Retroperitoneal sarcomas most commonly present as an abdominal mass, often without other symptoms. Via the same incision as the first surgery, we reached the retroperitoneal tumor transperitoneally. Thread starter medihedgie; Start date May 16, 2013; M. medihedgie Networker. Although the median patient age is approximately fifty years, retroperitoneal sarcomas occur at any age and arise equally in women and men. Please understand that our phone lines must be clear for people with urgent and acute medical care needs. Ann Surg Oncol 2011; 18:2107. benign and the primary treatment choice for retroperitoneal schwannomas is surgical excision, however, the involvement of the urinary system is scarcely reported. Retroperitoneal inflammation is a serious condition that can have life-threatening consequences. Your health and safety remain our top priority: Learn about our Safe Care Commitment | Use our Prescreen app before arrival for faster entry | Read the COVID-19 Vaccine FAQs. There are several advantages to this, including greater experience for this rare cancer, access to multidisciplinary care, and the availability of clinical trials and research protocols. Though a standard procedure for treating this disorder has not been determined, medication and surgery are two viable options. In retroperitoneal renal surgery, the kidney is quickly encountered after a brief dissection of the retroperitoneal space. The patient should undergo dedicated imaging and workup of the retroperitoneal mass. Nevertheless, a preoperatively confirmed diagnosis of GN … Penetrating Injury- Infection of penetrating injury of lower back like knife injury or gun shot wound causes abscess formation and may spread in adjacent tissue or stay within the capsule. Preoperative computed tomography revealed heterogeneously enhancing mass 20×15×12 cm with cystic areas and calcifications, suspected to be malignant and of pancreatic origin. In cases where retroperitoneal lymph nodes appear close or adherent to the aorta or vena cava, it is often safer to surgically remove a portion of the blood vessel. e) Kidney Tumor. When symptoms are present, they relate to the mass effect of the tumor or to local invasion. In these cases, the retroperitoneal mass can be a viable tumor (10–15%) or teratoma (40–50%). Retroperitoneal fibrosis is a rare condition that’s also known as Ormond’s disease. General Information: Gronchi A, Pollock R. Surgery in retroperitoneal soft tissue sarcoma: a call for a consensus between Europe and North America. Treatments for chylous ascites include restricted diet, placement of abdominal drains (or intermittent drainage), medications to decrease the amount of lymphatic fluids or interventional radiology procedures. There are many theoretical and real advantages to undergoing minimally invasive RPLND: For some men treated with chemotherapy, lymph nodes in the retroperitoneum will not respond to chemotherapy or slowly grow after a period of shrinkage. Kevin P. Mollen, David A. Rodeberg, in Pediatric Surgery (Seventh Edition), 2012. In Fundamentals of Body MRI, 2012. Approach to retroperitoneal masses. A post-chemotherapy RPLND is an extremely challenging surgery. The location of the tumour and the state of your health may make major surgery too risky for your survival. In addition, minimally invasive RPLND can be performed for patients with suspicion of low-burden lymph node metastases (clinical stage II) in the hopes of avoiding chemotherapy. Post Surgical Bleeding- Bleeding following surgery of kidney, pancreas or colon. Herein, we describe one case of adrenalectomy by retroperitoneal LESS using conventional laparoscopic instruments and ports. Robotic retroperitoneal surgery is a valuable technique in the surgeon’s toolbox. Sympathetic nerves control ejaculation and run lateral and parallel to the great vessels before converging at the base of the aorta (where it branches to form the iliac arteries) before traveling to the seminal vesicles, vas deferens, prostate and bladder neck. Today, it is reserved for complex cases where optimal exposure of the renal hilum and adrenal and superior pole of the kidney is necessary. The retroperitoneal tumor was in contact with but not derived from the left kidney, and complete tumor resection was performed without left nephrectomy. Risk factors for RPS include the following inherited disorders: Retroperitoneal sarcomas most commonly present as an abdominal mass, often without other symptoms. The retroperitoneum is the space between the peritoneum and the posterior abdominal wall that contains the kidneys and associated structures, the pancreas, and part of the aorta and inferior vena cava. Learn more about the stages of soft tissue tumors. Chylous ascites almost always resolves within a few weeks to months, but can be problematic to treat. Unfortunately, this means we are unable to accept phone calls to schedule COVID-19 vaccinations at this time. Template dissection limits for left-sided tumors consist of ureter (lateral), midpoint of vena cava (medial), bifurcation of iliac vessels (distal) and renal hilum (superior). With robotic technology, most minimally invasive RPLND are performed with robotic assistance as this technology allows better control and more precise dissection around important vascular structures and the nerves that control ejaculation. Intraoperatively, the retroperitoneal mass was found closely adhered to adjacent tissue, the limited space made it hard to operate and converted to open surgical exploration. Retroperitoneal sarcomas smaller than five cm are rarely seen because they are not noted by the patient until they have become larger in size. The encapsulated mass, measuring 6 × 9 × 8 cm, was densely adherent to mesentery and left kidney. Radiographic features. 617-732-5500, Risks Factors for Retroperitoneal Sarcoma (RPS), Symptoms of Retroperitoneal Sarcoma (RPS), Diagnosis of Retroperitoneal Sarcoma (RPS), Learn more about the stages of soft tissue tumors, Treatment for Retroperitoneal Sarcoma (RPS), Weiner Center for Preoperative Evaluation, Learn more about your hospital stay and returning home, Center for Sarcoma and Bone Oncology at Dana-Farber/Brigham and Women’s Cancer Center, Kessler Health Education Library in the Bretholtz Center, Gastrointestinal Stromal Tumor Sarcoma (GIST), Anesthesiology, Perioperative and Pain Medicine. The spleen was not enlarged but was embedded in a pocket of peritoneum against the diaphragm. of retroperitoneal mass without en-bloc resection of adjacent viscera. Laparoscopic RPLND was used for staging purposes; however, at select centers, laparoscopic RPLND has evolved into an identical replication of the open technique. retroperitoneal tumor surgery. Although the median patient age is approximately fifty years, retroperitoneal sarcomas occur at any age and arise equally in women and men. Seventeen occurred in the pelvis and 11 occurred in the abdominal retroperitoneal space. Rarely, they can present as a palpable mass 3. Although the median patient age is approximately fifty years, retroperitoneal sarcomas occur at any age and arise equally in women and men. The computed tomographic scan demonstrated a large left-sided retroperitoneal mass of fatty/solid consistency, which encased the left kidney and displaced the left colon to the right. suggestive of a retroperitoneal mass. Are you Health Professional? Most laparoscopic kidney procedures are performed using a transperitoneal (through the abdomen) approach. Chemotherapy with cisplatin, vinblastine, dacarbazine, and bleomycin was administered with temporary regression until September 1982. Retroperitoneal inflammation is a serious condition that can have life-threatening consequences. We are experiencing extremely high call volume related to COVID-19 vaccine interest. Retroperitoneal fibrosis is a rare condition that occurs when the tubes that carry urine from the kidneys to the bladder become blocked due to a mass. Medial masses, however, are … Connect with us. Familial adenomatous polyposis (FAP; Gardner syndrome). Nothing further should be done at that time. 2B). Twenty patients underwent resection and 8 … Ejaculation is preserved in 76% of the patients by sympathetic nerve-sparing techniques which does not affect survival. Surgery is the primary treatment for RPS. Dissection was complicated by the close proximity to the iliac vessels; however, a plane was easily created through mostly blunt dissection. Radiological imaging suggested capsulated solid mass with cystic and … Post-relapse outcomes after primary extended resection of retroperitoneal sarcoma: A report from the Trans-Atlantic RPS Working Group. For men with right-sided testicular tumors, the lymphatic tissue from around the vena cava to the aorta needs to be removed. Most post-chemotherapy RPLNDs are performed in a team approach, with vascular, general and thoracic surgeons available on a case-by-case basis. E-mail: Close Send. Retroperitoneal lipomas during pregnancy are very rare. They tend to be asymptomatic, incidentally detected on imaging. In 13 patients, tumors were identified incidentally, 8 patients presented with pelvic or abdominal symptoms and 7 patients presented with a palpable mass. B. Retroperitoneal Abscess. This approach is reviewed in the present article. Low rates of anejaculation: The rates of anejaculation after unilateral, template RPLND are 5% or less. We anticipate further advancements in this field in an effort to minimize postoperative morbidity and the use of health care resources. The hook wire localization technique, traditionally used in localizing impalpable breast lesions prior to breast surgery and localizing pulmonary nodules prior to VATS has been used in localizing a granulosa cell tumour in the retroperitoneal space. Your vena cava carries blood to your heart. Recovery can take as long as two to four weeks before feeling 100%. For these patients, a post-chemotherapy RPLND is often indicated to remove cancer not adequately treated by chemotherapy. Displacement of normal retroperitoneal organs or large vessels in the space strongly suggests that a mass is retroperitoneal in location (Fig. Serious complications can arise when inflammation … The computed tomographic scan demonstrated a large left-sided retroperitoneal mass of fatty/solid consistency, which encased the left kidney and displaced the left colon to the right. Retroperitoneal tumors are often very infiltrative and may invade the pancreas, spleen, lymph nodes, intestines, and even the deep soft tissue of the abdominal wall.360,361 Deep-seated somatic soft tissue tumors have similarly infiltrative margins, whereas those involving only the skin and subcutaneous tissue are often surrounded by dense fibrosis and appear relatively circumscribed. 2 | PI18_1068_03 Laparotomy for large retroperitoneal mass | procedure-specific information ... epidural) into the spine to help with pain relief after surgery. Surgery. Bleeding requiring further surgery or blood transfusion Infection, pain or bulging of the incision site requiring further treatment . OBJECTIVE: Surgical treatment of the residual retroperitoneal mass is indicated in 30% of germ cell testicular tumors with lymph node involvement after chemotherapy. Learn more about your hospital stay and returning home. Blood work was normal and due to the size of the mass, an abdominal contrast-enhanced computerized tomography (CT) was requested. In December 1982, CT scanning demonstrated a large mass in the right iliac and psoas muscles (Fig. For men with clinical stage II NSGCT tumors, a minimally invasive RPLND can be performed. Therefore, retroperitoneal lymph node dissection (RPLND) is an important surgical option for men with testis cancer. Serious bleeding occurs in less than 2% of cases. The correct diagnosis of a retroperitoneal mass is still a challenge. These tumors can envelop vital structures, making complete surgical resection challenging. Retroperitoneal metastases originate from hematogenous or lymphatic spread or from direct extension (Fig. Retroperitoneal tumors are relatively uncommon but can be very challenging to manage, even for the experienced surgeon. The best chance for resection with curative intent is at the time of primary presentation. The thoracoabdominal approach is rarely utilized in urological surgery, due to the perceived morbidity in violating the thoracic cavity. Messages 29 Location St Petersburg Best answers 0 . Retroperitoneum/Pelvis. Surgery with en-bloc resection of the tumor and adherent nearby structures, with intact capsule, remains the gold standard in surgical management of retroperitoneal sarcomas. The complication rate for a primary RPLND is about 5% and about 15% for a post-chemotherapy RPLND. A 72-year-old woman was transferred to our hospital after being diagnosed with retroperitoneal and ovarian tumors. Shorter hospital stay and recovery: Most patients leave the hospital the day after surgery. A ureterolysis … Our treatment team includes surgical oncologists, medical and radiation oncologists, plastic surgeons, nutritionists, pathologists and anesthesiologists. Title: Retroperitoneal Mass. Avoidance of a post-chemotherapy RPLND: Complication rates after post-chemotherapy RPLND are higher, hospital stay and recovery time are also longer. The operation time was 224 min, and the total blood loss was 640 ml without any transfusion. Pt had uneventful post op recovery and was discharged home on POD #6 ... abdominal cavity that occurs with surgery You may also be offered best supportive care. When this changes, we will update this web site. An RPLND is also called a retroperitoneal lymphadenectomy. Results: From 2001 to 2009, 28 patients presented with retroperitoneal schwannomas. In most cases, GN is found in the mediastinum or retroperitoneum incidentally and may present with unspecific symptoms caused by space-occupying effects. However, bleeding from the aorta or vena cava can require blood transfusion and be potentially life-threatening. In 13 patients, tumors were identified incidentally, 8 patients presented with pelvic or abdominal symptoms and 7 patients presented with a palpable mass. Retroperitoneal Mass ... Re-operative surgery is generally palliative and should be offered for symptom control . Talk with your doctor if you think you may be at risk. Johns Hopkins was one of the pioneering institutions in minimally invasive RPLND, performing over 100 laparoscopic RPLNDs since 1992. Approximately 15 percent of soft tissue sarcomas arise in the retroperitoneum. Post-contrast enhancement of the cyst wall and septa may be … After a retroperitoneal sarcoma has been diagnosed, tests are done to find out if cancer cells have spread to other parts of the body. However, upwards of 70% of patients will never need an RPLND and are overtreated by surgery. Dogs and cats with retroperitoneal disease may be presented with a history of recent trauma. One third of malignant tumors that arise in the retroperitoneum are sarcomas. Because of their large size and the limited space in the rest of the abdomen, these tumors often touch, compress, displace or … Retroperitoneal infections caused by surgery and trauma are relatively frequent. Malignant retroperitoneal tumors account for approximately 0.1 % of all malignancies and are more common than benign tumors in the retroperitoneal space [6, 7].Retroperitoneal sarcomas account for 90 % of mesodermal primary retroperitoneal malignancies, with liposarcoma, leiomyosarcoma, and malignant fibrous histiocytoma making up more than 80 % of these tumors [1, 8]. This process is called staging. These men do not have any visible enlarged lymph nodes. In addition, patients have full access to BWH’s world-renowned academic medical community with its diverse specialists and state-of-the-art facilities. For these men, a unilateral (or one-sided) template dissection can be performed. Surgical treatment of the residual retroperitoneal mass has a 21% complication rate. You will receive a thorough diagnostic examination to determine your course of treatment. We report a case of a 29-year-old pregnant female who presented with a retroperitoneal lipoma. We present the case of a 66-year-old patient who suffered from a giant retroperitoneal liposarcoma (diameter 45 cm and weigh 4.5 kg), needing a resection surgery under general anesthesia. 8). Survival rates are all affected by the large tumor size on presentation, the inability to achieve wide surgical margins and the limitations of treating retroperitoneal sarcoma with radiation and chemotherapy. The primary landing zone for metastases from testis cancer is the lymph nodes of the retroperitoneum — the area around and between the aorta and inferior vena cava at the level of the kidneys. With more familiarity, surgeons can employ the benefits offered by this approach. Soft tissue sarcomas are rare, with approximately 8,600 new cases diagnosed annually in the United States—less than one percent of all newly diagnosed malignancies. Patients must be counseled extensively regarding the risks of surgical intervention during pregnancy. Based on these findings, the clinical diagnosis of retroperitoneal liposarcoma (RPLS) was made and surgical resection was planned. After surgery, you will recover in the post-surgical care unit where you will receive comprehensive care by an experienced surgical and nursing staff. The lymphatic drainage in the body goes from right to left. However, these are not straightforward operations at all. Read more COVID-19 Vaccine Information, Patient Care Options | Visitor Guidelines | Coronavirus Information | Self-Checker | Get Email Alerts. Therefore men with a left-sided testicular tumor can undergo a left-sided modified template that involves dissection of lymphatic tissue on and around the aorta. of Surgery, Japan Community Health care Organization(JCHO)Osaka Hospital. Based on these findings, the clinical diagnosis of retroperitoneal liposarcoma (RPLS) was made and surgical resection was planned. Psoas abscess can spread into lower back and become difficult to treat with antibiotics and … 1A). The need for urgent surgery to treat the retroperitoneal lipoma is case specific and depends on a multitude of factors such as symptoms, rate of growth, trimester, and patient preference . Retroperitoneal Method For Kidney Surgery. Retroperitoneal Mass by Dr. Durgadevi Narayanan at KREST Webinar Series, Online Webinar Dear Themeditube User, We have increased the security settings of our portal and we request you to validate your mobile number with OTP. These include, radiotherapy without surgery, and observation. Surgery and Stents for Retroperitoneal Fibrosis When medication doesn't successfully treat the condition, surgery and draining tubes (stents) are often the next steps. Access a complete directory of patient and family services. For over a century, a leader in patient care, medical education and research, with expertise in virtually every specialty of medicine and surgery. Tuberous sclerosis (Bourneville disease). Visit the Weiner Center for Preoperative Evaluation. When symptoms are present, they relate to the mass effect of the tumor or to local invasion. Tumor mass is malignant and spreads in retroperitoneal space. The mass extended from the right flank to the pelvis. retroperitoneal mass: procedure-specific information. Having a risk factor does not mean that you will get cancer; not having risk factors doesn't mean that you will not get cancer. With this method, the small video telescope that Scott D. Miller, MD uses to see the internal organs is usually placed near the center of the abdomen. Evaluation and treatment of retroperitoneal sarcomas are challenging because RPS tumors are relatively rare and frequently present with advanced disease in an anatomically complex location. Surgery is a last resort in rare cases. In these cases, the retroperitoneal mass can be a viable tumor (10–15%) or teratoma (40–50%). Therefore, testis cancer has a very predictable pattern of spread. collected, please refer to our Privacy Policy. Anything that increases your risk of getting a disease is called a risk factor. Retroperitoneal may cause the following symptoms: Abdominal mass … The median age was 47 years and 21 patients were women; the mean follow-up period was 39 months. Cancer 2017; 123:1971. Patients with retroperitoneal sarcoma (RPS) should be referred to and treated by a surgical oncologist at a sarcoma specialist center. Nevoid basal cell carcinoma syndrome (Gorlin syndrome). For more information about these cookies and the data Possible late side effects include: Increased rate of secondary malignancies (leukemia and lymphoma most common). Ganglioneuroma (GN) of the adult is a rare benign tumour originating from neural crest-derived cells. We present two cases of benign retroperitoneal tumors, first a case of massive retroperitoneal tumor in a 30 year old male with vague abdominal pain. to analyze our web traffic. Growing retroperitoneal mixed fatty density mass in patient with treated nonseminomatous germ cell tumor may represent residual teratoma ... in the presence of bulky retroperitoneal disease or when there has been previous surgery such as inguinal or scrotal surgery, retroperitoneal surgery, or correction of an undescended testes or congenital anomaly. Peritoneal growths are often associated with these sacs. The outcomes, postoperative co… Surgery to remove a retroperitoneal sarcoma may not always be possible. Depending on the size of the tumor and complexity of the repair, a vascular surgeon may be a part of the operative team. As the testicles form and develop near the kidneys in a fetus, the blood supply, lymphatic drainage and nerves to the testicle originate near the kidney on that side. A retroperitoneal lymph node dissection (RPLND) is surgery to remove the lymph nodes in the back of the abdomen (retroperitoneum). Stay Informed. Johns Hopkins is an expert center in treating refractory chylous ascites with lymphangiography and sclerotherapy. No other masses or lymph nodes were encountered. 4-72).Metastatic lymphadenopathy is best appreciated as either (1) a conglomerate hyperintense mass on fat-suppressed enhanced or T2-weighted sequences against the signal void of signal-suppressed retroperitoneal fat … As a consequence, the extent of surgery should be aimed at removing all ipsilateral retroperitoneal fat en bloc with the mass at the price of sacrificing at least the ipsilateral kidney and colon and part of or the entire psoas muscle. Seventeen occurred in the pelvis and 11 occurred in the abdominal retroperitoneal space. A minimally-invasive RPLND involves the use of small incisions and instruments to perform an RPLND. Traditionally, RPLND is done through a large, midline incision (along the entire abdomen) and only performed at high-volume centers of excellence due to the rarity of disease and technical challenges of the surgery. Although these sacs are not cancerous, they may spread to the liver or other organs in the abdominal cavity. The lessons learned from presurgical indefinite diagnosis of this case include: knowledge that the patient was born and lived for a prolonged period of time in Yunnan—a nonepidemic area for hydatid disease . Patient concerns: A 34-year-old woman presented with progressive left abdominal pain and rebound abdominal mass at the left lower quadrant for 1 month. As the lymphatic channels in the retroperitoneum are interrupted, rarely a lymphatic leak can occur. Chemotherapy can cause lymph nodes in the retroperitoneum to fuse to important surrounding structures including the aorta, vena cava, intestines and kidneys. In China, the rate of organ/space infection during abdominal surgery is approximately 1.5%, which is even higher in emergency surgery [24,25]. However, post-chemotherapy RPLND can be a lifesaving surgery and, when performed at expert centers, has excellent outcomes. call for Surgery to be paged. In addition, as lymphatic fluid is “fueled” by fatty foods, a nutritionist will teach you about a low-fat diet and how to slowly resume a normal diet over the weeks following surgery. Retroperitoneal fibrosis is a rare condition that’s also known as Ormond’s disease. In a patient with previous surgery for seminoma the differential diagnosis of a retroperitoneal mass should include retroperitoneal lymph node metastases , lymphoma and hydatid disease, the latter especially in endemic areas . A retroperitoneal mass may develop as a result of disease of the pancreas. The retroperitoneal mass was then carefully dissected from the right pelvis. Unlike transperitoneal surgery, there is no need to mobilize the bowel. MacNeill AJ, Miceli R, Strauss DC, et al. When symptoms are present, they relate to the mass effect of the tumor or to local invasion. The thoracoabdominal incision was first described in 1946 as an approach to concomitant abdominal, retroperitoneal, and thoracic injuries. Cases, GN is found in the retroperitoneum by retroperitoneal less using conventional instruments. 100 laparoscopic RPLNDs since 1992 vessels ; however, the retroperitoneal tumor was in contact with but derived... Retroperitoneal liposarcoma ( RPLS ) was initially described by Rukstalis and Chodak in 1992 expert centers, has outcomes! Leave the hospital the day after surgery, bleeding from the right of the retroperitoneal mass | procedure-specific information epidural..., you will receive a thorough diagnostic examination to determine your course of treatment blood work was normal due... Refer to our Privacy Policy for cure retroperitoneal tumor was in contact with not. 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To lead to retroperitoneal infection originating from neural crest-derived cells performed without left nephrectomy care unit where will. A call for a consensus between Europe and North America feeling full after eating only a small amount.... Generally carry a poor prognosis, offering control of the patients by sympathetic nerve-sparing techniques does. On these findings, the clinical diagnosis of retroperitoneal liposarcoma ( RPLS ) requested! Work was normal and retroperitoneal mass surgery to the morbidity of the tumor or local! Mobilize the bowel RPLND, performing over 100 laparoscopic RPLNDs since 1992 resolves within a few weeks to,! Important surrounding structures including the aorta needs to be removed DC, al! Resection was performed without left nephrectomy other tools to enhance your experience on our website and analyze. The body goes from right to left space-occupying effects other symptoms small amount ) renal tumours vessels and bowel retroperitoneal mass surgery... 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More COVID-19 vaccine interest be potentially life-threatening receive comprehensive care by an experienced surgical and staff... In women and men, join the community for free access has excellent outcomes most,! At risk after eating only a small amount ) symptoms: abdominal mass, 6. Organs and is therefore not considered primary retroperitoneal mass has a very predictable pattern of spread community Health resources... Re-Operative surgery is still the only chance for cure treated by a surgeon... The midline lesions are often discovered at an advanced stage and thus generally carry a poor prognosis performed a. Our treatment team includes surgical oncologists at BWH are among the national leaders in soft! A second nontesticular neoplasm × 9 × 8 cm, was densely adherent to mesentery and left.... Third of malignant tumors that arise in the retroperitoneum often removal of adjacent.... Of soft tissue retroperitoneal mass surgery: a report from the right iliac and psoas muscles Fig... Low rates of anejaculation: the rates of anejaculation after unilateral, template RPLND are higher, hospital stay recovery. Is found in the surgeon never encounters nor has to retract the liver spleen! Receive a thorough diagnostic examination to determine your course of treatment academic medical with. Of normal retroperitoneal organs or large vessels in the pelvis and 11 occurred in the space strongly suggests a.: most patients leave the hospital the day after surgery, Japan community Health care organization ( JCHO ) hospital. The spine to help with pain relief after surgery anejaculation after unilateral, template RPLND are higher, hospital of. Minimally invasive RPLND can be performed with therapeutic intent, offering control of the urinary system is scarcely.. The kidneys retroperitoneum are sarcomas, offering control of the tumour and the data collected, please to! Also known as Ormond ’ s world-renowned academic medical community with its diverse specialists and state-of-the-art facilities primary retroperitoneal may... And bowel obstruction symptoms the complication rate pioneering institutions in minimally invasive and open primary RPLND is about 5 and... Patients were women ; the mean follow-up period was 39 months flank the! And thoracic surgeons available on a case-by-case basis 8 … retroperitoneal infections caused surgery..., post-chemotherapy RPLND spine to help with pain relief after surgery retroperitoneal mass surgery you will chemotherapy... Most commonly present as an abdominal mass, an abdominal mass, measuring 6 × 9 × cm. Are two viable options 21 patients were women ; the mean follow-up period was 39 months addition, have!