brief description of renal/ urinary system surgery including: pyelolithotomy, nephrectomy, nephron-sparing surgery, Ureterotomy, Cystotomy, Nephrolithotomy including surgical requirement for renal system surgery

1. Surgery of Renal System
M. Saad Saeed

2. Kidney surgery
 Also known as:
 Nephrectomy, Radical Nephrectomy, Partial Nephrectomy, Nephron
Sparing Surgery, Percutaneous Nephrolithotomy, Percutaneous
Nephrolithotripsy
 Kidney surgery is performed to treat a variety of conditions and is
usually performed by a urologist.

3. SPECIAL INSTRUMENTS
 Absorbable suture material, such as polydioxanone (PDS),
polyglyconate (Maxon), poliglecaprone 25 (Monocryl), or glycomer 631
(Biosyn), should be used in the kidney, ureter, and bladder.
 Nonabsorbable suture material may promote formation of calculus
and infection.
 Although PDS and Maxon maintain tensile strength and are more
slowly absorbed than is desirable for most urinary surgery, they have
less tissue drag than multifilament suture.
 The use of pediatric or ophthalmic instruments facilitates surgery of
the ureter. These instruments tend to be smaller and more delicate
and may cause less tissue trauma than larger instruments.

4. Conditions
 kidney cancer;
 chronic kidney diseases;
 kidney stones (removal);
 kidney infection;
 renal hypertension;
 traumatic kidney injury;
 kidney donation

5. Nephrectomy and Radical Nephrectomy
 Nephrectomy is the surgical
removal of a kidney. A radical
nephrectomy is the removal of
one entire kidney, surrounding
lymph nodes, and the adrenal
gland and is usually performed as
a first step in treating kidney
cancer. After removal of a
kidney, patients can lead normal,
healthful lives, as long as the
remaining kidney is functioning
well.

6. Partial Nephrectomy Or Nephron-
sparing Surgery (NSS)
 With partial nephrectomy or nephron sparing surgery (NSS) only the
tumor and tissue immediately surrounding the tumor is removed. This
type of kidney surgery is most often done as a first step in certain
kidney cancers and when it is important to maintain kidney function.
 For partial nephrectomy, use large, absorbable suture with two long,
straight needles attached.

7. Nephrotomy
 Nephrotomy usually is performed to remove calculi lodged in the renal
pelvis. Make a sharp incision along the capsule of the convex border of
the kidney, and bluntly dissect the renal parenchyma to the renal
pelvis. Remove the calculi and close the nephrotomy by apposing the
cut tissue and suturing the capsule in a continuous pattern with
absorbable suture material (see text for sutureless technique). If
adequate hemostasis is not achieved, or if urine leakage is a concern,
place absorbable sutures through the cortex in a horizontal mattress
fashion. Then suture the capsule in a continuous pattern with
absorbable suture material.

8. Nephrotomy

9. Pyelolithotomy
 Dissect the kidney from its sublumbar attachments and expose the dorsal
surface. Identify the ureter and renal vessels (A). Make an incision over the
dilated pelvis and proximal ureter, and remove the calculi (B). Flush the renal
pelvis and diverticula with warm saline to remove small debris. Next, flush
the ureter to ensure its patency. Close the incision in a continuous pattern
with 5-0 or 6-0 absorbable suture (C)

10. Ureterotomy
 Make a transverse or longitudinal
incision in the dilated ureter proximal
to the calculi and remove them (A).
Place a small, soft rubber catheter
into the ureter proximal and distal to
the incision, and flush the ureter with
warm fluid. Make sure that all calculi
have been removed and that the
ureter is patent. Close the incision in
a simple interrupted pattern with 5-0
to 7-0 absorbable suture (B). As an
alternative, if the ureter is not dilated
and if stricture formation seems likely,
make a longitudinal incision over the
calculi and close the incision in a
transverse fashion (C).

11. Cystotomy
 Isolate the bladder from the rest of the abdominal cavity by placing moistened
laparotomy pads beneath it. Place stay sutures on the bladder apex and trigone
to facilitate manipulation (A).
 Make a longitudinal incision in the ventral or dorsal aspect of the bladder, away
from the ureters and urethra, and between major blood vessels. Remove urine by
suction or perform intraoperative cystocentesis before cystotomy if suction is not
available. Excise a small section of the bladder wall adjacent to the incision to
submit for aerobic culture. Check the bladder apex for a diverticulum, and excise
it if necessary. Examine the mucosa for defects, and pass a catheter down the
urethra to check for patency. Close the bladder in a single layer using a
continuous suture pattern with absorbable suture material (see previous
discussion). For a two-layer closure, suture the seromuscular layers with two
continuous inverting suture lines (e.g., Cushing, followed by Lembert; (B).
 If the dog has severe bleeding tendencies, consider suturing the mucosa as a
separate layer with a simple continuous suture pattern.

12. Cystotomy
.

13. Percutaneous Nephrolithotomy/
Nephrolithotripsy (tunnel surgery)
 Percutaneous nephrolithotomy and nephrolithotripsy are both used to
remove kidney stones. In both procedures the surgeon accesses the
kidney through a small incision in the back and threads a nephroscope
(a miniature fiberoptic camera) and other small instruments through
the hole. The surgeon can then remove an intact stone through the
tube (nephrolithotomy) or will break up the stone first before
removing it (nephrolithotripsy).

14. Extracorporeal Shock Wave Lithotripsy
(ESWL or lithotripsy)
 Lithotripsy is a non-invasive medical procedure that uses shock
(sound) waves to break up stones in the kidney, bladder, or ureter
(tube that carries urine from the kidneys to the bladder). It is
normally done under general anesthesia or mild sedation and on an
outpatient basis.

15. Open vs. Minimally Invasive Surgery
 Open, or traditional, surgery usually involves an incision in the
abdomen or side, although some procedures access the kidney through
the lower back.
 Minimally invasive procedures allow access to the kidney
through smaller incisions and the use of a laparoscope and special
tools to view and work on the kidney. Benefits of minimally invasive
procedures include decreased blood loss, less pain and faster
recovery. There might be increased risks as well and not all surgeries
can be done as minimally invasive. Patients should always discuss
their surgical options and associated risks with their surgeon before
undergoing any type of surgery.