Open Pyelolithotomy Surgery with Steps (Renal Pelvis Stone Removal)




Open Pyelolithotomy: Introduction


  • It is the open surgery which uses the incision through the renal pelvis for removal of a stone.
  • Renal stones are usually removed by percutaneous nephrolithotomy (PCNL) or ESWL.
  • Pyelolithotomy is only rarely performed in recent times.


Indication 

  1. Failure or contraindication to both ESWL and PCNL.
  2. Presence of an associated anatomic abnormality requiring open operative intervention such as PUJ obstruction.


Preoperative Patient Preparation for a Flank Incision


fig. flank incision


  • Insertion of a transurethral catheter
  • Epidural anesthesia
  • General anesthesia
  • Patient positioning: the patient is placed in lateral position on a flexed operation table, see fig. flank incision.
  • Perioperative antibiotic prophylaxis, if the urinary or gastrointestinal tract is entered or if risk factors for a wound infection are present.


Flank Incision: Surgical Technique

  • The standard Pyelolithotomy is generally performed through a flank incision along the 12th rib.
  • In this approach, the Retroperitoneum is entered and Gerota’s fascia opened posteriorly near the lower pole of the kidney.
  • The proximal ureter is identified and taped with a vessel loop to prevent distal migration of the stone during the subsequent dissection.
  • Then the dissection is carried proximally toward the renal pelvis along the posterior aspect of the ureter
  • The kidney need not be mobilized more than is necessary to provide adequate exposure of the renal pelvis. Excessive mobilization may result in significant perirenal scarring
  • Once the renal pelvis is adequately exposed posteriorly, stay sutures are placed away from Pelvi ureteric junction.
  • The Pyelotomy is initiated with a curved banana blade and extended with a Potts scissor as for as necessary to extract the calculus under direct vision.
  • The stone is then removed with a standard Randalls forceps and a 6fr catheter is passed antegrade to the bladder to ensure ureteral patency.
  • The catheter is left in place to prevent distal migration of any stone fragments and the renal pelvis is irrigated with saline. 
  • Then the Pyelotomy is closed with interrupted 4-0 chromic sutures through the thick pelvic wall.
  • Internal stent is placed in case of the preoperated kidney (or) in the presence of infection.
  • External drainage is routinely provided with a penrose (or) closed tube drain placed in retroperitoneum and the wound is closed in a standard fashion.


References:

  • Video By: Michael Jonathan Latayan (https://www.youtube.com/watch?v=xee8HISGmfE)
  • http://www.urology-textbook.com/flank-incision.html
  • http://uroinformation.blogspot.in/2009/03/pyelolithotomy.html

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