clinical examination, a flank bulge could be confirmed in 25 patients, whereas in 18 patients, no bulging could be detected, leading to a corrected rate of flank bulge-positive patients of 20.8%. The corresponding relaxation values ranged from 1 to 1.44 and correlated with the clinical degree of bulging. A body mass index of ≥25 was identified as a risk factor. No correlation was found regarding age, gender, surgery side, access to the retroperitoneum, surgical procedure, and pathology. Thirty-seven patients complained about chronic pain or suffered from the cosmetic impact of bulging. Thirteen of those patients had shown a flank bulge during clinical examination, resulting in a symptomatic bulge rate of 10.8% (13/120 patients). Conclusion: Chronic pain and postoperative flank bulging are 2 of the most common long-term complications after open retroperitoneal access. If an open retroperitoneal approach is required, particularly obese patients should be thoroughly informed about the risk of flank bulging and chronic pain.
References
1.
Ferlay
J
, Colombet
M
, Soerjomataram
I
, Dyba
T
, Randi
G
, Bettio
M
, Cancer incidence and mortality patterns in Europe: estimates for 40 countries and 25 major cancers in 2018
. Eur J Cancer
. 2018 Nov
;103
:356
–87
. .2.
Capitanio
U
, Bensalah
K
, Bex
A
, Boorjian
SA
, Bray
F
, Coleman
J
, Epidemiology of renal cell carcinoma
. Eur Urol
. 2019 Jan
;75
(1
):74
–84
. .3.
Fiebig
J
, Kraywinkel
K
. Epidemiologie des Nierenzellkarzinoms in Deutschland
. Onkologe
. 2019
;25
(6
):483
–7
. .4.
Ljungberg
B
, Albiges
L
, Abu-Ghanem
Y
, Bensalah
K
, Dabestani
S
, Fernández-Pello
S
, European association of urology guidelines on renal cell carcinoma: the 2019 update
. Eur Urol
. 2019
;75
:799
–810
. .5.
Chatterjee
S
, Nam
R
, Fleshner
N
, Klotz
L
. Permanent flank bulge is a consequence of flank incision for radical nephrectomy in one half of patients
. Urol Oncol
. 2004
;22
(1
):36
–9
. .6.
Winfield
HN
, Donovan
JF
, Lund
GO
, Kreder
KJ
, Stanley
KE
, Brown
BP
, Laparoscopic partial nephrectomy: initial experience and comparison to the open surgical approach
. J Urol
. 1995 May
;153
(5
):1409
–14
. .7.
Matsen
SL
, Krosnick
TA
, Roseborough
GS
, Perler
BA
, Webb
TH
, Chang
DC
, Preoperative and intraoperative determinants of incisional bulge following retroperitoneal aortic repair
. Ann Vasc Surg
. 2006 Mar
;20
(2
):183
–7
. .8.
Inkiläinen
A
, Styrke
J
, Ljungberg
B
, Strigård
K
. Occurrence of abdominal bulging and hernia after open partial nephrectomy: a retrospective cohort study
. Scand J Urol
. 2018 Feb
;52
(1
):54
–8
. .9.
Albers
P
, Heidenreich
A
. Standardoperationen in der urologie
. Stuttgart
: Georg Thieme Verlag
; 2014
. p. 16
–35
.10.
Smith
J
, Howards
S
, Preminger
G
, Dmochowski
R
. Hinman´s atlas of urologic surgery
. Philadelphia
: Elsevir
; 2017
. p. 61
–82
.11.
Gardner
GP
, Josephs
LG
, Rosca
M
, Rich
J
, Woodson
J
, Menzoian
JO
. The retroperitoneal incision. An evaluation of postoperative flank “bulge”
. Arch Surg
. 1994
;129
(7
):753
–6
. .12.
Ozel
L
, Marur
T
, Unal
E
, Kara
M
, Erdoğdu
E
, Demir
T
, Avoiding abdominal flank bulge after lumbotomy incision: cadaveric study and ultrasonographic investigation
. Transplant Proc
. 2012 Jul–Aug
;44
(6
):1618
–22
. .13.
Ballard
JL
, Abou-Zamzam
AM
Jr, Teruya
TH
, Harward
TR
, Flanigan
DP
. Retroperitoneal aortic aneurysm repair: long-term follow-up regarding wound complications and erectile dysfunction
. Ann Vasc Surg
. 2006
;20
(2
):195
–9
. .14.
Crouzet
S
, Chopra
S
, Tsai
S
, Kamoi
K
, Haber
GP
, Remer
EM
, Flank muscle volume changes after open and laparoscopic partial nephrectomy
. J Endourol
. 2014 Oct
;28
(10
):1202
–7
. .15.
Zhou
DJ
, Carlson
MA
. Incidence, etiology, management, and outcomes of flank hernia: review of published data
. Hernia
. 2018 Apr
;22
(2
):353
–61
. .16.
Fahim
DK
, Kim
SD
, Cho
D
, Lee
S
, Kim
DH
. Avoiding abdominal flank bulge after anterolateral approaches to the thoracolumbar spine: cadaveric study and electrophysiological investigation
. J Neurosurg Spine
. 2011 Nov
;15
(5
):532
–40
. .17.
Honig
MP
, Mason
RA
, Giron
F
. Wound complications of the retroperitoneal approach to the aorta and iliac vessels
. J Vasc Surg
. 1992 Jan
;15
(1
):28
–4
. .18.
Sieunarine
K
, Lawrence-Brown
MM
, Goodman
MA
. Comparison of transperitoneal and retroperitoneal approaches for infrarenal aortic surgery: early and late results
. Cardiovasc Surg
. 1997
;5
(1
):71
–6
. .19.
Hoffman
RS
, Smink
DS
, Noone
RB
, Noone
RB
Jr, Smink
RD
Jr. Surgical repair of the abdominal bulge: correction of a complication of the flank incision for retroperitoneal surgery
. J Am Coll Surg
. 2004
;199
(5
):830
–5
. .20.
Timmermans
L
, Klitsie
PJ
, Maat
AP
, de Goede
B
, Kleinrensink
GJ
, Lange
JF
. Abdominal wall bulging after thoracic surgery, an underdiagnosed wound complication
. Hernia
. 2013
;17
(1
):89
–94
. .21.
Jagannathan
J
, Chankaew
E
, Urban
P
, Dumont
AS
, Sansur
CA
, Kern
J
, Cosmetic and functional outcomes following paramedian and anterolateral retroperitoneal access in anterior lumbar spine surgery
. J Neurosurg Spine
. 2008 Nov
;9
(5
):454
–65
. .22.
Kunihara
T
, Adachi
A
, Akimaro Kudo
F
, Shiiya
N
, Yasuda
K
. The less incisional retroperitoneal approach for abdominal aortic aneurysm repair to prevent postoperative flank bulge
. J Cardiovasc Surg
. 2005
;46
(6
):527
–31
.23.
Darling
C
3rd, Shah
DM
, Chang
BB
, Paty
PS
, Leather
RP
. Current status of the use of retroperitoneal approach for reconstructions of the aorta and its branches
. Ann Surg
. 1996 Oct
;224
(4
):501
–8
. .24.
Nakajima
T
, Kawazoe
K
, Komoda
K
, Sasaki
T
, Ohsawa
S
, Kamada
T
. Midline retroperitoneal versus midline transperitoneal approach for abdominal aortic aneurysm repair
. J Vasc Surg
. 2000
;32
(2
):219
–23
. .25.
Salameh
JR
, Salloum
EJ
. Lumbar incisional hernias: diagnostic and management dilemma
. JSLS
. 2004 Oct–Dec
;8
(4
):391
–4
.26.
Osman
T
, Emam
A
, Farouk
A
, ElSaeed
K
, Tawfeek
AM
, AbuHalima
A
. Risk factors for the development of flank hernias and bulges following surgical flank approaches to the kidney in adults
. Arab J Urol
. 2018 Jul 4
;16
(4
):453
–9
. .27.
Choi
JH
, Jang
JS
, Jang
IT
. Abdominal flank bulging after lateral retroperitoneal approach: a case report
. NMC Case Rep J
. 2016 Dec 12
;4
(1
):23
–6
. .28.
Phillips
MS
, Krpata
DM
, Blatnik
JA
, Rosen
MJ
. Retromuscular preperitoneal repair of flank hernias
. J Gastrointest Surg
. 2012 Aug
;16
(8
):1548
–53
. .29.
Pezeshk
RA
, Pulikkottil
BJ
, Bailey
SH
, Schaffer
NE
, Reece
EM
, Thornton
NJ
, An evidence-based model for the successful treatment of flank and lateral abdominal wall hernias
. Plast Reconstr Surg
. 2015 Aug
;136
(2
):377
–85
. .30.
Purnell
CA
, Park
E
, Turin
SY
, Dumanian
GA
. Postoperative flank defects, hernias, and bulges: a reliable method for repair
. Plast Reconstr Surg
. 2016 Mar
;137
(3
):994
–1001
. .31.
Edwards
C
, Geiger
T
, Bartow
K
, Ramaswamy
A
, Fearing
N
, Thaler
K
, Laparoscopic transperitoneal repair of flank hernias: a retrospective review of 27 patients
. Surg Endosc
. 2009 Dec
;23
(12
):2692
–6
. .32.
Zieren
J
, Menenakos
C
, Taymoorian
K
, Müller
JM
. Flank hernia and bulging after open nephrectomy: mesh repair by flank or median approach? Report of a novel technique
. Int Urol Nephrol
. 2007
;39
(4
):989
–93
. .33.
Veyrie
N
, Poghosyan
T
, Corigliano
N
, Canard
G
, Servajean
S
, Bouillot
JL
. Lateral incisional hernia repair by the retromuscular approach with polyester standard mesh: topographic considerations and long-term follow-up of 61 consecutive patients
. World J Surg
. 2013
;37
(3
):538
–44
. .34.
Springer
C
, Inferrera
A
, Kawan
F
, Schumann
A
, Fornara
P
, Greco
F
. Laparoendoscopic single-site versus conventional laparoscopic radical nephrectomy for renal cell cancer in patients with increased comorbidities and previous abdominal surgery: preliminary results of a single-centre retrospective study
. World J Urol
. 2013
;31
(1
):213
–8
. .35.
Lane
BR
, Campbell
SC
, Gill
IS
. 10-year oncologic outcomes after laparoscopic and open partial nephrectomy
. J Urol
. 2013
;190
(1
):44
–9
. .36.
Gill
IS
, Kavoussi
LR
, Lane
BR
, Blute
ML
, Babineau
D
, Colombo
JR
Jr, Comparison of 1,800 laparoscopic and open partial nephrectomies for single renal tumors
. J Urol
. 2007 Jul
;178
(1
):41
–6
. .© 2021 S. Karger AG, Basel
2021
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.
