Retroperitoneal Pyelolithotomy for Management of Renal Calculi, Chander J et al. Gerota’s fascia was either incised under vision or breached with the fingertip. The balloon was inserted and inflated with air (approximately 500 mL) inside Gerota’s fascia. The balloon was kept inflated for 3 to 5 minutes to achieve homeostasis. In cases where it was not possible to gain entry inside Gerota’s fascia, the balloon was inflated posterior to the kidney; a 0° telescope was introduced through this port; and the peritoneum was further stripped off the transversalis fascia with counterpressure from the opposite side. A second 10-mm port was placed in the line of the first port above the iliac crest. A third 5-mm port was placed anteriorly mid way between the first 2 ports in such a manner that the 3 ports formed an equilateral triangle. Secondary ports were inserted with finger guidance. A laparoscope was introduced through the first port after suitably tightening the incision around it. A 5-mm triflange retractor introduced through the third port was used to retract the kidney anteriorly. Dissection was carried out through the second port. We prefer to approach the pelvis directly; however, in cases where the pelvis is either not easily accessible or an aberrant vessel is present, the upper end of the ureter is exposed and traced upwards to the pelvis. The pelvis was dissected and a pyelotomy incision made with a hook dissector by using monopolar cautery. Gilvernet’s plane was dissected wherever neces- sary to carry out the extended pyelolithotomy. A longitu- dinal pyelotomy incision was made in patients with a single calculus in the renal pelvis; however, in cases of extended pyelolithotomy, a curvilinear pyelotomy inci- sion was made with extension of the incision into the appropriate calyx. After extraction of the calculus, the pyelotomy incision was closed meticulously with 3– 0 Vi- cryl. The operated area was drained with a draining tube and the wound closed. The drain was removed when drainage was less than 25 mL/day. The double “J” ureteral stent was removed on an outpatient basis. Postopera- tively, the kidneys, ureter, and bladder were x-rayed in all cases to confirm stone clearance. RESULTS The average operating time was 81 minutes. In the first half of the patients, it was 94 minutes, and in the second half, it dropped to 69 minutes. Of the 56 patients who underwent RP, 47 had extrarenal pelvis while 7 patients had intrarenal pelvis, and 2 patients had total intrarenal pelvis. Blood loss varied from 15 mL to 60 mL with the average being 27 mL. No blood transfusion was required in any of the patients. The drainage ranged from 1200 mL/day to 50 mL/day. Average drainage was 164 mL/day in the first 48 hours. The drain removal ranged from 48 hours to 7 days. The drain was removed in the first 48 hours in 34 (61%) patients. The drain was removed when- ever the drainage was less than 25 mL/day. Overall, stone clearance occurred in 54 of the 56 patients (96.4%). It was 100% in cases of pelvic renal calculi, and 2 of 6 failures occurred in caliceal calculi. The postoperative analgesic requirement was less, and on average, the pa- tients required 2 tablets of diclofenac sodium (100 75 mg of diclofenac). The average duration of hospital stay was 4.3 days. Time taken to resume normal activities was 1 0.3 days, and the number of person-days lost was 7.4 3.1 days. Two patients had peritoneal rents while performing retroperitoneal balloon dissection. Three pa- tients had balloon rupture while the retroperitoneal space was being created. There were no vascular, visceral, or neural complications during the course of the study. Two conversions to open pyelolithotomy were necessary due to nonprogression of surgery for more than 45 minutes; both were cases of caliceal calculi. Three patients devel- oped subcutaneous emphysema, and 2 patients devel- oped superficial wound infection of the port sites. DISCUSSION The development of retroperitoneoscopic surgery includ- ing RP has been slow compared with that of transperito- neal laparoscopic surgery due to the inability to establish adequate pneumoretroperitoneum with direct introduc- tion of a needle into the retroperitoneum. However, the advent of the balloon dissection technique by Gaur6 in 1992 has opened new horizons in the field of retroperito- neoscopic surgery. Gaur et al7 reported a small series of 8 cases of retroperitoneoscopic pyelolithotomy in 1994 with a success rate of 62%. Subsequently, Micali et al8 in 1997 reported a series of 11 cases and Hemal et al9 in 2001 reported a series of 7 cases with success rates of 90% and 71%, respectively. Of the 3 studies available for compari- son, 2 adopted the retroperitoneal approach, and the third was done through the transperitoneal route7–9 (Table 1). These studies had a small number of patients ranging from 7 to 11 with success rates varying from 62% to 90%. However, in the present study, the success rate is 96.4%, and the higher success rate could be because of the greater experience gained over time. In our study, success was 100% in pelvic calculi, and 2 failures occurred in caliceal calculi. Based on our experience so far, the pro- cedure does not seem suitable for caliceal calculi unless the pelvicaliceal system is dilated. Moreover, at present, 98 JSLS (2005)9:97–101