Volume 49, Issue 2, Pages 264-272 (February 2006) Retroperitoneoscopic Pyeloplasty for Ureteropelvic Junction Obstruction (UPJO): Solving the Technical Difficulties  A. Bachmann, R. Ruszat, T. Forster, D. Eberli, M. Zimmermann, A. Müller, T.C. Gasser, T. Sulser, S. Wyler  European Urology  Volume 49, Issue 2, Pages 264-272 (February 2006) DOI: 10.1016/j.eururo.2005.12.036 Copyright © 2005 Elsevier B.V. Terms and Conditions

Fig. 1 Building the self-made dissection balloon. To create the balloon, two mid fingers of a powder-free surgical glove are placed one inside the other and ligated onto the trocar sheath (left). After instilling 800–1000mL cold sterile saline the retroperitoneal space is bluntly extended (right). At the picture an initial right-sided retroperitoneal space after blunty balloon dissection is seen. Important anatomical structures are identifiable: P, peritoneum and the lower part of Gerotas’- fascia (medial); PR, peritoneal reflexion (ventral); LW, lateral abdominal wall (lateral); Psoas, virtual appearance of m. psoas (dorsal). European Urology 2006 49, 264-272DOI: (10.1016/j.eururo.2005.12.036) Copyright © 2005 Elsevier B.V. Terms and Conditions

Fig. 2 Peritoneal reflexion zone (PR). When turning the 30° optical system of the laparoscope just parallel to the inner layer of the abdominal wall, the peritoneal reflexion is easily identified. European Urology 2006 49, 264-272DOI: (10.1016/j.eururo.2005.12.036) Copyright © 2005 Elsevier B.V. Terms and Conditions

Fig. 3 Final trocar position for retroperitoneoscopic pyeloplasty. After entering the initial retroperitoneal space, the first 10-mm trocar is inserted just below the tip of the 12th rib. The second 5- or 12-mm trocar (depends if right- or left-sided operation) is inserted under vision control just 2–3cm away from the spina iliaca anterior superior in the anterior axillary line. The third 5-mm trocar is placed at the middle or one third between the connection line (dotted black line) of both already inserted trocars. The fourth trocar is optional and can be placed at the tip of the 10th or 11th rib. European Urology 2006 49, 264-272DOI: (10.1016/j.eururo.2005.12.036) Copyright © 2005 Elsevier B.V. Terms and Conditions

Fig. 4 The ureter-pelvic junction is longitudinally opened by a Pott scissor (P). First the pelvis is incised (left). Then the entire narrowed part of the ureter (U) is incised. After spatulating the remaining ureter for the following anastomosis, the obstructed ureter part is finally transacted (right). European Urology 2006 49, 264-272DOI: (10.1016/j.eururo.2005.12.036) Copyright © 2005 Elsevier B.V. Terms and Conditions

Fig. 5 Ureter-pelvic reanastomosis. Two 4-0 running sutures are carried out for anastomosis using a 15-cm slightly elastic monofil filament. At the end of each filament two absorbable clips (LT) are fixed. Starting from the most depend edge of the pelvic incision (a) and the apex of the spatulated ureter (b), the anastomosis of the dorsal wall (dotted green lines) is completed by a running suture (c-d). U, ureter; P, kidney pelvis; VC, vena cava. European Urology 2006 49, 264-272DOI: (10.1016/j.eururo.2005.12.036) Copyright © 2005 Elsevier B.V. Terms and Conditions

Fig. 6 Right-sided ureteropelvic reanastomosis. The first suture (JRB-1 4-0 Monocryl®) starts from outside-in at the most distant part of the pelvis (1). At the end of the filament two small absorbable clips are fixed. The suture is continued distally (2). Finally, the suture is tightened up carefully and two clips finish the first suture. The second suture is performed in the same way, starting at the most distant corner of the remaining incision. LT, Lapra-Ty®, absorbable clip; p, renal pelvis; LKP, lower kidney pole; u, ureter. European Urology 2006 49, 264-272DOI: (10.1016/j.eururo.2005.12.036) Copyright © 2005 Elsevier B.V. Terms and Conditions