Attempts at retroperitoneoscopy have mostly failed in the past due to the inability to create an effective pneumoretroperitoneum because of the dense areolar tissue binding the fat in the retroperitoneum, which could not be broken down merely by pneumo-insufflation. The newly devised balloon breaks the septae, lifts the peritoneum atraumatically and creates a workable space in the retroperitoneum. The view of the retroperitoneal structures provided is satisfactory. With this balloon dissector we have performed laparoscopic ureterolithotomy, renoscopy and renal biopsy, para-aortic lymph node biopsy and ligation of the internal spermatic vein.

Objective To analyse the technical details and the longterm results of laparoscopic ureterolithotomy. Patients and methods Laparoscopic ureterolithotomy was undertaken in 101 patients between 1991 and 2001; in only one patient with retroperitoneal ®brous adhesions was the procedure transperitoneal, being retroperitoneal in all the others, using Gaur's balloon retroperitoneoscopy. The mean (range) stone size was 16 (10±47) mm, and the stones were in the upper ureter in 75, mid-ureter in 11 and lower ureter in 15 patients. Nine patients had more than one stone, the maximum being six, in a megaureter. Most were impacted for >2 months, the maximum being 240 months. Results Laparoscopic ureterolithotomy was successful in 93 patients, with the eight failures being mostly early in the series. The mean operative duration was 79 min (66 min when the ureter was left open and 92 min when it was sutured). The overall mean duration of urinary leakage was 5.5 days, which was reduced to 3.2 days by stenting and suturing the ureter. The mean (range) blood loss was 25 (5±100) mL. The overall complication rate was high (31%) because of prolonged urinary leakage in 20 patients. No patient required morphine for pain relief and the mean for oral analgesic use was 2.5 days. The mean hospital stay was 3.5 days and that for resuming work 14 (7±28) days. Conclusions Laparoscopic ureterolithotomy by the retroperitoneal approach is a safe and reliable minimally invasive procedure. Although its role as a salvage procedure for failed extracorporeal shock wave lithotripsy and ureteroscopy is undisputed, in selected patients with large chronically impacted ureteric stones and particularly with solitary kidneys, it may be considered the ®rst-line treatment.

Pre-transplant nephrectomy was done in a 25-year-old man for calculous pyelonephritis using a retroperitoneal laparoscopic approach with a newly devised ligature applicator-dissector- kidney retractor.

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