Retroperitoneal vs transperitoneal laparoscopic lithotripsy of 20-40 mm renal stones within horseshoe kidneys

Figure 1 The trocar position during laparoscopic treatment. A: Transperitoneal procedure: Two 10-mm trocars were placed, one at the umbilicus and the other 2 cm below the umbilicus adjacent to the rectus sheath, respectively. The trocar at the umbilicus was the camera port. A 12-mm trocar was inserted 2 cm below the costal margin in the mid-clavicular line. The other two 5-mm trocars were placed 2 cm below the costal margin in the anterior axillary line and midaxillary line, respectively; B: Retroperitoneal procedure: One 10-mm trocar was located 1 cm above the level of the iliac crest in the midaxillary line as the camera port. One 12-mm trocar was placed 2 cm below the costal margin in the anterior axillary line. One 5-mm trocar was inserted 1 cm below the costal margin in the posterior axillary line.

Figure 2 Key operative steps in representative cases of the retroperitoneal group (A-E) and the transperitoneal group (F-J). In the upper row: (A) The isthmus (i) was supplied by an aberrant artery (a) from the abdominal aorta (aa). (B) The isthmus was completely isolated with a stapler. (C) The isthmus (i) was moved back to expose the ureter (u). (D) At the guideline of the ureter (u), the pelvis (p) was exposed and dissected to remove the stone. (E) A Double-J stent was inserted into the ureter (u). In the bottom row: (F) The isthmus (i) was exposed. (G) Anastomosis of the isthmus (i). (H) The isthmus was dissected by Mayo scissors. (I) The pelvis (p) was exposed and dissected to remove the stone. (J) A Double-J stent was inserted into the ureter (u).

Figure 3 Preoperative and postoperative imaging examination. A and C: Preoperative imaging examination; B and D: Postoperative imaging examination.