The extraperitoneal (prevesical) space is usually developed through an infraumbilical incision. Finger dissection and enlargement of the space by the use of the optic or a balloon take place [1, 27, 32, 33]. The camera trocar is then positioned. The trocar placement has some variations among the described techniques. The authors favor the placement of the trocars according to Stolzenburg et al. [32, 33]. In short, the camera trocar is placed through a right infraumbilical incision. Four other trocars are placed under direct visual control; a 12-mm trocar in the left iliac fossa 3 cm medially to the anterior superior iliac spine, a 5-mm trocar in the right iliac fossa at a mirror position to the previous trocar, a 5-mm trocar on the hypothetical line between the umbilicus and the right iliac spine approximately at lateral margin of the rectus abdominis. Another 5-mm trocar is placed 3 cm caudally to the crossing of the aforementioned hypothetical line with the left lateral margin of the rectus abdominis. The placement of the lateral left trocar should be as described 3 cm away from the iliac spine. Placement of the trocar closer to the iliac spine would result in clashing of the respective instrument to the bone pelvis. The performance of the anastomosis is performed with triangulation of instruments by some groups [27]. The surgeon is using the medial left and right trocars to perform the anastomosis. The authors favor the performance of all tasks by the surgeon with instruments inserted through the left trocars [32, 33]. The use of triangulation is considered to be easier for the performance of anastomosis. Nevertheless, the use of only the left trocars by the surgeon allows the assistant to be able to use two instruments during the anastomosis.

There is evidence showing that the retroperitoneal approach has advantages in terms of hemodynamic and cardiopulmonary parameters [12, 15]. Any postoperative fluid collection such as urine or blood or infected fluids is restricted in the retroperitoneal space and significant complications such as chemical or infectious peritonitis are avoided with the retroperitoneal access [14–16, 22]. Transperitoneal urologic laparoscopy has a risk of adhesion formation up to 22.2 % [25], while the retroperitoneal approach has a distinct advantage since the intraperitoneal space is completely avoided [15]. In addition, the retroperitoneal access allows a more direct access to the kidney without requiring any bowel mobilization [26]. Postoperative shoulder pain represents a complication of the transperitoneal approach and is never encountered in the retroperitoneal procedures [8, 10, 15, 31]. Postoperative pain and hospital stay have been shown to be lower in the case of the retroperitoneal approach in a number of comparative studies ([15, 20]; Fan 2012). Recent meta-analyses on studies comparing retroperitoneal and extraperitoneal radical and partial nephrectomies have concluded to advantages of the retroperitoneal access in the length of hospital stay [11, 26].

Disadvantages of retroperitoneal access are the spatial limitation of the narrow retroperitoneal working space which results in the reduced visualization of the field. In addition, there is always the risk of disorientation due to the above issues [26]. The argument that “the retroperitoneal anatomic orientation is not as familiar to many surgeons” should be considered as theoretical as the urologists are familiar with the latter space due to the performance of many procedures by lumbotomy [15, 36]. Morbid obese patients could be managed by the retroperitoneal approach despite the controversial reports of different investigating groups [20, 21].

The performance of procedures in the prevesical extraperitoneal space is associated with similar advantages to the retroperitoneal approach regarding the tamponade of any bleeding and urine out of the peritoneal cavity and the avoidance of intra-abdominal adhesions after previous surgery. Space limitations do not apply in the case the extraperitoneal access as the space is adequate for the performance of surgery [38]. Obesity and morbid obesity do not pose contraindications for the extraperitoneal approach [17, 18]. Disadvantage is the lack of access higher to the bifurcation of the iliac vessels which does not allow the performance of extended pelvic lymphadenectomy [17, 18]. Moreover, the incidence of lymphocele formation after a pelvic lymphadenectomy is higher in the case of the extraperitoneal approach and the fenestration of the peritoneum is necessary in order to decrease minimize the incidence of the above complication [35]. The literature includes a number of studies comparing the transperitoneal and extraperitoneal approach without concluding to the best possible approach [3, 4, 30].

The most important landmark for retroperitoneal surgery is the identification of the psoas muscle regardless of the side that the procedure is performed. The psoas should always represent the “floor” of the operative field. If the orientation of the surgeon is lost intraoperatively, the psoas should be identified again and then proceed with the procedure. The Gerota’s fascia is easily identified using the psoas muscle as a guide. The ureter and the gonadal vessels are very often identified during the initial balloon dilation. On the left side, the ureter and the gonadal vessels are identified and preparation of these structures leads to the renal hilum which could be also identified by the pulsation of the renal artery. On the right side, the Gerota’s fascia is incised and the vena cava is identified. The cephalad dissection leads to the right renal pedicle. The ureter could be also used as a guide to the renal hilum during the right sided dissection [36].

The retroperitoneal access is considered to be more appropriate for the approach to the posterior side of kidney, for example the excision of a renal tumor located posteriorly. For the approach to the anterior surface of the kidney has been advocated that the transperitoneal approach is more efficient [15]. A recent meta-analysis showed that the majority of the partial nephrectomies were performed by the retroperitoneal access when a posterior renal tumor was managed and by the transperitoneal approach when an anterior one was excised. The results showed that the retroperitoneal approach had an advantage in terms of operative time when compared to the transperitoneal approach. Nevertheless, the authors concluded that the selection of the approach is based on the preference of the surgeon and several parameters should be considered such as the location and technical complexity of tumor [26].