The urologist’s approach to retroperitoneal surgery has traditionally been through a flank or posterior incision to avoid violation of the peritoneal cavity. This approach also provides the most anatomically direct route to the organs of interest in the retroperitoneum. It was by adherence to this concept that urologists first founded retroperitoneoscopic surgery. Retroperitoneoscopic surgery was first described in 1979 and was then used only in the treatment of urolithiasis. In the early 1990s, transabdominal laparoscopy was first used for radical nephrectomy, which broadened the urologic scope of laparoscopic surgery and drew interest to the undertaking of more complex surgical procedures using laparoscopic technologies. Laparoscopic surgery was slowly adopted as a mainstay of treatment for both benign and malignant renal pathology. Now laparoscopy has become an essential technique in the modern urologist’s armamentarium.
In a transabdominal approach, the anatomic planes of dissection are similar to open surgery, making this approach easier for the novice laparoscopic surgeon to overcome the learning curve of laparoscopy. The retroperitoneoscopic approach has a steeper learning curve and has been slow to be adopted by practitioners owing to the small working space it affords as well as the lack of easily recognized anatomic landmarks. However, retroperitoneoscopic surgery minimizes the occurrence of adjacent organ injury because there is little need for retraction or mobilization of adjacent organs. Furthermore, minimal or no manipulation of the peritoneal contents results in an earlier return of bowel function and shorter convalescence than with the transabdominal laparoscopic approach. The disadvantage of the technique is a higher incidence of injury to the great vessels or the renal hilum.
Indications and Contraindications
Retroperitoneoscopic surgery has been used for a vast spectrum of operative indications for both benign and malignant diseases of the adrenal gland, kidney, and urinary collecting system. Adrenalectomy, simple and radical nephrectomy, partial nephrectomy, nephroureterectomy, renal cyst decortication, renal ablative therapy, pyeloplasty, lymph node dissection, pyelolithotomy, and renal biopsy may be performed via a retroperitoneoscopic approach. In the setting of prior abdominal surgery, particularly ventral hernia repair involving mesh, the retroperitoneal approach offers a more facile and direct route to the operative area of interest. In the case of partial nephrectomy or cyst decortication, retroperitoneoscopic surgery also facilitates a more direct approach to very posterior tumors or cysts.
Contraindications specific to retroperitoneoscopic surgery are dense fibrosis of the retroperitoneal and perinephric fat as would be expected from recent infection, radiation, or recent surgery of the retroperitoneum or kidney.
Patient Preoperative Evaluation and Preparation
Thorough preoperative evaluation is paramount before retroperitoneoscopic surgery. History and physical examination should be directed toward evaluation of cardiopulmonary status and should elucidate the presence or history of coagulopathy, abdominal infection, or previous abdominal surgery. Review of radiographic images is also essential in surgical planning and will help distinguish the most ideal surgical approach.
Traditional bowel preparation is not necessary before retroperitoneoscopic surgery. A clear liquid diet the day before surgery will suffice.
Patient Positioning and Operating Room Configuration
The patient is placed in the lateral decubitus position with attention to padding of all pressure points, in particular the feet, ankles, and knees. An axillary roll is used to prevent compression nerve injury and should be placed at the level of the areola in men or just inferior to the true axilla in women. The top arm should be gently supported at a 90-degree angle to the thorax and should not be moved too far laterally or abducted above the head. The operative table should be flexed to expose the ipsilateral abdomen. The kidney rest should be left in a neutral position to help avoid postoperative rhabdomyolysis. The kidney rest is to be raised only in select cases in which it is necessary to further expose the abdomen and retroperitoneum. The patient is secured to the table using silk tape and belt restraints.
Contrary to transabdominal laparoscopy, during retroperitoneoscopic surgery the surgeon stands facing the patient’s back. If a robotic surgical system is being used, the robotic system is docked over the patient’s forehead for the retroperitoneoscopic approach rather than from the patient’s back or shoulder for the transabdominal approach.
Creation of Retroperitoneal Working Space and Trocar Placement (See )
The foundation of retroperitoneoscopic surgery is based on the creation of an adequate working space within the retroperitoneum. The following section outlines trocar placement for both retroperitoneoscopic and robotic-assisted retroperitoneoscopic approaches.
Initially, a 1.5-cm horizontal incision is made for the first port. The incision is carried down to the level of the flank musculature. The flank musculature is split bluntly with the aid of S -shaped retractors until the lumbodorsal fascia is visualized. The lumbodorsal fascia is incised, allowing entry into the retroperitoneal space. Alternatively, visual laparoscopic entry to the retroperitoneum may be used. A 12-mm trocar with a visual obturator and laparoscope may be guided through the subcutaneous tissue, flank musculature, and lumbodorsal fascia into the retroperitoneum. Either method can safely establish a tract to the retroperitoneum and is used based on surgeon preference.
Next, blunt finger dissection is used between the kidney and along the posterior abdominal wall musculature ( Fig. 10-1 ). The retroperitoneal working space is then created with balloon dilation by placing the balloon just ventral to the posterior abdominal musculature. Balloon dilation displaces the Gerota fascia and the kidney anteromedially ( Fig. 10-2 ). The balloon dilator is removed and a 12-mm trocar is placed through the established tract. Pneumoretroperitoneum is achieved by insufflation with carbon dioxide to a pressure of 15 mm Hg. The remaining trocars should be placed under direct vision when possible; their position will vary slightly depending on the particular surgery being performed.
