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.
- Failure or contraindication to both ESWL and PCNL.
- Presence of an associated anatomic abnormality requiring open operative intervention such as PUJ obstruction.
Preoperative Patient Preparation for a 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.
- Video By: Michael Jonathan Latayan (https://www.youtube.com/watch?v=xee8HISGmfE)