Retroperitoneal and pelvic extraperitoneal laparoscopy: an international perspective.

OBJECTIVES: To assess technical preferences and current practice trends of retroperitoneal and pelvic extraperitoneal laparoscopy. METHODS: A questionnaire survey of 36 selected urologic laparoscopic centers worldwide was performed. RESULTS: Twenty-four centers (67%) responded. Overall, 3988 laparoscopic procedures were reported: transperitoneal approach (n = 2945) and retroperitoneal/extraperitoneal approach (n = 1043). Retroperitoneoscopic/extraperitoneoscopic procedures included adrenalectomy (n = 74), nephrectomy (n = 299), ureteral procedures (n = 166), pelvic lymph node dissection (n = 197), bladder neck suspension (n = 210), varix ligation (n = 91), and lumbar sympathectomy (n = 6). Mean number of total laparoscopic procedures performed in 1995 per center was 41 (range 5 to 86). Major complications occurred in 49 (4.7%) patients and included visceral complications in 26 (2.5%) patients and vascular complications in 23 (2.2%). Open conversion was performed in 69 (6.6%) patients, electively in 41 and emergently in 28 (visceral injuries, n = 16; vascular injuries, n = 1 2). Retroperitoneoscopy/extraperitoneoscopy is gaining in acceptance worldwide: in 1993, the mean estimated ratio of transperitoneal laparoscopic cases versus retroperitoneoscopic/ extraperitoneoscopic cases per center was 74:26; however, in 1996 the ratio was 49:51. CONCLUSIONS: Retroperitoneoscopy and pelvic extraperitoneoscopy are important adjuncts to the laparoscopic armamentarium in urologic surgery. The overall major complication rate associated with retroperitoneoscopy/extraperitoneoscopy was 4.7%.

Retroperitoneal endoscopic ureterolithotomy: our experience in 12 patients.

Retroperitoneal endoscopic ureterolithotomy was successful in 9 of 12 patients who had calculi impacted in the upper and mid ureter with gross hydronephrosis and recurrent infection. This procedure was made possible by the technique of balloon retroperitoneoscopy recently described by the author.

Simple nephrectomy: retroperitoneal approach.

Direct extraperitoneal surgery has become the preferred approach to laparoscopic nephrectomy since the introduction of the balloon dilation method. The lateral decubitus position provides good exposure, but the prone position is used at some centers to gain better exposure with the aid of gravity. The open conversion rate ranges from 0 to 16% and the complication rate from 5% to 45%, with most complications being minor. Retroperitoneal laparoscopic simple nephrectomy is definitely superior to open nephrectomy as judged by analgesic use and recovery time. The higher complication rate and lower efficiency can be taken care of by experience and proper case selection.

Laparoscopic suturing and knot tying: the Indian rope trick.

Laparoscopic suturing and knot tying require a lot of patience and practice and can be difficult, time consuming, and frustrating in spite of the advances made in the fields of instrumentation, optics, and imaging. The new technique described here is an effort to make the procedure simpler by providing extracorporeal control of one limb of the suture. It involves percutaneous placement of the needle end of the suture in the abdomen and its removal using a modified 10 cm long cloth-sewing needle. The part of the suture hanging from the abdominal wall helps in the formation and the tying of both the extracorporeal and the intracorporeal knots. The extracorporeal knot is just pulled in percutaneously to make it intracorporeal and can be tightened easily without a knot pusher. The loop for making the intracorporeal knot is formed in one of three ways, and the half hitch or the surgeon's knot can be tightened by pulling one end extracorporeally and the other intracorporeally. The technique has now been used for 36 laparoscopic procedures (8 transperitoneal and 28 retroperitoneal), including cholestectomy, varicocelectomy, ureterolithotomy, pyelolithotomy, pyeloplasty, and nephropexy. Compared with the conventional method of laparoscopic suturing and knot tying, it was found to be easier to learn.

Laparoscopic condom dissection: new technique of retroperitoneoscopy.

The laparoscopic condom dissection is an advancement on the recently described balloon dissection technique of retroperitoneoscopy. It allows a simultaneous balloon dissection and retroperitoneal laparoscopic dissection using a telescope placed inside a condom balloon. In spite of a mild masking effect by the balloon, the clarity of vision was satisfactory, and adequate dissection could be carried out in all five patients in whom the condom was placed deep to the fascia transversalis or Gerota's fascia.

PIP: The laparoscopic condom dissection technique is an advancement on the recently described Gaur balloon technique for retroperitoneal dissection. The condom device allows for controlled expansion into the required operative area. The authors describe their experience using this technique. Under general anesthesia the patient is placed in a lateral position with the kidney bridge elevated. Two techniques are then described. Using technique 1, the condom cannula is inserted deep to the fascia transversalis through a 2-cm incision, after creating a retroperitoneal space by digital dissection. In technique 2, an 11-mm trocar-cannula is inserted into the retroperitoneal space. The cannula with attached condom is then introduced through this channel. A 10-mm telescope is then inserted. The condom is then inflated to 300 mL. A fiberoptic light source may be inserted through the cannula. Superficial dissection of the retroperitoneal structures may be performed through the balloon itself. Technique 1 was performed on 5 patients with success. Technique 2 was performed on 3 patients with unsatisfactory results. In summary, laparoscopic condom dissection is a new technique that requires further evaluation.

Retroperitoneal laparoscopic pyelolithotomy for staghorn stones.

PURPOSE: To establish the feasibility of the retroperitoneal laparoscopic approach for treatment of patients with staghorn renal calculi who are under consideration for an open pyelolithotomy. PATIENTS AND METHODS: Retroperitoneal laparoscopic pyelolithotomy was performed in three patients with impacted staghorn renal calculi between 22 and 45 mm in largest diameter. One of the patients also had multiple caliceal stones. These patients wanted an open procedure but had agreed to have their stone removal done laparoscopically in view of our experience. The previously described retroperitoneal laparoscopic approach was used, and the handling of some of the specific problems in such patients is described in the text. RESULTS AND CONCLUSION: The stones were removed successfully in all the three patients, and there were no complications. Although no definitive conclusion can be drawn from this small series, the paper shows the feasibility of the retroperitoneal laparoscopic approach in a select group of patients with staghorn renal calculi.

Mini-access for retroperitoneal laparoscopy.

The purpose of this study was to establish the feasibility of primary mini-access to the retroperitoneal space to perform certain retroperitoneoscopic procedures in which an enlarged port is not required for extraction of the specimen. Mini-laparoscopy or needlescopic laparoscopy has been performed in the past via the transperitoneal route, but this has not yet been reported for a retroperitoneoscopic procedure. Through a 5-mm primary access and 3- or 5-mm secondary ports, retroperitoneoscopic surgery was performed in seven adults for ureterolithotomy, renal biopsy, simple nephrectomy, nephropexy, cyst decortication, or drainage of a subphrenic abscess. The access technique used was a mini-version of a previously described percutaneous access technique with some modifications. The retroperitoneoscopic procedure was successful in all seven patients, and no complications developed. The operative time, blood loss, analgesic intake, and length of hospital stay were comparable with those of a standard retroperitoneoscopic procedure. However, the cosmetic results were better. Mini-retroperitoneoscopy is feasible and is a better alternative for patients in whom the whole procedure can be performed through 5-mm or smaller ports.

Retroperitoneoscopy: the balloon technique.

Retroperitoneoscopy was performed in 101 patients using the author's recently described balloon technique. Various urological procedures, were undertaken including renoscopy and renal biopsy, para-aortic lymph node biopsy, varicocelectomy, ureterolithotomy, pyelolithotomy, pyeloplasty, nephrolithotomy, nephrectomy, decortication of renal cyst, adrenalectomy, pelvic lymphadenectomy and ligation of deep penile veins.

Retroperitoneal laparoscopic ureterolithotomy.

Retroperitoneal laparoscopic ureterolithotomy was successfully performed in five patients with calculi impacted in the upper and middle ureter, using the recently described method of retroperitoneoscopy. All of the patients were discharged the following day but could have been treated as day cases.

Retroperitoneal surgery of the kidney, ureter and adrenal gland.

Seventy-one retroperitoneal endoscopic procedures on the kidney, ureter and adrenal gland were performed in 69 patients, using the balloon technique of retroperitoneoscopy. There were 9 failures in this series, all of which were converted into an open procedure. The balloon satisfactorily dissected the kidney and the ureter in 59 patients (85%). There were no major complications and the minor complication rate was 20%. Forty-nine patients were discharged the next day, while 20 were kept in hospital for 2 to 5 days. The balloon technique of retroperitoneoscopy is safe, simple and reliable for exposing the kidney, ureter and the adrenal gland.

Single implants in the treatment of erectile impotence.

A total of 12 patients with erectile impotence underwent implantation of a Finney flexirod penile prosthesis in 1 corpus cavernosum only. This procedure has a special advantage in developing countries since the cost of the operation in reduced by approximately 50 per cent. The penis is less rigid and longer, and in case of failure the other corpus cavernosum is readily available. This procedure is the method of choice in cases of psychogenic impotence since there is a considerable amount of super erection present in all of the cases.

Laparoscopic operative retroperitoneoscopy: use of a new device.

Attempts at retroperitoneoscopy have mostly failed in the past due to the inability to create an effective pneumoretroperitoneum because of the dense areolar tissue binding the fat in the retroperitoneum, which could not be broken down merely by pneumo-insufflation. The newly devised balloon breaks the septae, lifts the peritoneum atraumatically and creates a workable space in the retroperitoneum. The view of the retroperitoneal structures provided is satisfactory. With this balloon dissector we have performed laparoscopic ureterolithotomy, renoscopy and renal biopsy, para-aortic lymph node biopsy and ligation of the internal spermatic vein.

Endourethral urethroplasty--use of a new catheter.

Endourethral split skin grafting following visual internal urethrotomy was done successfully in 7 selected patients with stricture of the bulbomembranous urethra. Open substitution or anastomotic urethroplasty might otherwise have been necessary in these patients. The technique involves the use of a specially designed double balloon catheter, in which the second balloon, when distended, keeps the split skin graft in close opposition with the urethral raw area. This function ensures a near 100 per cent graft take, keeps the strictured area wide open and allows early ambulation of the patient, since no perineal compression dressing is required.

Retroperitoneal laparoscopic nephrectomy: initial case report.

Pre-transplant nephrectomy was done in a 25-year-old man for calculous pyelonephritis using a retroperitoneal laparoscopic approach with a newly devised ligature applicator-dissector- kidney retractor.

Retroperitoneal laparoscopic varicocelectomy.

Retroperitoneal laparoscopic varicocelectomy was performed in 27 of 29 patients with clinical varicoceles. Postoperative pain was minimal and all patients were discharged from the hospital within 24 hours. The technique is relatively safe and easy to learn, although identification of the internal spermatic vein may sometimes be difficult. It could become a viable alternative to the transperitoneal laparoscopic procedure in patients with pelvic adhesions or those having recurrent varicoceles due to high collaterals.

Retroperitoneal laparoscopic pyelolithotomy.

Retroperitoneal laparoscopic pyelolithotomy was successful in 5 of 8 patients using the recently described balloon technique of retroperitoneal laparoscopy. All patients were considered for this new minimally invasive procedure only on economic grounds. However, with improved technique and instrumentation, the retroperitoneal laparoscopic approach could become a practical alternative for the management of patients with medium sized pelvic stones not amenable to extracorporeal shock wave lithotripsy nor ideally suitable for percutaneous nephrolithotomy, or when both of these facilities are not available.

Laparoscopic renal biopsy via retroperitoneal approach.

Renal biopsy was performed in 17 patients using the balloon technique of endoscopy of the retroperitoneum. There was good exposure of the kidney and a sufficient amount of renal tissue was obtained in all patients with minimum postoperative morbidity. The preliminary results show that this method could become a safe and reliable alternative to open surgical biopsy.

A single-centre experience of retroperitoneoscopy using the balloon technique.

OBJECTIVE: To report the experience in one centre of the efficacy and safety of retroperitoneal laparoscopic procedures (RLPs). PATIENTS AND METHODS: During 1991-2000, 351 RLPs using the balloon technique were undertaken in 340 patients (mean age 34.9 years, range 4-74); the details and outcome were reviewed. Initial access was by the mini-open digital dissection technique in 152 and by the closed percutaneous technique in the remaining 199 procedures. Patients had not undergone previous retroperitoneal procedures, except for nine who had a percutaneous nephrostomy and eight ipsilateral abdominal surgery. There were 172 renal, seven adrenal, 97 ureteric, 50 gonadal, 13 lymphatic system, three vesical, two autonomic nervous system and seven vertebral RLPs. Nitrous oxide was used for pneumo-insufflation in 103 procedures, instead of CO2. RESULTS: The RLP was successful in 318 of the 351 procedures (90.6%). The operative duration was 0.5-5.5 h, depending on the difficulty of the procedure and the presence or absence of adhesions. The overall incidence of complications was 12.9%, but decreased to 9% for the last 100 procedures. There were only five major complications, e.g. avulsion of the ureter, torn renal pelvis, colonic injury and severe hypotension, but none were related to balloon dissection. The mean blood loss was 37.7 mL and the reason for transfusion in three patients was not operative blood loss but displacement of the ligature in two and severe hypotension after removing a phaeochromocytoma in one. The mean duration of analgesic use was 2.5 days, the hospital stay 3 days and return to work 14 days. CONCLUSION: Retroperitoneal laparoscopy using the balloon technique is a reasonably safe, efficient and reliable minimally invasive procedure. The efficiency, efficacy and safety of RLPs depend more on experience than on the type of access technique, type of balloon or medium used to inflate the balloon. Balloon rupture causes no tissue damage, and expansion to approximately 800 mL in adults is safe if the retroperitoneal space has not previously been invaded. The use of nitrous oxide for pneumo-insufflation in the retroperitoneal space is safe if proper precautions are taken.

Laparoscopic ureterolithotomy: technical considerations and long-term follow-up.

OBJECTIVE: To analyse the technical details and the long-term results of laparoscopic ureterolithotomy. PATIENTS AND METHODS: Laparoscopic ureterolithotomy was undertaken in 101 patients between 1991 and 2001; in only one patient with retroperitoneal fibrous adhesions was the procedure transperitoneal, being retroperitoneal in all the others, using Gaur's balloon retroperitoneoscopy. The mean (range) stone size was 16 (10-47) mm, and the stones were in the upper ureter in 75, mid-ureter in 11 and lower ureter in 15 patients. Nine patients had more than one stone, the maximum being six, in a megaureter. Most were impacted for > 2 months, the maximum being 240 months. RESULTS: Laparoscopic ureterolithotomy was successful in 93 patients, with the eight failures being mostly early in the series. The mean operative duration was 79 min (66 min when the ureter was left open and 92 min when it was sutured). The overall mean duration of urinary leakage was 5.5 days, which was reduced to 3.2 days by stenting and suturing the ureter. The mean (range) blood loss was 25 (5-100) mL. The overall complication rate was high (31%) because of prolonged urinary leakage in 20 patients. No patient required morphine for pain relief and the mean for oral analgesic use was 2.5 days. The mean hospital stay was 3.5 days and that for resuming work 14 (7-28) days. CONCLUSIONS: Laparoscopic ureterolithotomy by the retroperitoneal approach is a safe and reliable minimally invasive procedure. Although its role as a salvage procedure for failed extracorporeal shock wave lithotripsy and ureteroscopy is undisputed, in selected patients with large chronically impacted ureteric stones and particularly with solitary kidneys, it may be considered the first-line treatment.

Retroperitoneal laparoscopic ureterolithotomy for multiple upper mid ureteral calculi.

A 30-year-old man presented with upper mid ureteral calculi and gross hydroureteronephrosis. The 4 large and 2 small calculi were removed successfully using Gaur's technique of retroperitoneal laparoscopy.