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Laparoscopic and open stone surgeryafter inserting a Double-J stent (Figures 4 and 5).However, some authors state that a suture was not necessarywhen a stent was put in place. A drain should beinserted to prevent the formation of an urinoma irrespectiveof the closure technique (32, 38, 40, 49, 60).Retroperitoneal accessThe patient is placed in flank position. A 15 to 18 mmincision is made in the lumbar triangle (Petit´s triangle)between the twelfth rib and the iliac crest, bounded bythe lateral edges of the latissimus dorsi and externaloblique muscles. After creating a tunnel to the retroperitonealspace using overhold forceps for blunt dissection,the tunnel is dilated until an index finger can be inserted.The peritoneum is pushed forward by the index finger,a retroperitoneal cavity is created. Now the cavity iswidened using a balloon-trocar system. Under palpationwith the index finger, which is introduced through theprimary access, two secondary trocars (10 mm and 5mm) are inserted. The primary incision is closed arounda camera port to prevent gas leakage. The pneumoretroperitoneumis established using a maximum carbondioxide pressure of 12 mm Hg and a flow of 3.5l/min. A forth trocar can be inserted if needed.Independent of the retroperitoneoscopic procedure performed,Gerota’s fascia is incised completely. The psoasmuscle is exposed as the most important anatomicallandmark. Now, all further anatomical structures such asureter, spermatic/ovarian vein and the lower pole of thekidney can be exposed. The incision of the renal pelvisor of the ureter for stone removal is done in a similar wayas described for the transperitoneal access.Figure 4.Insertation of a Double-J-stent.Figure 5.Intracorporal suturing of the ureter after stone removal.DISCUSSIONTechnique of open and laparoscopic stone surgeryThe size and the location of a ureteral stone play animportant role in the decision between endourologicaltreatment, shock wave therapy, open surgical therapyand laparoscopic stone removal. As described in an articleby Park et al., there is a relevant difference in the successrates of ureteroscopic treatment of distal and proximalureteral stones (94.6% versus 75.0%). Freedom fromstones is achieved after one session of shock wavelithotripsy in 84% of all cases with a stone size up to 10mm, but only in 42% of the cases with larger stones (61).Pace et al. reported similar results of shock wavelithotripsy depending on stone size (74% in patientswith stones < 10 mm versus 43% in individuals withstones > 10 mm) (62). Keeley et al. however, stated thatindications for open and laparoscopic stone surgery willfurthermore be minimized due to technical improvementsin endourology (for example due to the introductionof Holmium laser in ureteroscopy) (37).This prediction will surely come true in Europe andNorthern America. In contrast, there is a completely differentsituation in developing countries. In those countries,a high incidence of huge renal and ureteral stonesis found, combined with very poor financial resourcesand problems in medical infrastructure and availabilityof modern endourological instruments. In this environmentopen stone surgery provides several advantages:The instruments needed are simple, wide-spread, inexpensiveand low-maintenance. The wages of medicalpersonal and the costs of operating facilities are low. Inopen surgery, the consumption of resources is significantlylower than in endourological procedures.Freedom from stones is usually reached within one singlehospital stay. This results with low costs for thepatients who usually do not have an adequate healthinsurance. Repeated hospital stays for the treatment ofthe same stone are avoided. Interestingly, Kijvikai andPatcharatrakul from Thailand reported that more andmore surgeons in their country use the benefits oflaparoscopy: Laparoscopy combines the main advantagesof open stone surgery, the high stone-free rate within onetreatment session, with the benefits of minimally-invasivetreatment (shorter hospital stay and convalescence,less consumption of analgesics) (49).Concerning the technique of laparoscopic stone surgerycan be stated that a larger working space and a morefamiliar overview of the anatomical landmarks are theArchivio Italiano di Urologia e Andrologia 2010; 82, 167