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Associate Professor, Department of Urology, Bombay Hospital Institute of Medical Sciences, Bombay, India.

Laparoscopy is being universally used to indicate endoscopic inspection of the peritoneal cavity. However, it is etymologically not correct. In Greek language, the word ‘lapara’ means flank. Therefore, only the procedure for inspecting the structures in the lumbar region i.e. retroperitoneoscopy, should be called laparoscopy. However, since Jacobeus first used the term laparoscopy in 1910, for the inspection of the peritoneal cavity using a cystoscope, it is still being used to indicate its historical significance rather than its literal meaning.[1] The term laparoscopy is now commonly used for both the intraperitoneal and the extraperitoneal endoscopic procedures, but to specify them, it is preceded by the adjectives of transperitoneal and retroperitoneal. However, some continue to call them laparoscopy and retroperitoneoscopy.

As retroperitoneal organs are routinely exposed by an extraperitoneal approach at an open operation, retroperitoneal laparoscopy automatically becomes the procedure of choice for endoscopic exploration of these organs. Though, transperitoneal laparoscopy has been performed for more than 50 years, mainly as a result of the pioneering work done by Semm in the field of operative laparoscopic gynaecology,[2] retroperitoneal laparoscopy could not become popular because of the uniformly poor results in the past.

The reason for the failure of retroperitoneal laparoscopy in the past was the copycat attitude of the workers in this field. They tried to perform retroperitoneoscopy the same way as laparoscopy was being performed without realizing that there was no preformed space in retroperitoneal area. Quite naturally, they failed to create a satisfactory pneumoretroperitoneum merely by insufflation through a Veress needle.

Some progress was made only after the realization that some type of disruptive force to break up the tough fibrous trabeculae and dense areolar and fibro-fatty tissue in the retroperitoneum was necessary to allow creation of a satisfactory pneumoretroperitoneum.[3] Bartel in 1969 first reported endoscopic visualization of the pelvic retroperitoneum with a mediastinoscope4 and some 5 years later, Wittmoser performed a retroperitoneal endoscopic lumbar sympathectomy.[5] The technique called ‘lumboscopy’ was extensively used and popularized by Sommerkamp (1974) for exposing the kidney for renal biopsy.[6]

However, it was a direct vision semi-open technique, requiring specially designed long slender suction cannula, clip applicator, aspiration needle, biopsy forceps and endoscopic scissors. It was a simple and economical procedure as no endocamera, telescope or pneumoinsufflation was required. However, it could not be widely accepted due to the field of vision and the access being limited.

Retroperitoneal laparoscopy, using a laparoscope and pneumoinsufflation, was only started in 1979 by Wickham, for performing a ureterolithotomy.[7] However, subsequent attempts at retroperitoneal laparoscopy by Wickham and Miller (1983) were not encouraging due to their inability to create a satisfactory pneumoretroperitoneum.[8]

Thinking in the line of using some disruptive force to open up the retroperitoneal space, Bay-Nielsen and Schultz (1982) and Clayman et al (1985) performed retroperitoneal endoscopic ureterolithotomy, by using a laryngoscope and an Amplatz sheath respectively.[9,10] The laparoscope was used by Eshghi et al (1985) to monitor percutaneous transperitoneal removal of a staghorn calculus in a pelvic kidney. Weinberg and Smith (1988) performed a nephrectomy in a pig by sucking it out through a nephrostomy with an endoscopic ultrasonic aspirator.[11,12] They had to perform prior embolization of the renal artery and the vein for obtaining haemostasis.

It was Clayman’s historical report of a transperitoneal laparoscopic nephrectomy in 1991 that created world wide interest in laparoscopic surgery of the retroperitoneal organs. Clayman et al had also performed a retroperitoneal laparoscopic nephrectomy, but their subsequent nephrectomies were mostly performed transperitoneally, as they considered the retroperitoneal approach to be very unsatisfactory.[13,14]

Retroperitoneal laparoscopy only took off after Gaur reported his innovative balloon technique of dissection of the retroperitoneal space prior to pneumoinsufflation in 1992.[15,16] The impact of this discovery was so great that compared to less than a dozen articles on retroperitonesocopy published during the last 80 years, more than a dozen appeared in the world literature within a year.[17-31]


In spite of this sudden surge in the retroperitoneal laparoscopic activity, the urologists were unable to compete with the general surgeons and the gynaecologists. This is shown by the fact that so far their contribution has been a mere 6% of the total number of laparoscopic articles published in the world medical literature.

There are two explanations for this gross disparity between the urological and the non-urological laparoscopic activity. One is that most urological laparoscopic procedures have a steep learning curve, especially if performed by the retroperitoneal approach. The urologist has to perform a relatively larger number of procedures to have the same degree of confidence as his counterparts in other specialties, where most of the work consists of simpler procedures on the appendix, gall bladder and the fallopian tubes.

The other reason is that, while an average laparoscopic urologist is mostly searching for an indication, his colleagues in general surgery and gynaecology, generally have a big waiting list for a procedures like cholecystectomy, appendectomy, herniorrhaphy, fundoplication and tubectomy.

There is one more reason for the smaller number of laparoscopic urological procedures being performed. While the role of laparoscopy in gynaecology and general surgery has been long established, its role for many urological procedures is still being debated.


Retroperitoneoscopic urological procedures like renal biopsy, varicocoelectomy, pelvic lymphadenectomy, renal cyst decortication, nephropexy and colposuspension were more frequently being performed earlier. However, most of these have either been discontinued or much less frequently performed. The reasons being that there are not many indications for such procedures or the long-term results are not satisfactory or alternative less invasive therapeutic procedures are available.


Nephrectomy for benign disease

Though, Gaur et al first published the report of simple nephrectomy by the retroperitoneal laparoscopic approach, Clayman et al had performed it earlier.[16] Since then retroperitoneal laparoscopic nephrectomy has become established as a minimally invasive procedure of choice for patients who have symptomatic benign non-functioning kidney.[32-34] The efficiency, efficacy and safety of the procedure is reflected in a recent series of 185 retroperitoneal laparoscopic simple nephrectomies by Hemel et al. They had an operative time of 100 minutes, an open conversion rate of 10.3% and major complication rate of 3.78%.[35] With more experience in this field even a tubercular nonfunctioning kidney can not be considered a contraindication any more.[36,37]


The first retroperitoneoscopic adrenalectomy was reported by Uchida et al and since then it has been performed by using both the posterior and the lateral approach.[33,34,38] Most surgeons agree that the upper limit of the size of the adrenal tumour for retroperitoneoscopic removal should not exceed 5 or 6 cm due to the high incidence of malignancy in larger tumours.[39,40] There are advocates who even suggest retroperitoneoscopic partial adrenalectomy. Sasagawa et al and Suzuki et al have used a stapler and an ultrasonic knife respectively for performing the procedure.[41,42] The results of retroperitoneoscopic and transperitoneal laparoscopic adrenalectomy have been compared by Fernandez-Cruz et al who found no difference in operative time, analgesic requirement, hospital stay and return to normal activity.[43] The results of transperitoneal laparoscopic, lateral retroperitoneoscopic and the posterior retroperitoneoscopic approaches have been compared by Baba et al who found that the posterior approach was most effective for retroperitoneoscopic adrenalectomy in regard to the simplicity of the vascular control.[44] The efficacy, efficiency and safety of the posterior retroperitoneoscopic approach has been shown in a recent series of 142 adrenalectomies by Waltz et al. They had an operative time of 101 minutes, success rate of 95% and there were no major complications.[45] However, Gill et al and Suzuki et al claim that a lateral retroperitoneoscopic approach is equally effective, simple and safe.[46,47]


Reconstructive urological procedures

Reconstructive retroperitoneoscopic surgery has not yet been widely accepted because of the inherent problems in laparoscopic suturing and the problems of manipulation due to limited space available. Due to this reason, non-dismembered pyeloplasty procedures for ureteropelvic junction obstruction like, exopyelotomy and Fenger-plasty were initially performed.[48,49] However, very soon they were followed by retroperitoneoscopic dismembered pyeloplasty.[50-52] The efficiency and efficacy of the procedure has been shown by Eden et al to be quite with a mean operative time of 164 minutes, open conversion rate of 4% and success rate of 95%.[53]

Tomour nephrectomy

Retroperitoneal laparoscopic radical nephrectomy is slowly gaining popularity for the treatment of T1-T2 NOMO renal tumours since it was first reported by Kinukawa et al in 1995.[54] Clayman et al study have shown that the results of laparoscopic radical nephrectomy for T1-T2 renal tumours up to 10 cm were quite comparable with those of open radical nephrectomy series. They had no port site recurrence in any patient.[55] Gill et al have not only shown identical results but these authors also claim that T1-T2 NOMO tumours even as large as 12 cm can be safely removed by the retroperitoneal laparoscopic approach.[56]

Radical nephroureterectomy

Gill et al have used a novel endoscopic approach for excising a cuff of bladder for this purpose and have recently compared the results of retroperitoneoscopic radical nephroureterectomy and the open procedure.[57,58] Their conclusion was that laparoscopy was superior in regard to surgical time, blood loss, specimen weight, resumption of oral intake, narcotic analgesia requirements, hospital stay, return to normal activities and convalescence. In an attempt to further simplify the procedure, Salomon et al use a small iliac incision for distal ureterectomy and excision of the cuff of bladder and Igarshi et al employ a gasless hand assisted retroperitoneoscopic technique.[59,60]

Nephron sparing surgery

Gill et al reported retroperitoneal laparoscopic partial nephrectomy using a double loop apparatus and argon beam coagulator for acquiring haemostasis.61 Various modalities for achieving haemostasis during this procedure like ultrasound, radiofrequency, microwave, cable-tie, fibrin glue, biological glue, hydro jet and electrosurgical snare have been used from time to time.[62-67] Though retroperitoneal laparoscopic renal cryoablation, is a much simpler nephron-sparing procedure, is safe and effective but its long term results are still awaited.[68]

Ureteral surgery

The real indication for retroperitoneal laparoscopic ureteral surgery is a salvage ureterolithotomy as an alternative to an open procedure in patients where URS and ESWL have failed. However, Gaur has even recommended the retroperitoneoscopic approach as a primary procedure, if one feels that the chances of failure with the existing minimally invasive procedures could be high due to size of the stone, degree of its impaction or a co-existing ureteral anomaly.[69] It is also an excellent approach for ureterolysis, treatment of ureteral stricture or retrocaval ureter.

Renal stone surgery

After Gaur et al reported the first retroperitoneal laparoscopic pyelolithotomy in 1994, only a few papers appeared in the medical literature.[70-72] On account of its being less invasive to the renal parenchyma and having a better chance of total stone clearance, it may be given priority over percutaneous nephrolithotripsy in select group of patients with large renal stones.[73] With advances in technique and instrumentation, retroperitoneal laparoscopic pyelolithotomy might become an acceptable minimally invasive alternative for patients with staghorn stones in due course of time.

Live donor nephrectomy

Though, retroperitoneoscopic live donor nephrectomy was performed sometime back, it could not become popular mainly due to the problem of limited space.[74] Gasless retroperitoneoscopy assisted live donor nephrectomy being a simpler procedure is slowly gaining acceptance.[75,76] Even a hand assisted standard retroperitoneoscopic live donor nephrectomy has recently been reported.[77]

Radical prostatectomy

Schuessler et al reported the first laparoscopic radical prostatectomy in 1992 and Guillonneau et al later popularized the technique using the transperitoneal laparoscopic approach.[78,79] The retroperitoneal laparoscopic surgeons are not far behind and Bollens et al have even performed it retroperitoneoscopically and have since reported 42 procedures with a reasonable mean operative time of 317 minutes.[80]


It is hoped that it would soon be possible to universally perform almost all reconstructive and ablative urological procedures by the retroperitoneal laparoscopic approach.

However, this would require perfection in the already existing tissue approximation techniques, tissue retrieval methods, tissue ablation techniques, haemostasis techniques, intraoperative imaging techniques, 3-D video imaging, virtual reality, telerobotics and miniaturized robotics.[81-82] The invasiveness of the retroperitoneal laparoscopic procedure would be further reduced by the use of needlescopes and microlaparoscopic instruments, which are at present only being used for the transperitoneal procedure.[83] This is because of the problem of needlescopic access to the retroperitoneal space and it is hoped that soon this barrier would also be overcome.


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