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I perform the classic Montsouris technique. I simply believe that this allows one to preserve the neurovascular bundle along its entire course with minimal traction in an antegrade direction. What I mean specifically is, during the Montsouris technique the seminal vesicles are dissected at the onset of the operation. By approaching the seminal vesicles in this fashion, one is able to virtually pluck the seminal vesicles out of their vascular bed and tease the nerve bundles off the seminal vesicles with excellent visualization, as there is minimal bleeding early in the operation. This is in contrast to the extraperitoneal approach, where the seminal vesicles are approached late in the dissection after the bladder neck has been divided. With this approach, one has to reach down and dig the seminal vesicles out from a hole with limited visualization, due to bleeding as well as urine in the field; and I am convinced that this is likely to result in more traction on the nerve bundles.

Placement of a trocar two fingerbreadths above the pubic symphysis in the midline improves retraction during the procedure, especially with upward mobilization of the seminal vesicles and vas deferens. I also use stay sutures placed at the base of the prostate, so that the assistant can better retract the prostate via the suprapubic port. This allows for easier development of the recto-prostatic plane. The third trick that I like to use is to over-inflate the Foley catheter just prior to division of the prostato-vesical junction and then have the assistant intermittently pull on the catheter to help define the bladder neck. I found that by doing this I can initially start my dissection sharp and then with the other assistant providing superior traction on the bladder and the assistant using the catheter, pulling the catheter upward, that this plane will develop very easily.

Iatrogenic injuries, both endoscopic and external, are currently the most common cause for ureteral strictures. Endoscopic treatment is the appropriate initial management option for short-segment strictures causing partial ureteral obstruction. Reconstructive procedures are reserved for strictures that are longer, obliterative, or that have failed endoscopic treatment. The reconstructive treatment options range from primary ureteroureterotomy, uretero-neocystostomy, psoas-hitch, Boari flap, and ileal ureter interposition, depending on the length and location of strictures. In select patients, these surgical techniques can be been performed laparoscopically with success.

We are dealing with pediatric patients. Pediatric open surgical results are already excellent. So indications and results should be carefully assessed. There should be the least possible blood and nephron loss. In children, the space is very limited for trocar placement. Working space is also limited, especially when using the retroperitoneal approach. Monopolar diathermy should be used with extreme caution. We prefer using bipolar diathermy at all times.

In preparation, whether one is doing a simple nephrectomy or a more complex case, I think one always has to be prepared for complications, the most significant being vascular and bowel-related. As far as vascular injuries are concerned, I always have my laparoscopic suture instruments and the laparoscopic applicators available in the room, not necessarily open, but they should always be in the room. The nice thing about the Lapra-Ty® is that you can get a 5–6-inch length of suture and put a Lapra-Ty on the end of it and you can rapidly sew and follow yourself. For example, let’s say you lacerate the gonadal vein. One important thing, I think, is always to be aware of the colon during kidney and adrenal surgery. Colonic injuries can be devastating. The presentation of a patient with a bowel injury is distinctly different from the presentation of a patient after open surgery. A patient with bowel injuries due to laparoscopic surgery tends to present with unique symptoms. They generally do not have peritonitis, but what they do tend to complain about is pain localized to one trocar site.