Retroperitoneoscopy is our preferred technique for performing laparoscopic renal and adrenal surgery in most instances. The one exception is partial nephrectomy. Currently, our primary indications for transperitoneal laparoscopy include large renal and adrenal masses, cryoablation of anteriorly located renal tumors, partial nephrectomy for anterior and lateral tumors, pyeloplasty, and living donor nephrectomy. Compared with transperi-toneal laparoscopy, retroperitoneoscopy is associated with a sharper learning curve. Meticulous attention during port placement is critical to ensure optimal positioning. Although the retroperitoneum initially affords a smaller working space than the peritoneal cavity, as the dissection proceeds, the retroperitoneal space can be readily enlarged and developed as necessary. Retroperitoneoscopy does offer potential advantages. Foremost is the facile exposure of the renal hilum. Because the bowel is not manipulated, paralytic ileus may be minimized. Inadvertent injury to peritoneal viscera is minimized, yet not eliminated, since intraperitoneal organs are separated only by the peritoneal membrane. The techniques discussed here have become an integral part of the training program in our department, and our experience to date indicates that the learning curve of retroperito-neoscopy will be significantly shorter for the subsequent generation of surgeons.

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