Intervention group (RA with renal‑rotation techniques)
tumor, pheochromocytoma, fibrous
RENAL, TUMOR, PHEOCHROMOCYTOMAS, DECUBITUS, URETER, KIDNEY, GIANT, CREST
The patients were placed in the full-flank lateral decubitus position and intubated by the anesthesia team. The surgeon stood facing the patient’s back. The retroperitoneal space was set up by finger dissection, and a three-port (or four-port) channel was established, as shown in Fig. 
Diagrammatic sketch of ports location and renal-rotation strategy(A) A 2-cm incision is made between the tip of the 12th rib and the iliac crest, then a 12 mm port is placed in the incised site (a); The second 12 mm port is placed 2 cm above the anterior superior iliac spine (b); The third 12 mm port is placed 3 to 4 cm medial and slightly inferior to the first port in the anterior axillary line (c); An alternate site (d) for 5 mm port can be added in the midpoint between a and c sites. (B) The renal rotation processes in the front view of coronal plane. (C) The renal rotation processes in the lateral view of sagittal planeFor right-sided GP (exemplified in Fig. 
Preoperative imaging data of a patient with typical right-sided giant pheochromocytoma(A) The maximum diameter of the tumor is 9.3 cm. (B) The right kidney is squeezed by the tumor and displaced. (C) The front view of the 3D anatomical location of the tumor. (D) The rear view of the 3D anatomical location of the tumor
Renal mobilization and tumor exposure surgical processes of a patient with typical right-sided giant pheochromocytoma (A) Gerota’s fascia was adequately incised, incision upper bound reached the diaphragmatic crura. (B) Incision lower bound was down to the middle ureter level, to fully expose the entire kidney and lesion area. (C) Dorsal side of kidney was dissociated along the psoas major fascia, the renal pedicle area and inferior vena cava were carefully exposed. (D) Ventral side of kidney was subsequently dissected, and tumor was progressively exposed. (E) Dragging down the kidney while dissecting its upper pole, then sealing the exposed nourishing vessels in the tumor surface with harmonic scalpel. (F) As the dissection progressed, the kidney had automatically tilted under the influence of gravityRotation of the kidney was then conducted in two steps. First, the kidney was dragged downward as far as possible, causing the upper pole to descend adequately (Fig. 
Renal rotation and tumor resection surgical processes of a patient with typical right-sided giant pheochromocytoma (A) Kidney was laid horizontally in the direction of its inclination to provide ample space and excellent field view for tumor resection. (B) The fibrous tissue was dissected along the vena cava to expose the central adrenal vein which was then controlled by Hem-O-Loks. (C) Neoplastic vasa vasorum usually crisscrossed in the base of tumor, and renal rotation offered sufficient space for exposing and sealing these basal vessels. (D) After the thorough dissociation of tumor’s basal part and two flanks, upper pole of tumor was finally dissected. (E) After the tumor was completely freed, it was placed in a plastic retrieval bag and extracted. (F) Finally, the kidney was rotated back to its original position and the surgery was finishedFor the left-sided GP ( Fig. 
Preoperative imaging data of a patient with typical left-sided giant pheochromocytoma (A) The maximum diameter of the tumor is 10.5 cm. (B) The left kidney is squeezed by the tumor and displaced. (C) The front view of the 3D anatomical location of the tumor. (D) The rear view of the 3D anatomical location of the tumor
Renal mobilization and tumor exposure surgical processes of a patient with typical left-sided giant pheochromocytoma (A) Gerota’s fascia was adequately incised, incision upper bound reached the diaphragmatic crura. (B) Incision lower bound was down to the middle ureter level, to fully expose the entire kidney and lesion area. (C) Dorsal side of kidney was dissociated along the psoas major fascia, the renal pedicle area was carefully exposed. (D) Dragging down the kidney while dissecting its upper pole, then sealing the exposed nourishing vessels in the tumor surface with harmonic scalpel. (E) The kidney was fully mobilized by circumferentially dissecting its each side. (F) As the dissection progressed, the kidney had automatically tilted under the influence of gravity, and the tumor was progressively exposed
Renal rotation and tumor resection surgical processes of a patient with typical left-sided giant pheochromocytoma (A) Kidney was laid horizontally in the direction of its inclination to provide ample space and excellent field view for tumor resection. (B) The fibrous tissue was dissected along the renal vein to expose the central adrenal vein which was then controlled by Hem-O-Loks. (C) Neoplastic vasa vasorum usually crisscrossed in the base of tumor, and renal rotation offered sufficient space for exposing and sealing these basal vessels. (D) After the thorough dissociation of tumor’s basal part and two flanks, upper pole of tumor was finally dissected. (E) After the tumor was completely freed, it was placed in a retrieval bag and extracted. (F) Finally, the kidney was rotated back to its original position and the surgery was finishedAfter complete dissection of the tumor, the tumor body was removed (Figs. Corresponding surgical videos of right-sided and left-sided GP can be seen on 