In this study, the results of laparoscopic pyelolithotomy using transperitoneal or retroperitoneal approaches were compared by a single surgeon. The success rates were similar between the two groups, but the retroperitoneal approach led to faster recovery and lower rates of postoperative fever and intraoperative hemorrhage. This study, involving 104 patients, suggests that the retroperitoneal approach may be a better option for treating patients with large kidney stones. Another study by Al-Hunayan et al compared transperitoneal and retroperitoneal laparoscopic pyelolithotomy in 48 patients with kidney stones larger than 3 cm and found that patients in the TLPL group had longer hospital stays than RLPL. They reported no significant difference in blood loss between the two groups, but the operative time favored the retroperitoneal group. It should be remembered that the TLPL group in their study had a higher BMI [17]. In contrast, our study showed no significant difference in the operative time between the two groups. The transperitoneal approach aids in finding the pelvis faster due to anatomical landmarks and provides a wider working space for easier suturing. Conversely, in the retroperitoneal approach, there is no need for bowel reflection, especially for the left-sided kidney, which may contribute to decreased operative time. Nevertheless, limited working space in the retroperitoneal approach causes difficulties in intracorporeal suturing and stent placement. In the Al-Hunayan series, 33% of the pyelotomy incisions were left unclosed in the retroperitoneal approach compared with 18% in the transperitoneal approach [17]. Similarly, in Abat's report for ureterolithotomy, JJ stent was not placed in 32% of patients in the retroperitoneal group which may have caused prolonged leakage in this group [16]. Large working space in the TLPL may work as a double-edged sword when the stone migrates to the peritoneal cavity. This may prolong the operative time or cause collection between bowel loops if unnoticed. Al-Hunayan reported a case of peritonitis due to an unrecognized migrated stone into the peritoneal cavity during TLPL. They performed open laparotomy and exploration to remove the infected collection. Similarly, infected urine may affect the recovery of bowel function after TLPL. In the reported series, the postoperative ileus is higher after TLPL [17]. Even non-infected urine, including tiny stone particles, may contain bacterial products that could be linked to a higher rate of postoperative fever in patients undergoing TLPL in our study [12]. This complication would be eliminated using RLPL.
In a meta-analysis of randomized controlled trials comparing percutaneous nephrolithotomy (PCNL) with laparoscopic pyelolithotomy (LPL), both groups had a similar average hospital admission period of 4.8 and 4.5 days, respectively [11]. However, our study showed that patients who underwent RLPL had a faster discharge of 2.3 days on average. Specifically, 92% of patients in the RLPL group were hospitalized for less than three days, including the operative day, whereas this rate was 70% for the TLPL group. This suggests that RLPL is associated with faster recovery and can be a viable alternative to the trend of discharging patients more quickly after the PCNL procedure [19]. The learning curve for laparoscopic pyelolithotomy is steep, especially when it comes to challenges such as removing the staghorn stone from the pyelotomy incision, intracorporeal suturing, and placing a JJ stent. Since this procedure is typically performed by surgeons experienced in advanced laparoscopic procedures, there is limited data on the learning curve for laparoscopic pyelolithotomy. In contrast, it has been reported that an inexperienced surgeon would need to perform around 60 cases of percutaneous nephrolithotomy (PCNL) to achieve surgical competence [20]. The transperitoneal approach is considered easier due to the wider working space, making suturing easier and providing more familiar anatomical landmarks. This is particularly important in academic settings where the procedure is being taught to less experienced surgeons. A study comparing the results of retroperitoneal versus transperitoneal laparoscopic ureterolithotomy found that the mean hospital stay and urinary leakage were higher in the retroperitoneal approach while operating time was longer in the transperitoneal approach. However, this study had limitations, such as significant differences in stone size favoring the retroperitoneal group, and comparing two different surgeons performing each approach [16]. A key advantage of our study is that all operations were performed by a single surgeon, ensuring consistency in patient care. However, the surgeon had prior experience with the transperitoneal approach before transitioning to the retroperitoneal approach, which may have influenced the results. Nonetheless, the operative time was similar between the two approaches. Despite these findings, there is a need for a randomized clinical trial to be conducted in a center experienced in both approaches to provide more conclusive evidence.