Urolithotomy

1. URETERO-LITHOTOMY
Presented by----
Mrs. Usha Rani Kandula,
MSc.Nursing, Assistant professor,
Department of Adult Health Nursing,
College of Health Sciences,
Arsi University, Asella, Ethiopia.

2. DEFINITION
 Removal of calculi from the ureter, renal
pelvis, or kidney.

3. Different methods for stone
removal
lithotriptic procedures, e.g.,
-Extracorporeal shock wave lithotripsy
(ESWL),
-ultrasonic,
-Electro-hydraulic,
-nephroscopic and trans-cystoscopic
-Laparoscopic or laparoscopic assisted
technique

4. PROCEDURE
Proximal Calculi.
-A flank incision is made.
-(with the patient in the lateral position);
-rib resection (twelfth) is optional.

5.  -For stones within the renal parenchyma
(requiring nephrolithotomy),
 -temporary interruption of the renal
circulation is achieved by occluding the
main vessels atraumatically.

6. -After the position of the stone is
ascertained, the parenchyma is incised
and the calculus is removed; the kidney is
repaired.
-Fatty tissue may be used to bolster the
suture line.

7. -Stones in the renal pelvis require
pyelolithotomy,
-while stones in the proximal ureter require
ureterolithotomy
-and are extracted through incisions
overlying the stones.

8. -Atraumatic clamps, tapes, or vessel loops
occlude the distal ureter to prevent
migration of stone fragments.
-The collecting system is irrigated and
sutured closed.
-Drainage may be employed.
-The wound is closed in layers.

9. -Control of the ureter proximal and distal to
the stone is achieved with vessel loops or
atraumatic clamps.

10. -The ureter is opened and the stone
retrieved.
-The ureter is irrigated and closed.
-Wound drainage may be employed.
-The wound is closed in layers.

11. -Distal Calculi.
-The patient is supine when the calculi
are located in the distal ureters.
-The approach may be retroperitoneal,
employing an inguinal, lower midline
abdominal, or transverse oblique incision.

12.  -The stone is palpated, noting that the
ureter proximal to it may be dilated.

13. -N.B. The surgeon may inject a mixture of
calcium chloride, thrombin, and
cryoprecipitate to form a “clot” around the
calculus to prevent its migration.

14. Placement of double J ureteral
stent
-A double J ureteral stent may be placed
prior to closure of the ureterotomy.
-Dye (e.g., indigo carmine) instilled into the
bladder via Foley catheter is employed to
determine the integrity of the ureteral
closure.

15. PREPARATION OF THE PATIENT
 Antiembolitic hose is applied, when
requested.
 A Foley catheter is inserted.
 -The patient is positioned in the lateral
position when the stone is located in the
kidney or proximal ureter.

16. Supine position
 The supine position is indicated for stones
located in the distal ureter.

17. SKIN PREPARATION
Lateral Position for Flank Approach.
Begin at the level of the 12th rib,
extending from the axilla to several inches
below the iliac crest.

18. -Supine Approach.
-Begin at the site of the intended incision,
extending from axilla to mid-thighs.

19. Draping
 Folded towels and a transverse sheet (lateral
or abdominal approach)
Equipment
 -Sequential compression device with
disposable leg wraps, as ordered
 -Forced-air warming blanket or warming
mattress, when requested

20.  -Padded kidney rests with larger blade in
the front, pillows, etc. (lateral approach)
 -Suction
 -ESU
 -Fiber-optic light source, e.g., Xenon 300
W (for percutaneous lithotomy), optional

21. INSTRUMENTATION
 Major procedures tray
 Long instruments tray
 Kidney tray
 Thoracotomy instruments tray
(lateral approach)

22.  Nephroscope or nephroureteroscope and
cord, bridge, and grasping forceps.
 Ligating clip appliers, e.g., Hemoclip
appliers (assorted sizes and lengths)

23. SUPPLIES
 -Antiembolitic hose
 -Blades, (2) #10, (1) #15, (1) #11, (1) #12
 -Basin set
 -Suction tubing
 -Electrosurgical pencil and cord with holder
and scraper

24.  -Needle magnet or counter
 -Graduated pitcher
 -Ligating clips, e.g., Hemoclips (assorted
sizes)
 -Vessel loops and umbilical tapes
 -Dissectors (e.g., peanut)

25.  -Calcium chloride, thrombin, and
cryoprecipitate for “clot” preparation,
 optional Syringe and needle for injecting
“clot” material, optional
 -Disposable tubing for irrigation when
scopes are used (optional)
 -Penrose drain, 1′′ (retraction)

26.  -Stent (e.g., double J ureteral), optional
 -Dye (e.g., indigo carmine), syringe, and
medicine cup (optional)
 -Sterile labels and marking pen (optional)
 -Closed-suction wound drainage unit, e.g.,
Hemovac or Jackson Pratt (optional)

27. SPECIAL NOTES
 Arrangement of the
equipments/Instruments.
 Assisting the surgeon during procedure.
 Labeling of medication containers to
prevent medication errors.
 Recording of the procedure.
 Sending investigated samples to the lab.

28. THANKING YOU