Retroperitoneal Pyelolithotomy for Management of Renal Calculi, Chander J et al. have resulted in the aforementioned problem. In this study, Gilvernet’s plane was dissected in 10 cases. It is easier to dissect Gilvernet’s plane in RP compared to in open surgery because the laparoscope offers a direct view of the renal sinus with excellent anatomical display of all the structures, which is often not possible with the naked eye. In this series, the only significant complications were peritoneal rent, subcutaneous emphysema, and superfi- cial wound infection. But the peritoneal rent did not create much difficulty in dissection and the progression of surgery. All 3 patients who had peritoneal rent were thin and emaciated. Therefore, the peritoneum was adherent firmly to the psoas sheath; and in the absence of a fat cushion, the peritoneum and the psoas sheath were not easily separable, thereby leading to peritoneal rent due to forced separation. In emaciated and small-sized patients, the balloon should not be inflated to full size, which often leads to peritoneal rent. It was observed that inflation of the balloon to 400 mL prevented peritoneal rent in such cases. Excess fat is a disadvantage in RP, as it occupies a major portion of otherwise confined space, leaving little room for dissection and retraction. Also, it leads to bleed- ing during dissection, but a moderate amount of fat was found suitable as peritoneum could be separated easily and dissection was relatively easier. It is advantageous to insert the balloon inside Gerota’s fascia and posterior to the kidney, so that only the posterior half of Gerota’s fascia and perinephric fat are striped off. The anterior half of fascia is kept adherent to the kidney, which helps in keeping the kidney in a relatively fixed position. Follow- ing creation of pneumoretroperitoneum, kidney ‘hangs up’ with the posterior half exposed, thereby requiring a minimal retraction. Subcutaneous emphysema could be another major prob- lem in RP. In our study, this complication was kept to a minimum with the use of the Tristar port (Ethicon Endo- Surgery, Inc., Cincinnati, OH), which has a conical sleeve with a flange around the port that tightly fits into the primary incision and thereby prevents leakage of carbon dioxide gas into parietes. Bleeding in the retroperitoneum can be of either generalized ooze from the dissected peritoneum and parietis or from a specific operative site like the renal pelvis. Keeping the balloon inflated for 3 to 5 minutes to achieve perfect homeostasis can easily con- trol the first type of bleed. The second type of bleed, that is the bleed from a specific operative site, can be mini- mized by precise knowledge of retroperitoneal anatomy and meticulous dissection. It is necessary to place the double “J” ureteral stent pre- operatively as it is very difficult to insert the stent from the ports intraoperatively due to the paucity of space and continuous leakage of gas. When this occurs, the proce- dure becomes very cumbersome. Also, the double “J” ureteral stent acts as a guide and helps the surgeon to localize the stone. To decrease the morbidity related to prolonged drainage, meticulous closure of the renal pelvis should be carried out. Therefore, it is recommended that surgeons, who are well versed with intracorporeal knot- ting techniques, should perform this procedure. The mean total analgesic requirement for RP is 100 75 mg of diclofenac, which is equivalent to 2 tablets of diclofenac. However, in a parallel study conducted by us, the difference was significant when compared with that of ESWL, where the mean total requirement of diclofenac was 1000 600 mg. This difference is highly significant and can be explained by the fact that passage of stone fragments causes ureteric colic requiring round-the-clock analgesic cover for several days after ESWL. The number of hospital visits in patients undergoing RP was 2.7 0.5. This is significant, as the patients managed with ESWL required multiple visits to the hospital (4.5 2.8) CONCLUSION RP is a safe, simple, and effective minimally invasive procedure and is an exciting option for management of renal calculi. It has potential to replace PCNL/ESWL as a procedure of choice in a subset of patients with staghorn, large, and multiple calculi. Although at present, it seems relatively unsuitable for caliceal calculi, with more expe- rience and the availability of better hand instruments, even caliceal calculi may become equally amenable to this procedure. References: 1. Doublet JD, Barreto HS, Degremont AC, Gattegno B, Thibault P. Retroperitoneal nephrectomy: comparison of lapa- roscopy with open surgery. World J Surg. 1996;20:713–716. 2. Rassweiler JJ, Henkel TO, Stock C, et al. Retroperitoneal laparoscopic nephrectomy and other procedures in the upper retroperitoneum using a balloon dissection technique. Eur Urol. 1998;33(5):489 – 496. 3. Uno Y, Katoh N, Kinukawa T, Matsura O, Ohshima S. Lapa- roscopic nephrectomy via the retroperitoneal approach. J Urol. 1996;156:1101–1104. 4. Clayman RV, Kavoussi LR, McDougall EM, et al. Laparo- 100 JSLS (2005)9:97–101