CONTEXT:The retroperitoneoscopic or retroperitoneal (RP) surgical approach has not become as popular as the transperitoneal (TP) one due to the steeper learning curve.AIMS:Our single-institution experience focuses on the feasibility, advantages and complications of retroperitoneoscopic surgeries (RS) performed over the past 10 years. Tips and tricks have been discussed to overcome the steep learning curve and these are emphasised.SETTINGS AND DESIGN:This study made a retrospective analysis of computerised hospital data of patients who underwent RP urological procedures from 2003 to 2013 at a tertiary care centre.PATIENTS AND METHODS:Between 2003 and 2013, 314 cases of RS were performed for various urological procedures. We analysed the operative time, peri-operative complications, time to return of bowel sound, length of hospital stay, and advantages and difficulties involved. Post-operative complications were stratified into five grades using modified Clavien classification (MCC).RESULTS:RS were successfully completed in 95.5% of patients, with 4% of the procedures electively performed by the combined approach (both RP and TP); 3.2% required open conversion and 1.3% were converted to the TP approach. The most common cause for conversion was bleeding. Mean hospital stay was 3.2 ± 1.2 days and the mean time for returning of bowel sounds was 16.5 ± 5.4 h. Of the patients, 1.4% required peri-operative blood transfusion. A total of 16 patients (5%) had post-operative complications and the majority were grades I and II as per MCC. The rates of intra-operative and post-operative complications depended on the difficulty of the procedure, but the complications diminished over the years with the increasing experience of surgeons.CONCLUSION:Retroperitoneoscopy has proven an excellent approach, with certain advantages. The tips and tricks that have been provided and emphasised should definitely help to minimise the steep learning curve.

What ' s known on the subject? and What does the study add? For long complex anterior urethral stricture augmentation urethroplasty is considered the standard procedure but the best substitute material is still to be ascertained.Preputial/penile skin is a very good substitute especially when used as a dorsal onlay. It demonstrates exceptional functional and cosmetic results even in patients with unsuitable oral mucosa. OBJECTIVE• To present our experience of single-stage reconstruction of urethral stricture with preputial/penile skin fl ap, as a dorsal onlay fl ap (DOF) where there is an adequate urethral plate and as a tubularized fl ap (TF) where there is a compromised urethral plate, in cases of complex anterior urethral strictures. MATERIALS AND METHODS• We retrospectively reviewed 144 patients, who underwent single-stage repair of pendular /bulbar urethral strictures with preputial/penile fl ap as either a DOF or a TF, between January 2001 and December 2008.• Patients were divided into three groups: Group 1 consisted of patients who underwent transverse preputial DOF; Group 2 consisted of those who underwent tube urethroplasty; and Group 3 consisted of those patients who were circumcised and for whom the penile skin was used as a DOF (circumpenile fl ap).• Patients were followed up by physical examination, retrograde urethrography, urofl owmetry and post-void residual urine measurement. RESULTS• The mean follow-up was 40.1 months (range 36 -84 months).• The primary success rates at 1 year follow-up were 90, 85 and 93.3% for Groups1, 2 and 3, respectively, and at 3-years follow-up they were 85, 75 and 86.7%, respectively.• Half of the recurrences were successfully managed with a single visual internal urethrotomy or dilatation.• The secondary success rate was defi ned as recurrent stricture managed by a single endoscopic procedure and was 5, 10 and 6.8% in Groups 1, 2 and 3, respectively. The overall success rate was 90.85 and 93.3%, respectively.• A total of 75% of the patients in the study completed 60 months of follow-up with no additional recurrence. CONCLUSIONS• A preputial/penile fl ap for complex anterior urethral stricture is a good treatment option, with results similar to other techniques, has acceptable donor site morbidity and is effective even in circumcised patients and for those patients with unsuitable oral mucosa.• A DOF is less likely to lead to diverticula formation and post-void dribbling. TFs have a higher failure rate than DOFs but, when combined judiciously with secondary endoscopic procedures, can provide good results. KEYWORDS