Upper Tract Retroperitoneal Access Techniques

Abstract

The laparoscopic approach has been applied to a wide variety of procedures in the field of urology. Since urologists initially adopted laparoscopy from other specialties, most procedures described have been based on the traditional transperitoneal approach. Well-defined organ systems and a relative paucity of intraperitoneal fat allow the rapid identification of landmarks. Instilled gas expands the space in a predictable manner to enable optimal visualization. In contrast, it is technically difficult to develop a consistent working area in a potential retroperitoneal space occupied by areolar and fat tissues. This may explain why most initial urological laparoscopic procedures have been performed transperitoneally. Initial efforts to establish a retroperitoneal working space have been limited by inadequate distention of the retroperitoneal space, but over the last decade several techniques for retroperitoneal access have been described. We describe the increasing experience at various centers over the years, which have led to refinement of retroperitoneal laparoscopic access techniques, utilizing different access devices. Methods that take advantage of the strengths, while overcoming the perceived disadvantages of this approach have been explained.