From October 1992 to June 1994, 12 nephrectomies (all for benign diseases), one nephropexy and 7 adrenalectomies (one pheochromocitoma, three adenomas, one cyst) were performed. In all the cases the retroperitoneal working space was created with direct CO2 insufflation (without balloon) with the patient in prone position. Four 10-12 mm ports were always inserted in the lumbar area. Eighteen procedures were successful (90%), 2 failed (one nephrectomy and one adrenalectomy) and underwent open surgery. Twelve procedures were carried out with the patients in prone position, six (one nephropexy and 5 nephrectomies) were performed with the patients in lateral de cubitus. The removal of organs was managed either through an enlarged port (phi 2 cm.) or by joining vertically the stabs of the two ports lateral to the sarcospinalis muscle. The average operative time was 4.10 hours) range 2.30-5.20). Both CO2 absorption and blood loss were negligible. No major complications were observed. Postoperative pain never required medications. All patients were able to stand on the 1st postoperative day. Mean postoperative hospitalisation was 4 days. Direct retroperitoneal approach provides optimal access for laparoscopic renal, proximal ureteral and adrenal surgery, avoiding extensive dissection and handling of intraperitoneal structures.