Urolithiasis management- surgical open

Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
1

Professors:
 Prof. Dr.G.Sivasankar, M.S., M.Ch.,
 Prof. Dr.A. Senthilvel, M.S., M.Ch.,
Asst Professors:
 Dr.J. Sivabalan, M.S., M.Ch.,
 Dr.R. Bhargavi, M.S., M.Ch.,
 Dr.S. Raju, M.S., M.Ch.,
 Dr.K. Muthurathinam,M.S., M.Ch.,
 Dr.D.Tamilselvan, M.S., M.Ch.,
 Dr.K. Senthilkumar,M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

INTRODUCTION
 AUA guidelines - open surgery should be reserved for cases when endourologic
procedures are not suitable or have failed
 Performed more commonly in centers when percutaneous or endoscopic
equipment is not readily available
3
Dept of Urology, GRH and KMC, Chennai.

4

ANATROPHIC NEPHROLITHOTOMY
5

 Anatrophic nephrolithotomy was first described by Smith and Boyce in 1968.
 Their description involved creating a nephrotomy in the relatively avascular plane
of the kidney in order to prevent damage to the vasculature and avoid renal
atrophy
 Hence,this procedure was given the name anatrophic
( not causing atrophy due to ischemia )
6

PREOPERATIVE PLANNING AND PREPARATION
 Evaluation - 3 dimensional reconstruction of CT of the abdomen to understand the
spatial orientation of the renal anatomy and stone.
 Function of the kidney - nuclear medicine renogram
 Urine culture
 If positive, oral culture–specific antibiotics should be started 7 days prior to
surgery
7

 If urine culture is negative - broad-spectrum antibiotic 7 days before surgery
(complex stones may be colonized with bacteria)
 Intraoperative antibiotics should cover known urine organisms and be broad
spectrum
8

OPERATIVE TECHNIQUE
 A flank incision is used to access the kidney.
 An 11th or 12th rib incision is made depending on the location of the kidney.
9

 The pleura and diaphragm are mobilized cranially,and the peritoneum is
mobilized medially
 Resection of the tip of the 12th rib is usually unnecessary
 Resection of the 11th rib may be necessary if the kidney is located high in the
retroperitoneal cavity
10

 The Gerota fascia is encountered and opened in a cranial-caudal fashion over the
posterior aspect of the kidney to allow for covering at the time of closure.
 The kidney is fully mobilized;
11

 Perinephric fat is dissected off the kidney taking care not to enter a subcapsular
plane.
 Superior dissection must be performed gently to separate and free the adrenal
gland and inferior dissection to separate the lower pole.
 Each renal pole should be free to facilitate dissection and further manipulation of
the renal hilum
12

 The renal hilum is identified and the ureter,renal artery(ies),and renal vein(s) are
surrounded with vessel loops
 The posterior segmental branch of the renal artery is typically dissected as it
courses around the posterior aspect of the renal sinus.
 At this point, an intraoperative plain film or fluoroscopy can be performed to help
with planning the optimal location for nephrotomy.
 Intraoperative ultrasound may also be used to facilitate stone location and help to
direct nephrotomy.
13

 The posterior segment is then temporarily clamped with a bulldog clamp or
rubber shod, and the patient is given 10–20 ml intravenous methylene blue
 This will result in blanching of the posterior segment of the kidney, the blue-
colored parenchyma allowing delineation of the avascular intersegmental
plane ( Brodel line )
14

•This plane is marked using Bovie
electrocautery on the capsule
•The clamp on the posterior segmental artery
is removed
15

 The kidney is then surrounded by a plastic drape, 12.5 g of mannitol is given
intravenously,and 10 minutes later the renal hilum is clamped using bulldog clamps or a
vascular clamp
 The kidney is covered in ice slush for
10 minutes to achieve a parenchymal
temperature of 15° C
 Ice slush should be replaced at least every
30 minutes while clamped
16

 Incise the capsule sharply along the previously marked line,
even if it is irregular
 Make the incision as short as deemed necessary
 Using a Penfield dissector or the back of a scalpel, bluntly
separate the parenchyma until the collecting system is
encountered
 Take care not to dissect into the poles of the kidney
 Sharply transect any interlobar vessels encountered;
few should be seen if in the appropriate avascular plane
17

 Use the Potts scissors to open calyces to access
all ramifications of the stone
 Open the collecting system sharply with a Potts
scissor or scalpel and expose the stone
18

 Once the stone is exposed,gently free the stone with a blunt Randall forceps
19

 Complex stone ramifications or stones located in calices with stenotic infundibulum
may require a separate nephrotomy incision directly over the moiety where the stone is
located;
 this may decrease extension of the main
incision and prevent injury to a segmental
arterial branch
20

 Inspect each calyx in succession and gently palpate the renal parenchyma to
ensure all stone is removed
 A nephroscope (flexible cystoscope or ureteroscope) can be used to ensure all
calyces are free of stone
 Intraoperative plain-film imaging or fluoroscopy can help identify any residual
stone
 Antegrade ureteral stent is placed
21

CLOSURE
 All transected vessels are oversewn with 4-0 absorbable polyglactin suture
 The collecting system is then closed in a running fashion using 5-0 polyglactin
suture
 Stenotic infundibula should be repaired to prevent future stone formation
22

 Calicoplasty is performed by either suturing the mucosal edges of the infundibulum to the
adjacent renal pelvis, which shortens and widens the infundibulum,or by suturing the
mucosa of two adjacent infundibula together
23

 The remainder of the collecting system is closed with a running 4-0 polyglactin suture
24

 The renal capsule is closed using either a running 4-0 polyglactin suture or horizontal
mattress stitches over a fat bolster to prevent tearing of the capsule
25

 The ice slush is removed,and the bulldog clamps are removed
 The patient is given another dose of 12.5 g of mannitol to decrease renal reperfusion
injury
 The kidney is then bathed in warm saline with rapid return of good turgor
26

 Any bleeding encountered from the nephrotomy site can be controlled with light
pressure to the incision
 Tissue sealants may be applied if low-volume bleeding persists
 If high-volume bleeding ensues,the incision should be reopened and a search
should ensue for an actively bleeding vessel
27

 The Gerota fascia is then reapproximated over the incision using 2-0 polyglactin
sutures
 A Jackson Pratt drain is placed posterior to the kidney and brought out through a
separate stab incision
 The fascial layers and skin are closed in a standard fashion
28

POSTOPERATIVE CARE AND COMPLICATIONS
 Hemoglobin and creatinine are closely monitored for hemorrhage and renal insufficiency
 Allowed to ambulate in the next morning if stable
 The urethral catheter is removed on the second or third day if no significant urine leak is
evident,
 The Jackson Pratt drain is removed when output is less than 50–100 mL over 24 hours
 The patient is discharged with oral antibiotics for 5–7 days and the ureteral stent is removed 4
weeks postoperatively
29

 Pain is common because of the size of the incision
 A thoracic epidural or a lidocaine infusion pump can be considered to help reduce
postoperative pain
 Pulmonary atelectasis is common and can be reduced with aggressive incentive
spirometry and ambulation
30

 Pneumothorax is a possible complication with a flank incision and occur in less
than 5% of patients
 Venous thrombosis can occur and can be prevented with sequential compression
devices
31

 Delayed hemorrhage can occasionally occur as a result of breakdown of absorbable
sutures that were used to ligate intrarenal vessels
 This should initially be treated conservatively with fluids and transfusion if necessary
 If multiple transfusions are required,superselective angioembolization can be
performed to stop the bleeding
 Bleeding that occurs 1–4 weeks postoperatively may indicate the formation of an
arteriovenous fistula or false aneurysm
32

 Persistent infection may indicate residual stone burden
 This requires antibiotic therapy and subsequent percutaneous or retrograde
surgery to remove the remaining stones
 Subsequent procedures should not be undertaken for at least 6 weeks after
surgery
33

PYELOLITHOTOMY
34

PREOPERATIVE PREPARATION,PLANNING, POSITION, AND INCISION
 Similar to anatrophic nephrolithotomy,urine culture,axial imaging, and basic lab
tests should be obtained prior to surgery.
 This procedure should not be performed if the patient has an intrarenal pelvis
 The patient is prepped and positioned similarly to anatrophic nephrolithotomy
 A flank incision is made below either the 11th or 12th rib depending on the
position of the kidney
35

OPERATIVE TECHNIQUE
 Gerota fascia is incised in a cranio-caudal direction
 The perinephric fat is dissected off the kidney taking
care not to enter a subscapular plane
 The proximal ureter is encountered and isolated
 The ureter is dissected proximally to the renal pelvis
 Care is taken not to damage the posterior segmental artery as it crosses just inside the
posterior renal sinus
36

 A U-shaped incision is made in the renal pelvis over the stone using a hooked 12-blade
scalpel or a Potts scissor,with the apex of the incision at least 1 cm away from the
ureteropelvic junction
37

 If multiple small stones are present,pass an 8-French feeding tube down the ureter to
prevent stone migration
 Once the stone is exposed,a blunt Randall forceps is used to gently grasp and remove the
stone
38

EXTENDED PYELOLITHOTOMY AND RESIDUAL CALYCEAL STONES
 If any ramifications of the stone enter a calyx making it difficult to remove the stone, an
extended pyelolithotomy can be performed by reflecting the renal parenchyma and
extending the pyelotomy incision into the respective infundibulum
39

40

41

42

 If residual stone exists in a
calyx that cannot be removed
through the infundibulum,
locate the stone by pushing it
towards the capsule with a
clamp of a finger
43

clamp of a finger
 Sharply incise the capsule
circumferentially (Radial
nephrotomy) over the stone,
and then bluntly dissect the
parenchyma using a Penfield
dissector or the back of a
scalpel
44

clamp of a finger
 Sharply incise the capsule
circumferentially (Radial
nephrotomy) over the stone,
and then bluntly dissect the
parenchyma using a Penfield
dissector or the back of a
scalpel
 Extract the stone through
the nephrotomy with a
blunt Randall forceps
 The nephrotomy is
closed using horizontal
mattress sutures over fat
bolsters
45

 If the parenchyma is thick,it may be useful to place a bulldog clamp temporarily
on the renal artery
 If clamping will be prolonged, cold ischemia may be employed with intravenous
mannitol administration
 Close the nephrotomy with horizontal mattress 3-0 polyglactin sutures over a fat
bolster
46

COAGULUM TECHNIQUE
 Obtain two bags of thawed cryoprecipitate (about 30 mL total) and keep them at room
temperature
 Add a few drops of methylene blue
 Obstruct the ureter using a wrapped Penrose drain
 Place a small Angiocath needle into the renal
pelvis and aspirate any residual urine
47

 Add 1 mL of 10% calcium chloride solution into the syringe with the cryoprecipitate
immediately prior to injection.
 Through the Angiocath, inject the cryoprecipitate solution to fill, but do not overfill the
renal pelvis, then remove the Angiocath.
 Wait for 5 minutes
 Open the pelvis with a U-shaped incision
and carefully extract the coagulum
ensuring it is removed intact
48

 Thoroughly irrigate the renal pelvis and ureter.
 This technique is particularly useful when multiple stones are located in the pelvis
and collecting system, to prevent stone migration to the ureter,or multiple remote
calculi during stone manipulation.
49

CLOSURE
 A nephroscope (flexible cystoscope or ureteroscope) can be used to evaluate the
calyces to ensure no residual stone remains
 An antegrade double-J stent is then placed
for drainage
50

 The renal pelvis is closed with running 5-0 polyglactin suture
51

 Irrigate the wound copiously
 The Gerota fascia is reapproximated using 2-0 polyglactin sutures
 A Jackson Pratt drain is placed posterior to the kidney through a separate stab
incision
 The fascial layers and skin are closed in a standard fashion
52

POSTOPERATIVE CARE AND COMPLICATIONS
 Postoperative care is similar to that for patients who have undergone anatrophic
nephrolithotomy
 Complications are similar to anatrophic nephrolithotomy,with significantly less risk
of bleeding or transfusion.
 Acute tubular necrosis rates are lower because of a lack of interruption in renal
blood flow.
 Subsequent ureteropelvic junction obstruction is a rare possible complication of
this procedure.
53

URETEROLITHOTOMY
54

 Current indications include
 stones with a low likelihood of treatment success using extracorporeal shock wave
lithotripsy (ESWL),ureteroscopy,or percutaneous techniques;
 secondary treatment for treatment failures after less invasive techniques;
 medically underserved areas or developing countries without access to
ureteroscopic or lithotripsy equipment;
 In patients who have a planned open or laparoscopic procedure for another
condition in which simultaneous treatment of the stone is requested
55

PREOPERATIVE PLANNING
 It is imperative to know the location of the stone before performing
ureterolithotomy because this will impact surgical approach.
 A recent computed tomography (CT) scan or kidneys–ureter– bladder (KUB)
radiography study demonstrating the stone location is required before performing
ureterolithotomy.
56

 If there is concern about a nonfunctioning kidney based on preoperative imaging,
a dimercaptosuccinic acid (DMSA) scan is recommended to assess renal function.
 If the stone is present in association with a poorly functioning kidney, the patient
may be better treated with a nephrectomy as opposed to a ureterolithotomy.
 A urine culture should be obtained before the procedure,and the patient should
be treated with culture-specific antibiotics if a urinary tract infection is present.
57

 The surgical approach for an open ureterolithotomy depends on the location of the
stone.
 For all locations, an extraperitoneal approach can be performed.
 However,if the patient is undergoing a concomitant intraperitoneal surgery for
another indication, a transperitoneal approach can be used.
58

 Proximal ureter:
 A supracostal,subcostal,or flank incision provides optimal exposure.
 Alternatively,a lumbotomy can be used for proximal stones
 If needed, a midline extraperitoneal or intraperitoneal approach can also be
used.
59

 Distal ureter:
 approached extraperitoneally via a low midline, Pfannenstiel, or Gibson incision.
60

 Generally,the ureter can be accessed extraperitoneally.
 Care should be taken in the dissection of the ureter to preserve as much
periureteral tissue as possible to minimize stone migration and ureteral
devascularization.
 The stone can be located either by visualizing a bulge within the ureter or by
gentle palpation
61

 After the stone is identified, a vessel loop
should be placed around the ureter both
proximally and distally to the stone to prevent
migration of the stone
62

 The ureter is opened longitudinally over the
stone with a scalpel and extended with Potts
scissors if needed
63

 The stone is then loosened from the ureteral wall and
removed intact
 After removal of the stone,a 5-Fr feeding tube is
placed proximally and distally to interrogate the
ureter for remaining stone fragments
64

 A stent can be placed at the discretion of the surgeon but is recommended to
control any potential urinary leaks that could result in stricture
 The ureterotomy is closed longitudinally with interrupted absorbable sutures.
 The ureter can be wrapped with periureteral fat, and a drain is placed.
65

 The drain should be placed near the ureterotomy but not in direct contact.
 A Foley catheter is left in place.
 The Foley catheter can be removed on postoperative day 1, and the drain can be
removed 24 hours later if output is low.
66

67

Urolithiasis management- surgical open

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