Laparoscopic Retroperitoneal Extirpative and Reconstructive Renal Surgery *

Abstract

Retroperitoneal laparoscopy for renal surgery is a viable and versatile alternative to transperitoneal access. Location of the kidneys in the retroperitoneum makes it an attractive approach. The development of both approaches paralleled during the last two decades; however, retroperitoneal laparoscopy witnessed a steep learning curve because of the constraint of working space, lack of obvious landmarks, and appropriate instrumentations. This approach has several advantages and is currently being used for extirpative and reconstructive procedures for various renal pathologic conditions. After creation of retroperitoneal space, the techniques can be tailored to the desired indication for successful culmination. The learning curve can be shortened by adequate training; subsequently, with experience, this can be used proficiently.

Introduction

T he development of retroperitoneoscopic surgery has been very interesting. Wickham performed a retroperitoneoscopic ureterolithotomy,¹ and Clayman and associates² performed endoscopic ureterolithotomy via the retroperitoneal approach, creating interest in this access. The report of the first transperitoneal laparoscopic nephrectomy by Clayman and coworkers³ spurred interest in exploration of the retroperitoneal approach. The description of the balloon technique of retroperitoneal dissection by Gaur,⁴ however, rekindled interest in this approach.

The retroperitoneum is a potential space necessitating creation of space to work in this area, thus leading the way for retroperitoneal laparoscopy to gain access to the kidneys. In last two decades, several refinements have taken place, and it has become as an established surgical technique.

Surgical Anatomy of the Retroperitoneum

The retroperitoneum is bounded anteriorly by the peritoneal cavity and its contents, superiorly separated from the thorax by the diaphragm, and is contiguous with the extraperitoneal portions of the pelvis inferiorly. The posterior abdominal wall forms the posterior and lateral limits of the retroperitoneum. The lumbodorsal fascia originates from the lumbar vertebrae from the posterior midline and extends anterolaterally. The lumbar or the Petit triangle is located in the posterior part of the abdominal wall and is bounded anteriorly by the posterior margin of the external oblique, posteriorly by the anterior border of the latissimus dorsi muscle, and inferiorly by the iliac crest. The floor of the triangle is formed by the internal oblique and the transversus abdominis muscles. This area can be used for gaining direct access to the retroperitoneum.

The posterior surface of the retroperitoneum is flanked bilaterally by the psoas muscles. The psoas muscles are covered by a glistening white fibrous fascia, the psoas sheath, which is contiguous with transversalis fascia. As one moves laterally, the lateral portion of the quadratus lumborum extends behind the lateral margin of the psoas. The anterior layer of the lumbodorsal fascia covers this muscle.

The kidneys and the adrenal glands are surrounded by perirenal fat, and these together are loosely enclosed by the Gerota fascia. The anterior and posterior leaves of the Gerota fascia, which extend anterior and posterior to the kidney, become fused on three sides around the kidney laterally, medially, and superiorly, but not inferiorly.

Techniques of creation of retroperitoneal space

The creation of retroperitoneal space is the most important and integral part of laparoscopic retroperitoneal surgery, and successful culmination of the procedure depends on this step. Several authors have described their own modifications:

Guar technique

In the Gaur⁴ technique, the patient is placed in the lateral decubitus position. A 1-cm skin incision is made immediately below the costal margin just posterior to the midaxillary line. A clamp is used to bluntly enter the retroperitoneum through the two layers of lumbodorsal fascia, and the fascial opening is spread. A 10-mm access port with a blunt obturator is inserted into the retroperitoneum. A 10-mm laparoscope is passed through the access port, and the tip of the laparoscope is used to bluntly dissect the space under direct vision. Once adequate space is created, a preprepared retroperitoneal dissecting balloon is passed through the port. The balloon is removed, and CO₂ insufflation is begun through the access port. Using this technique, authors performed nephrectomy and reported.⁵

McDougall and colleagues

These investigators⁶ described that a 1.2-cm incision is made just superior to the iliac crest over the Petit triangle and a Veress needle is placed through two layers of fascia (transversalis and lumbodorsal) into the retroperitoneum. Insufflation with CO₂ is begun, and a 10-mm access port is placed into the retroperitoneal space; a preprepared retroperitoneal dissecting balloon is passed through the port. The balloon is inflated with 1 L of saline and then it is emptied. After removing the balloon, CO₂ inflation is begun through the access port.

Gill and associates

These authors⁷ reported that a 1.5 to 2 cm incision is made immediately anterior to the tip of the 12th rib. The posterior lumbodorsal fascia is incised between stay sutures, muscle layers are bluntly separated, and anterior lumbodorsal fascia is incised under vision. The fingertip is then inserted through the incision; the lower pole of the kidney is palpated, and a retroperitoneal space is created. A dissecting balloon is passed into the space and inflated to 1 to 1.2 L and emptied after 5 minutes.

Rassweiler and coworkers

The authors⁸ prefer to make a 1.5-cm skin incision between the 12th rib and the anterior superior iliac spine, between the lateral rim of the latissimus dorsi and the external oblique. A clamp is used to bluntly enter the retroperitoneum through the fascia. A “balloon-trocar sheath” is prepared with the dissecting balloon attached to a 10-mm access port. A 10-mm laparoscope is passed into the balloon-trocar sheath. The laparoscope and balloon-trocar sheath are placed into the retroperitoneal space under laparoscopic vision. The balloon is filled with 900 to 1200 mL saline in adults and emptied after 5 minutes.

Hemal

I prefer⁹ to position the patient in the lateral flank position, which is further opened up by flexing the table and a tilt toward the anterior side, allowing the peritoneum and its contents to fall off anteriorly. A 1.5 to 2 cm incision is made 2 cm below and posterior to the tip of the 12th rib in the posterior axillary line; however, this can be changed according to the need, nature of surgery, build, and body habitus of the patient. Subsequently, it is depended down to thoracolumbar fascia. The incision is deepened, taking care that subcutaneous and muscular planes are not separated. This step helps in preventing surgical emphysema.

The retroperitoneal space is entered by sharp incision with a knife, and a finger is used to bluntly dissect the area to create a small retroperitoneal space for placing the balloon to create the retroperitoneal space. In some cases after incising the thoracolumbar fascia, the initial space to harbor the balloon was created by a Hegar or Clutton dilator; alternatively, digital dissection can be undertaken. A balloon is made from two fingerstalls of size 7.5 to 8 latex glove, sleeved one inside the other, over a 20F red rubber catheter. The catheter is advanced well into the base of the balloon to help early and prompt deflation of the balloon. The balloon is inflated with 500 to 600 mL of water once directed superiorly and then inferiorly to create retroperitoneal space. The balloon is left inflated for at least 5 minutes to ensure hemostasis.

The other alternative to use commercially available trocar mounted balloon (OMS-PDB 1000, Autosuture,™ Tyco Healthcare, U.S. Surgical, Norwalk, CT) in place of the indigenous one. This balloon device is placed in the retroperitoneum, and air is insufflated inside it using a bulb device; each thrust pumps about 20 to 30 cc air, and up to 500 to 800 cc air is instilled. The balloon dilation can be done toward the superior and inferior pole of the kidney, outside or inside the Gerota fascia. The biggest advantage of the trocar mounted balloon is that a laparoscope can be passed inside the transparent balloon and the creation of space can be watched and expanded according to the need; it also helps in easy visualization of retroperitoneal landmarks, such as the psoas muscle, Gerota fascia, ureter, gonadal vein, and diaphragm. If using a reusable port or the incision has become inadvertently bigger and there are chances of leakage of gas, then stay sutures are taken after balloon deflation, including skin, subcutaneous tissue, muscle, and thoracolumbar fascia, to close the dead space and thus prevent surgical emphysema from the primary port site; also, a port can be anchored. A 10-mm blunt tip trocar—BTT (Blunt tip trocar, Autosuture, ™ Tyco Healthcare, U.S. Surgical, Norwalk, CT)—is placed as a primary port, which has a round internal retention balloon and an external sponge cuff that can be cinched down to create an airtight seal at the primary wound site; carbon dioxide is now connected to create a pneumoretroperitoneum of 15 mm Hg.

Indications and Instrumentation

Retroperitoneal laparoscopy has been used for a variety of surgical procedures on the kidney (Table 1). This access can be used for any procedure on the kidney, but relative contraindications are very large renal tumor, morbidly obese patient, dense perirenal adhesions, and a patient with previous retroperitoneal surgery. Other contraindications for this approach are the same as for laparoscopic surgery described in other articles in this issue. There is no specific instrumentation needed for this accept for the balloon and primary port, which has been mentioned above.

Table 1.

Indications

Extirpative Laparoscopic Retroperitoneal Renal Surgery

A. Nephrectomy for benign nonfunctioning or poorly functioning kidneys (NFK) because of:

• Small atrophic or hypoplastic kidneys

• Ureteropelvic junction obstruction

• Kidney or ureteral urolithiasis

• Tuberculosis

• Congenitally anomalous kidneys

• Post-transplant patients having source of infection

B. Nephroureterectomy for benign NFK because of:

• Ureteral stones

• Ureteral strictures

• Ureteral reflux

• Megaureter

C. Renal cyst/renal cystic disease necessitating ablation or marsupialization or decortication

D. Radical nephrectomy for malignant conditions

E. Radical nephroureterectomy with excision of cuff of bladder for upper tract transitional-cell carcinoma

F. Lymphadenectomies

G. Removal of native kidney in pre- or post-transplant patients for benign, infective, and malignant pathologies

H. Renal biopsy, cryoablation, radiofrequency ablation

B. Reconstructive Laparoscopic Retroperitoneal Renal Surgery

I. Donor nephrectomy for renal transplantation

J. Pyeloplasty

K. Pyelolithotomy, extended pyelolithotomy, and anatrophic nephrolithotomy

L. Partial nephrectomy

M. Ureteric reimplantations/reconstruction of megaureter/retrocaval ureter/ureteric stricture

N. Chyluria

Preoperative Workup

A standard preoperative workup is performed with attention to the patient's cardiorespiratory and medical conditions. Blood profile, coagulation, and imaging studies are conducted as per requirements. Based on health issues, a consultation with a cardiologist or other physician and a preoperative assessment by the anesthesiologist before surgery may be necessary.

Preoperative Preparation

It is important to stop blood thinners before surgery unless it is necessary. I recommend that the patient take a Fleet or glycerine enema the night before and early in the morning before coming to the hospital. The patient is instructed to have nothing to eat or drink after midnight of the night before surgery.

Surgical Steps

Step 1. Patient position and establishment of retroperitoneal space

Under general anesthesia, after placement of a nasogastric tube and a Foley catheter, the patient is placed in a full lateral decubitus position (flank) with the diseased kidney up. The affected side is hyperextended by elevating the kidney bridge of the operating table or placing a roll underneath to increase the space between the costal margin and the iliac crest. A tilt toward the anterior side allows the peritoneum and its contents to fall off anteriorly. A 1.5 to 2 cm skin incision is given below and posterior to the tip of the 12th rib or below the 12th rib in the posterior axillary line in the flank and is deepened down to the layer where the space is to be created. This could be inside the Gerota fascia for benign lesions or outside it for malignant ones.

Cost-reductive indigenous technique involved the use of a balloon made from the finger stalk of a surgical glove tied over a tube that was connected to a pneumatic pump of a blood pressure apparatus, or progressive distention of this balloon using either air or water creates a working space by separating the retroperitoneal loose alveolar tissue. All these techniques were found to be simple, safe, and effective. Fluid distention probably allows better dissection of the retroperitoneum than gas because of the lower compressibility of fluid. This balloon, however, can rupture, and water can spill into the retroperitoneum, compromising vision initially. It is also important to remove a ruptured latex piece of the balloon, if seen in the retroperitoneal space.

The balloon distention devices are now commercially available from a number of surgical device manufacturers. These have the additional advantage of being trocar mounted, which allows simultaneous insertion of a telescope and direct visualization of the operative field while the distention is taking place; this allows monitoring of the creation of space.

Step 2. Placement of ports

The primary port is invariably placed through the incision made for creation of the working space. The location for this incision may be both just below and posterior to the tip of the 12th rib or the inferior lumbar (Petit) triangle. A care is taken to make the primary incision small to prevent leakage of gas and snuggly allowing the port to stay in position. If you are using a reusable metal cannula, then it should be fixed with the retention suture to prevent port extrusion and leakage of gas. BTT provides excellent fixation and helps decrease the chances of subcutaneous emphysema; also, there is more space in the retroperitoneum, because the tip of the cannula abuts inside the abdominal wall.

Once the primary port is established, carbon dioxide pneumoretroperitoneum (12 to 15 mm Hg) is maintained, and a laparoscope may be inserted to visualize the dissection to place secondary ports; if needed, further dissection can be performed under endoscopic vision. Secondary trocars are usually placed using one of two techniques. It is preferred, however, to place these under endoscopic vision after insertion of the laparoscope. This helps ensure that we do not transgress the peritoneum or injure adjacent organs. Hence, it is important to move the peritoneum away from the undersurface of the anterior abdominal wall to avoid transgression of the peritoneum while placing secondary ports. The other alternative is a bimanual technique⁹ using finger guidance for secondary trocar placement.

It is important to reflect the peritoneum off the anterior abdominal wall to avoid transgression of the peritoneum. The placements of secondary trocars are dictated with the indication for surgery and the patient's body habitus. The most common configuration uses two secondary trocars—one in the renal angle, one in the anterior axillary line; additional trocars can be placed as per requirement. The strategic port placement is more important to provide dexterity and ergonomic movements of instruments by the surgeon in the retroperitoneal approach than the transperitoneal because of the limited working space.

Technique of Retroperitoneal Laparoscopic Nephrectomy (RPN) for Benign Diseases with Subtle Modifications for Different Conditions

Basic principles for RPN

This is one of the most common indications that include a wide variety of pathologies, including ureteropelvic junction obstruction, hypoplastic, dysplastic, nonfunctioning kidneys from ureteral obstruction, and infective pathologies, such as nonfunctioning kidneys from stone disease, pyonephrosis, xanthogranulomatous pyelonephritis, and tuberculosis. There is some variation in surgical technique in each of these diseases. Identification of the kidney is the first step in all RPN procedures. This can be done by identifying the retroperitoneal landmarks, such as psoas muscle (kidney lies above it), gonadal vein, or the ureter, and these can be traced up to the renal hilum.

Once the retroperitoneal space is created, an incision is made in the transversalis or Gerota fascia parallel to the psoas muscle to expose the renal hilar area and to observe renal artery pulsation. In patients with minimal inflammation and kidneys that are not exceptionally large, the preferred approach is to directly access the renal vessels; the renal artery is first to be encountered.¹⁰ Once the renal artery is visualized, we place an extra-large Hem-o-lok clip before further dissection. This step helps to decrease bleeding while further dissection is performed. If it is easy to perform hilar dissection, then the renal artery is first clipped and divided and is followed by the vein. This may be done outside the Gerota fascia for inflammatory conditions, because it is difficult to dissect from perihilar tissue (tubercular kidney, pyonephrosis, stone disease). The kidney is subsequently mobilized, sparing the ipsilateral adrenal gland, followed by clipping and dividing the ureter.

Modifications for hydronephrotic kidney

In patients with hugely dilated kidneys, it is important to avoid puncturing the kidney during the initial port placement. After the initial incision is made in the flank, digital dissection is used below the thoracolumbar fascia to create the initial space. Once the balloon is placed, it should not be distended more than 300 to 500 mL. Sometimes, space can be created using metal dilators. In these cases, dissection of the kidney is performed first, because the tense hydronephrosis prevents access to the renal hilum. Renal dissection, on the other hand, is easier because of obvious visualization.¹¹ Once reasonable initial dissection is performed, the kidney is deflated by puncture and suctioning the content out. Thereafter, tackling the renal vessels is easier, and the deflated kidney can be manipulated as per need. If necessary, a pole of the kidney may be brought out through one of the port sites by extending the incision for extracorporeal retraction; otherwise, use of the fourth arm allows free manipulation in robot-assisted surgery. This step allows intracorporeal countertraction for dissection and mobilization.¹²

Modifications for congenital anomalous kidneys

While a CT or angiography may aid in preoperative identification of the vascular supply of anomalous kidneys, these investigations are not a must. A careful dissection of the hilar area allows safe identification of aberrant vessels. The magnification provided by the robot helps identify even smaller vessels before they cause troublesome bleeding. In cases of horseshoe kidneys, even isthmusectomy is possible without many difficulties. Intracorporeal isthmusectomy may be performed after tying the isthmus with intracorporeal suturing; ultrasonic scalpel or bipolar energized devices with cutting mechanism can also be used for dividing the isthmus.^13,14

Modifications for tuberculous kidney

Tubercular nonfunctioning kidneys have been considered relatively difficult for RPN. This is predominantly because of dense perinephric adhesions and fibrosis, which preclude safe and easy dissection. Conversions are because of excessive bleeding and poor progress. We modify our technique of RPN for such cases. The balloon is inflated outside the Gerota fascia, lifting the kidney off anteriorly. Because the adhesions are perinephric, this space is likely to be better to dissect the renal hilum, and pulsation of the renal artery can be seen from the posterior aspect; once the renal artery is seen, a Hem-o-lok clip is applied before further dissection. This decreases the bleeding encountered during the subsequent dissection. Once both renal vessels are clipped and divided, then the kidney is mobilized. It is also important to excise the ureter as low as possible even if it is not inflicted, because it may avoid unfurling subtle disease in the ureter. The blood loss and complications were significantly lower by RPN, with a shorter hospital stay and analgesia requirement than the open surgery group.¹⁵

Modifications for bariatric patients

Despite initial circumspection about performing laparoscopy in bariatric patients, RPN can be performed well. Creation of the retroperitoneal space in this group is a bit challenging because of the large amount of fat; often retroperitoneal landmarks may not be very obvious. The biggest advantage of this approach, however, is that the peritoneum keeps the fat-laden bowel mesentery and omentum away from the site of surgery. The majority of the fat is located in the pannus, which, in any case, shifts anteriorly during the lateral positioning with anterior tilt. Normal ports or, if needed, bariatric ports can be used.¹⁶

Modifications for RPN in patients with renal stones, pyelonephritis, or other inflammatory conditions

The technique in these patients varies with the degree of perinephric inflammation encountered. In the absence of significant adhesions, we prefer to place the balloon below the Gerota fascia, because this allows rapid and easy dissection of the kidney. The hilum is then approached and the vessels clipped and divided. In patients with a history of pyelonephritis or renal scarring, the approach is usually similar to that described for tubercular nonfunctioning kidneys.¹⁷ The hilar vessels are approached first to minimize bleeding during the subsequent dissection of the kidney. It is important to avoid puncturing the kidney during mobilization lest infected material spill in the retroperitoneal space; if this happens, then copious lavage with antibiotic solution is recommended. In pyonephrotic, infective hydronephrotic kidneys, diversion of urine with placement of a nephrostomy tube allows inflammation and edema to subside and subsequently makes removal of the kidney less difficult. If a kidney is badly stuck with the Gerota fascia and to the colon, then a subcapsular nephrectomy or staying out of the Gerota fascia helps to avoid injury to the bowel and contiguous structures.

A patient with pyonephrosis is fraught with the possibility of injury to vital organs, and one should be very careful to avoid such cases in the initial experience of RPN.¹⁶ In all patients who need subcapsular nephrectomy, initial hilar vessels control helps to decrease bleeding in separating out the kidney from the surrounding structures. The retroperitoneal approach allows a thorough washing with antibiotic solution without contaminating the peritoneal cavity when spillage occurs. If the patient has a nephrostomy tube, it needs to be removed before surgery, because it prevents creation of the retroperitoneal space.¹⁸ Most of the time, the tract was disrupted while creating the retroperitoneal space, but occasionally, the fibrotic tract had to be divided with ultrasonic or monopolar current.

Retroperitoneoscopic donor nephrectomy

While most centers prefer to perform this surgery transperitoneally, the retroperitoneoscopic route has been shown to be effective and safe. A three- or four-port approach is generally used. The kidney is initially completely mobilized before mobilization of the hilar vessels. An incision for retrieval is preplaced either in the flank or in the iliac fossa. The vessels are then ligated or clipped or stapled, and the specimen is retrieved through the incision.¹⁹

Retroperitoneoscopic Nephrectomy for Native Kidney in Transplant Patients

Retroperitoneoscopic nephrectomy should also be offered as a standard treatment modality to patients needing pretransplant or post-transplant native kidney nephrectomy for different indications.²⁰

Nephroureterectomy

While performing nephroureterectomy for benign indications, in addition to three standard ports, a fourth port is usually needed medial to the anterior superior iliac spine. After mobilization of the kidney, the table is tilted posteriorly to make the patient partly supine. The distal ureter is dissected downward until the ureterovesical junction where it can be divided after applying a clip.²¹

Radical Nephrectomy for Malignant Conditions

Retroperitoneoscopic radical nephrectomy

Nephrectomy for malignant conditions necessitates the removal of the kidney without violation of the Gerota fascia. The most important technique modification, therefore, is the creation of retroperitoneal space outside this fascia. This is akin to the technique described for inflammatory conditions. The advantages of RPN are that renal vessels can be readily accessed from the retroperitoneum and the artery and vein can be easily clipped before dissection of the kidney. Retroperitoneoscopy allows control of the renal artery first; probably this step allows less bleeding in subsequent mobilization. The remaining dissection is also performed outside the Gerota fascia. In addition to this, lymphadenectomy can be performed.^22,23

Retroperitoneoscopic radical nephroureterectomy (RPNUT)

The surgical issues with radical nephroureterectomy revolve around the management of the lower end and the bladder cuff. RPNUT was performed using a standard retroperitoneal technique, as described earlier.^24,25 The ureter is dissected until the lower end, and then the distal ureterectomy with bladder cuff excision is performed with one of the following technique:

Open technique

A modified Gibson incision is made. The dissected kidney and ureter are pulled out of the incision. Using an extravesical approach, the complete distal ureter with a cuff of bladder is divided to remove the specimen en bloc. The defect in the bladder is closed in two layers using 2-0 polyglactin suture.

Laparoscopic stapling using the Endo-GIA device

The ureterovesical junction is mobilized well, and an Endo-GIA stapler is used to remove the distal ureter with the bladder cuff. The disadvantage of this technique is stone formation around the staple line reported by some authors; however, this has been refuted by others. With availability of absorbable staples, this may be the easy way out in the future.

Laparoscopic excision with scissors and free hand intracorporeal suturing

The ureter is dissected until the lower end, and the ureterovesical junction is pulled cephalad; the bladder cuff is divided, including the detrusor muscle and mucosa, using scissors followed by free hand intracorporeal suturing to close the bladder defect. For this part, unibarbed suture can be used, which helps in easy suturing.

A hilar lymph node dissection can be performed, if needed. The specimen is removed intact without morcellation using a 5 to 7 cm modified Gibson or Pfannenstiel incision in a specimen entrapment device.

Miscellaneous Retroperitoneal Renal Surgery

Chyluria

Chylous drainage into the urine resulting in chyluria is a particularly distressing condition, generally seen in areas with an endemic infestation with filariasis or with other parasitic infestation, especially in Asia. Cases recalcitrant to conservative or medical treatment necessitate pyelolymphatic disconnection, which can be accomplished with a retroperitoneoscopic approach. Nephrolympholysis and ureterolysis can be performed effectively with this approach.²⁶ This procedure needes extensive mobilization of the kidney and the upper ureter from all surrounding structures. Major communicating vessels are often well seen because of the magnification provided by the laparoscope; it is important the these enlarged lymphatic channels are clipped or nicely fulgurated before division. Failure to clip them results in persistent lymph drainage in the postoperative period and predisposes to recurrence of symptoms.

Renal cysts

Decortication of symptomatic renal cysts, particularly those located on the posterior aspect of the kidney, can be achieved easily with retroperitoneoscopy. Direct access to the posterior surface along with intact peritoneal membrane helps prevent spillage and soiling of the peritoneal cavity. In these cases, it is generally preferable to create the working space inside the Gerota fascia. Most cysts are exophytic and are visible as bluish structures on the surface of the kidney. These can be marsupialized and the edges can be cauterized to prevent bleeding. Intraoperative laparoscopic ultrasonography allows delineation of the endophytic component.²⁷

Renal biopsy, cryoablation, radiofrequency ablation

Increased use of imaging modalities leads to the diagnosis of an increasing number of small asymptomatic renal masses. A number of these masses are indicated for renal biopsy, cryoablation, and radiofrequency ablation, which can be accomplished with the retroperitoneoscopic approach. A laparoscopic ultrasound probe is often needed in such cases to localize the mass before biopsy. A retroperitoneoscopic access is also used to guide placement of cryoprobes and radiofrequency ablation for renal masses.²⁸

Specimen Retrieval in Ablative Retroperitoneoscopic Surgery

The specimen removal is an integral part of ablative surgery. Most urologic organs are solid or bulky and therefore need either morcellation or extension of incision to remove the specimen after the procedure. Various procedures, such as morcellation, fractionation, and intact specimen removal, have been described (Table 2). The implication of specimen removal depends on the technique, and it translates into operative time, cost, and cosmesis. In the true sense of laparoscopy, the incision should be minimal; however, it may not be justified in all cases, such as in patients with transitional-cell carcinoma, renal tumors, and in laparoscopic donor nephrectomy. For benign pathologic conditions, morcellation of the specimen is acceptable, because the advantages of a totally laparoscopic procedure are obvious. For renal tumor and transitional-cell carcinoma, an intact removal of the specimen is recommended in a impermeable laparoscopic sac to decrease port site metastasis.

Table 2.

Advantages and Disadvantages of Various Methods of Specimen Removal

Method	Advantages	Disadvantages
Intact specimen removal	• Reduced operative time	• True benefit of entirely cosmetic laparoscopic procedure is lost as scar is bigger
	• Reduced cost
	• Avoids the potential risk of tumor spillage
	• Staging and grading of tumor possible
	• Does not increase the morbidity of the procedure
Morcellation	• Scar is small	• Increased cost
		• Risk of tearing the laparoscopic sac with potential of local and port site recurrence
		• Loss of tumor staging
Fractionation	• Reduced cost	• A small risk of tearing the sac
	• Less risk of tumor spillage
	• Staging and grading of tumor possible
	• Smaller scar

Postoperative Care

The advantage of RPN is that the patient can be allowed oral intake the same day and can be mobilized. The rest of the care is standard, as described in other chapters for laparoscopic surgery.

Management of Intraoperative and Postoperative Complications

The establishment of any surgical procedure depends to a large extent on the demonstration of an acceptably low complication rate. During retroperitoneoscopy, beginning with the creation of the retroperitoneal space, if an indigenous balloon is used then balloon rupture can be problem; however, it can be prevented by using a commercial balloon or by the use of two fingers of the glove instead of one and advancing the catheter to the tips of the balloons. Proper balloon placement is important, and finger dissection anterior to psoas muscle is vital.^29

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Subcutaneous emphysema

This is another significant problem. This can be avoided by the use of a specially designed cannula (blunt tip trocar) as described above. Care needs to be taken to avoid dissection between tissue planes during insertion of the ports, and the skin incisions should be snug around the ports. Full-thickness sutures around the ports are another way of solving this problem.

Anatomic landmarks

These are important in retroperitoneoscopy, which helps in orientation. The best landmark is a psoas muscle, and the camera should be placed in such a way that this muscle is maintained horizontal. Peritoneal rents were often considered a frustrating problem necessitating conversion to transperitoneal or open surgery. With increasing experience, this can be handled. A Veress needle or angiocath can be introduced into the peritoneum to vent the gas and allow expansion of the retroperitoneal space. Simultaneously, the patient can be tilted a further 15 degrees toward the contralateral side and a fan retractor can be used to retract and cover the peritoneum medially. Apart from the initial cases where some form of conversion was needed, however, it has not caused any significant difficulty in the subsequent cases. Sometimes, location of the renal hilum is difficult. Then the Gerota fascia can be exposed, ureter or gonadal vein can be followed to the hilum, or the inferior pole of the kidney is dissected and tented up to look for the hilar vessels (pulsation) medial to the psoas muscle.

Injuries

Among the major intraoperative complications, vascular and visceral injuries are the most common. These may arise both during trocar placement and during the dissection. Unforeseen hemorrhage can occur at any time during the procedure, but this does not make it any different from open surgery. Good laparoscopic view, adequate suction, and use of Codman (Johnson and Johnson, RaynHam, MA) or gauze piece or laparoscopic sponge helps to pack and allow search for the source for prompt control. Injuries that occur during trocar placement can also be handled similarly. Endoscopic trocar placement with transillumination of the abdominal wall can preempt these injuries to a large extent. In lower abdominal wall trocar placement, care must be taken to avoid the epigastric vessels. Injuries to major vessels during trocar insertion usually lead to massive bleeding and necessitate immediate conversion to open surgery.

Visceral injuries, likewise, can occur at any time during the procedure. In the retroperitoneal approach, however, the problem is significantly less, because the intraperitoneal organs are avoided. One of the major reasons for these injuries is the use of monopolar cautery with poor insulation or direct injury by instrument. Judicious use of monopolar cautery, use of new energy sources, and perfect insulation are some of the ways of overcoming this problem.

Minor complications in the form of wound infection and ileus have not been shown to differ significantly from the open surgical group. The incidence of incisional hernia is extremely rare. Complications and conversions were closely related to the initial learning curve, skill, and experience of the surgeon and, most importantly, the underlying pathology of the kidney.

Advantages and Disadvantages

The retroperitoneoscopic approach is a preferred approach for a variety of indications worldwide. The advantages and disadvantages are described in Table 3.

Table 3.

Advantages and Disadvantages of the Retroperitoneal Approach

Advantages

1. Because the peritoneal cavity is not entered with this approach, hence, there are remote chances of postoperative adhesions.

2. There is no risk of contamination of the virgin peritoneal cavity by the spillage of contents of the urinary tract, such as urine, infected stones, or infected abscess, etc.

3. There is less risk of injuring intra-abdominal organs.

4. There is no need for retraction of intra-abdominal organs during retroperitoneoscopy because the reflected peritoneum serves as a natural retractor.

5. Incidence of ileus in the postoperative period is not observed, because there is no need to mobilize the gut to expose the retroperitoneal located kidney and, hence, faster recovery.

6. Because the kidney lies in the retroperitoneum, access to the kidney is direct.

7. Fewer laparoscopic trocar punctures are needed, because there is less requirement for retraction.

8. It is an appropriate and a safe procedures in patients with a history of intraperitoneal surgeries and post-transplant patients, while dealing with the diseased kidney.

9. Less incidence of hernia formation compared with the transperitoneal approach.

Disadvantages

1. Limited space is a drawback to perform the renal surgery, especially while dealing with a large kidney or for intracorporeal freehand suturing.

2. There are few standard landmarks in the retroperitoneum, which can be troublesome for a naïve surgeon; thus, it needs a longer learning curve.

3. There are reports that suggest that there is greater absorption of CO₂ by this access and a higher incidence of pneumothorax or pneumomediastinum; however, that is not the case in routine practice.

4. This space may be sometimes obscured in patients with an infected kidney.

Conclusions

The retroperitoneal laparoscopic approach is a minimally invasive alternative to open surgery for a variety of ablative and reconstructive indications for different pathologic conditions. After adequate training and experience, the surgeon can proficiently use this approach. Despite the limitation of working space, a direct posterior access to the kidney and renal hilum make this access attractive as it allows early renal vessels control. Emerging techniques, such as single port or single incision, can also be performed in select subset of patients. Furthermore, reproducibility of this technique worldwide has been an indirect testimony of the successful use.

Footnotes

Disclosure Statement

No competing financial interests exist.

Abbreviations Used

*

A coordinating article with video is available in Videourology 25/1 at www.liebertonline.com/vid/doi/full/10.1089/vid.2010.0160

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