Patient Positioning and Retroperitoneal Access

The lateral decubitus position is utilized. The first port is placed via an open access technique just below the tip of the 12th rib. The flank muscle fibers are separated bluntly, and the thoracolumbar fascia pierced with a hemostat or fingertip. The posterior pararenal space is developed initially with the index finger and further developed with a balloon dilator.

In our experience of retroperitoneoscopy for pyeloplasty and nephrectomy, we have found that when this space is first developed with the index finger, it is important not to sweep the finger anteriorly because this can tear the peritoneum.

Sung et al. (53) also state that it is important to finger dissect along the psoas and therefore stay outside of Gerota's fascia. The authors describe balloon dilation using a commercially available trocar-mounted balloon dilator. We use a similar system for extraperitoneal laparoscopic radical prostatectomy; however, for retroperitoneoscopy, to provide maximal protection to the peritoneum, we utilize the middle finger of a number 8 glove secured with a silk tie to the tip of an 18 French urethral catheter and instill, depending on the patient's body habitus, 500 to 700 mL of saline into the catheter.

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