Access to the retroperitoneum in the operating room has traditionally been through a flank or posterior incision to avoid violation of the peritoneal cavity. This approach provides urologists the most anatomically direct route to the organs in the retroperitoneum. It was the use of these initial techniques that allowed urologists to perform the first retroperitoneoscopic surgery. Retroperitoneoscopic surgery was first described in 1979 and was initially pioneered in the treatment of urolithiasis. In the early 1990s, transperitoneal laparoscopy was first used for radical nephrectomy, which broadened the scope of laparoscopic surgery in the treatment of urologic diseases. Interest grew and indications expanded with urologists performing more complex surgical procedures using laparoscopic technologies. Laparoscopic surgery slowly expanded to become one of the mainstays of treatment for both benign and malignant renal pathology, with laparoscopy now an essential technique in the modern urologist’s armamentarium.
In transperitoneal surgery, dissection proceeds similar to open surgery anatomically, making this approach easier for the novice laparoscopic surgeon to deal with the learning curve of laparoscopy. The retroperitoneoscopic approach has a steeper learning curve. Its adoption has been slower, most likely because of the smaller working space and the variation in easily recognized anatomic landmarks. However, retroperitoneoscopic surgery can minimize the risk of adjacent organ injury. It also obviates the need for retraction or mobilization of adjacent organs (spleen, liver, colon, duodenum, etc.). Furthermore, with minimal manipulation of the peritoneal contents, surgeons can expect quicker return of bowel function and recovery in patients. This benefit is a tradeoff with the higher incidence of injury to the local vasculature.
Indications and contraindications
Retroperitoneoscopic surgery has been used for myriad urologic indications with both benign and malignant diseases of the adrenal glands and upper tracts. Adrenalectomy, simple and radical nephrectomy, partial nephrectomy, nephroureterectomy, renal cyst decortication, renal ablative therapy, pyeloplasty, lymph node dissection, pyelolithotomy, and renal biopsy have all been performed via the retroperitoneoscopic approach. In patients with a history abdominal surgery, particularly those with extensive prior surgical history, gaining entry into the abdomen represents the most treacherous aspect of the operation. The retroperitoneal approach allows a more facile and direct route to the operative area of interest. Additionally, in the specific case of partial nephrectomy or cyst decortication with a specific posterior target, retroperitoneoscopic facilitates a more direct approach.
Relative contraindications specific to retroperitoneoscopic surgery are related to fibrosis or adhesed tissue planes within the retroperitoneal space. Recent infection, radiation, or surgery of the retroperitoneum or kidney can obliterate these tissue planes and increase the expected scarring of the perinephric fat.
Preoperative evaluation and planning
Thorough preoperative evaluation prior to retroperitoneoscopic surgery is critical. History and physical examination then follow in a manner similar to all preoperative evaluations. Evaluation is directed toward the cardiopulmonary reserve and should identify the presence or history of coagulopathy, abdominal infection, or prior abdominal surgeries. Review of available imaging is also essential in surgical planning and choosing the surgical approach.
Traditional bowel preparation is not required prior to retroperitoneoscopic surgery. Some surgeons request patients transition to a clear liquid diet the day before surgery, but it is not a requirement.
Intraoperative patient positioning
The patient is placed in the lateral decubitus position with all pressure points (feet, ankles, knees, etc.) appropriately padded. An axillary roll is used to prevent compression of the brachial plexus and resultant nerve injury. The axillary roll 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. The arm should not be extended excessively laterally or abducted above the head. The operative table can be flexed to further expose the ipsilateral abdomen based on surgeon preference. The kidney rest should be left in a neutral position to help avoid postoperative rhabdomyolysis. It is raised only in select cases when necessary to further expose the abdomen and retroperitoneum. The patient is secured to the table, and their arms are secured using silk tape and belt restraints.
In retroperitoneoscopic surgery the surgeon stands behind the patient, which is contrary to transabdominal laparoscopy. In the case of robotic-assisted surgery, the robotic system is docked over the patient’s head rather than from the patient’s back or shoulder, which is typical for the transabdominal approach.
Establishment of pneumoretroperitoneum (see 
)
Generation of adequate working space within the retroperitoneum is essential to performing surgery via this approach. 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, just inferior to the 12th rib. 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 (or can be bluntly penetrated with a clamp or nimble finger), 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 is guided through the subcutaneous tissue, flank musculature, and lumbodorsal fascia into the retroperitoneum under direct vision (typically referred to as the Visiport entry method). Either method can safely establish a tract to the retroperitoneum, and the choice between these two methods is based on surgeon preference.
Next, blunt finger dissection is used to establish a plane between the kidney and the posterior abdominal wall musculature ( Fig. 11.1 ). 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. 11.2 ). Notably, multiple rounds of balloon dilation are sometimes required depending on patient anatomy to gain adequate space. The balloon dilator is removed, and a 12-mm trocar is next placed through this established tract. Pneumoretroperitoneum is then achieved by insufflation though this trocar. The remaining trocars should be placed under direct vision when possible; their position will vary slightly depending on the particular surgery being performed.
