This video demonstrate Retroperitoneoscopic Nephrectomy and Ureterolithotomy. The emergence of minimally invasive surgery about 20 years ago revolutionized urological surgery. Advances in retroperitoneoscopy allowed the widespread use of minimally invasive techniques in almost the entire range of urology. In this context, laparoscopy and later retroperitoneoscopy were developed and applied in a wide spectrum of urological diseases. Both approaches have since presented benefits and disadvantages that have been documented in various series. However, few comparative studies have been conducted. Retroperitoneoscopy can be accomplished placing the patient in lateral or prone position. This technique requires experience to find the way to the retroperitoneum. The main landmark during surgery is the psoas muscle. The prone approach is very versatile because it gives the surgeon the chance to reach the adrenal gland and the upper and lower urinary tract, and also allows a bilateral procedure to be achieved. Furthermore, this access leaves the kidney in place and has the advantage of a direct approach to the vessels. On the other hand, it is not the best option when mobilization of the lower ureter and urgent conversion are needed.

Advances in minimally invasive surgery have revolutionized urology, offering patients faster recovery, reduced pain, and fewer complications. Among these innovations, retroperitoneoscopic nephrectomy and ureterolithotomy have emerged as highly effective alternatives to traditional open surgery for the management of kidney and ureteral diseases.

Understanding Retroperitoneoscopy

The retroperitoneal approach involves accessing the kidney and ureter through the back, directly entering the retroperitoneal space without traversing the peritoneal cavity. This technique offers several advantages:

• Reduced risk of intra-abdominal organ injury

• Minimal postoperative adhesions

• Faster recovery and shorter hospital stay

• Lower incidence of bowel-related complications

Retroperitoneoscopy is especially beneficial in patients with previous abdominal surgeries or intra-abdominal adhesions, where a transperitoneal approach may be challenging.

Retroperitoneoscopic Nephrectomy

Nephrectomy is the surgical removal of a kidney, indicated in conditions such as:

• Non-functioning kidneys due to chronic obstruction or infection

• Renal tumors

• Severe trauma

• Congenital anomalies

Surgical Technique

1. Patient Positioning: The patient is placed in a lateral decubitus position with the affected side up.

2. Port Placement: Small incisions (usually 3–4 ports) are made in the flank to insert the laparoscope and working instruments.

3. Retroperitoneal Space Creation: A balloon dissector or finger dissection is used to create working space.

4. Dissection: The kidney is carefully mobilized, with identification and control of the renal artery and vein.

5. Kidney Removal: The kidney is extracted through one of the port sites, sometimes requiring slight enlargement of the incision.

Advantages

• Less postoperative pain

• Minimal blood loss

• Early ambulation

• Shorter hospital stay (usually 2–3 days)

Retroperitoneoscopic Ureterolithotomy

Ureterolithotomy involves surgical removal of ureteral stones that cannot be treated with less invasive methods like shock wave lithotripsy or ureteroscopy. The retroperitoneoscopic approach provides direct access to the ureter while minimizing trauma.

Indications

• Large ureteral stones (>1.5–2 cm)

• Impacted stones resistant to endoscopic removal

• Stones causing recurrent obstruction or infection

Surgical Technique

1. Patient Positioning: Similar lateral decubitus position.

2. Port Placement: 2–3 ports are inserted in the flank region.

3. Identification of Ureter: The ureter is located using anatomical landmarks and dissected carefully.

4. Stone Removal: A small incision is made over the ureter, and the stone is extracted.

5. Closure: The ureter is sutured meticulously, and a stent may be placed to ensure patency.

Advantages

• Minimally invasive with less postoperative discomfort

• Short recovery time

• Direct visualization allows precise stone removal

Postoperative Care

Patients undergoing retroperitoneoscopic procedures typically experience rapid recovery. Postoperative management includes:

• Pain control using minimal analgesics

• Early ambulation to prevent complications like deep vein thrombosis

• Monitoring for urinary leaks or bleeding

• Follow-up imaging to confirm complete stone clearance or successful nephrectomy

Conclusion

Retroperitoneoscopic nephrectomy and ureterolithotomy are safe, effective, and patient-friendly alternatives to open surgery. By avoiding the peritoneal cavity, these procedures minimize complications, accelerate recovery, and improve patient outcomes. With advancements in laparoscopic technology and surgical expertise, these procedures are increasingly becoming the standard of care for kidney and ureteral surgery.