Open Pyelolithotomy

Open pyelolithotomy, pielolitotomi terbuka, operasi terbuka batu ginjal

1. OPEN PYELOLITHOTOMY TECHNIQUE

2. The indications for removing stones surgically ( 1) economy and the personal convenience of the patient, ( 2) associated disorders that require open operation, ( 3) infected cases need- ing definitive and expeditious clearance of calculi, ( 4) cases that have failed lithotripsy and endoscopic removal, and ( 5) cases that for technical reasons cannot be managed by litho - tripsy . open procedure is still indicated in cases of obstruction of a caliceal infundibulum, the ureteropelvic junction, or the lumbar ureter and when the volume and configuration of the stones contraindicate extracorporeal shock wave lithotripsy (ESWL) or a percutaneous approach, such as with caliceal stones larger than the renal pelvis.

3. Instruments D eep blades for the ring retractor; Gil- Vernet retractors; coagulum materials; Randall , Russian, and vascular forceps; a gallbladder set; a grooved sound; a portable x-ray with sterile plastic bag cover; an ultrasonic probe; a flexible nephroscope ; an 18 F red rubber catheter or infant feeding tube; a J stent; a Water- Pik ; a Kuttner dissector; a hooked scalpel blade; angled Potts scissors; Andrews suction; a hand-held electrode; Allis-Adair clamps; and Stevens scissors.

4. Incission a flank incision or an anterior subcostal extraperitoneal incision In children, a lumbotomy incision may be effective With a flank incision, raise the kidney rest slowly to allow for circulatory stabilization

5. Open Gerota's fascia laterally to provide for later fatty enclosure of the pyelotomy . After renal exposure, have the assistant rotate the kidney toward the midline with clamps on Gerota's fascia and the perirenal fat or with a sponge stick. Locate the ureter and encircle it with a small Penrose drain. Continue the dissection sharply and bluntly above the ureteropelvic junction into the hilum, working in the plane found directly on the adventitia of the pelvis. Russian forceps are useful if the fat is matted.

6. Simple Pyelolithotomy Draw the hilum anteriorly with vein or Gil- Vernet retractors placed in the lip Incise the pelvis transversely in the form of a U, starting with a hooked blade and continuing with Potts scissors. Stay well away from the ureteropelvic junction. If small stones are present, pass an 8 F infant feeding tube though the ureteropelvic junction to prevent stone migration. Stay sutures may not be needed; they can tear the tissue.

7. Withdraw the stones with forceps or a Mixter clamp. If a large stone adheres to the pelvic wall, free it by passing a probe around it. Irrigate the interior with water through a cut-off Robinson catheter. Use a Water- Pik . Insert a flexible nephroscope if concern remains about residual adherent stones. Alternatively, close the pelvis and inject coagulum (Step 4).

8. Coagulum Technique Obtain two bags of thawed cryoprecipitate (about 15 ml each), and keep them at room temperature. Add a few drops of methylene blue to them in a pan. Draw the cryoprecipitate into the 35-ml syringe. Obstruct the ureter by placing traction on the encircling Penrose drain. Insert an angiocatheter into the renal pelvis, withdraw the stylet, and drain the urine , estimating its volume.

9. Draw 1 ml of 10 percent calcium chloride solution into the syringe containing the cryoprecipitate just before instilling the mixture into the pelvis. Attach the syringe to the angiocatheter , and inject enough of the solution to fill, but not overfill, the pelvis. Remove the angiocatheter .

10. Wait 5 minutes; then open the pelvis with a U- shaped incision, and gingerly extract the coagulum with the stone. Sometimes pressure on the kidney parenchyma helps extraction. After removing the clot, flush the ureter with saline through the 8 F infant feeding tube.

11. Inspect the coagulum to be certain it is intact. Thoroughly irrigate the pelvis and ureter.

12. It may be worth-while before closure to pass a ureteral catheter or infant feeding tube to the bladder to be sure that no fragments are caught in the ureter, which would promote prolonged postoperative drainage. Make a watertight closure of the pelvis with a running 4-0 or 5-0 SAS with an occasional lock stitch. Suture a Penrose drain by the long suture technique near the closure, being sure its end does not touch the anastomosis. Tack the edges of Gerota's fascia together, and close the wound.

13. Extended Pyelolithotomy (Gil- Vernet ) Alternatives are anatrophic nephrolithotomy partial nephrectomy Contraindications to this intrasinusal approach previous extended pyelolithotomy , extremely intrarenal pelvis, staghorn calculi in clubbed calyces. Expose the kidney as for simple pyelolithotomy . Proceed with complete mobilization of the kidney to allow control of the renal artery and to facilitate roentgenography . Have the assistant rotate the kidney toward the midline. Feel for the arterial pulsation, and expose the renal artery. Draw a sling around it with a right-angle clamp. Try applying a bulldog clamp on it for size and clearance.

14. Dissect along the posterior surface of the pelvis, entering the renal sinus beneath the sinus fat exactly on the adventitia of the pelvis

15. Excise excess fatty tissue. It is not necessary to clear out all the fat; the portion remaining cushions the closure line.

16. Separate the pelvis from the renal hilum and peripelvic fat in the avascular plane by blunt dissection. Avoid the retropelvic artery, which is the posterior branch of the main renal artery. It originates near the superior edge of the pelvis and passes behind it, sometimes outside and sometimes inside the hilum. The scissors must be kept in close contact with the adventitia of the pelvis. Even if there is considerable reaction in the peripelvic fat, this plane remains intact. Insert special Gil- Vernet retractors over the whole mass of peripelvic fat, and insinuate the corner of a moist, opened 4 X 8 gauze pad to expose the bases of the infundibula. Have your assistant lift and rotate the kidney to bring the pelvis into view. If the pelvis is extrarenal , the assistant should relax pressure on the retractors occasionally to allow flow through the retropelvic artery. If exposure is difficult, place a bulldog clamp on the renal artery to reduce parenchymal turgor.

17. Incise the pelvis in an open U shape with a hooked scalpel blade and Potts scissors. Design the cut to fit the configuration of the periureteral portion of the stone, keeping well away from the ureteropelvic junction. Usually make the incision from the base of the lowest calyx to the base of the uppermost. Stay sutures are not needed and may tear the pelvic wall.

18. First wipe around the extension of the stone in the ureteropelvic junction with a blunt probe to free it from the pelvic epithelium.

19. Lever the periureteral extension out first, thereby exposing as much as 70 percent of the stone.

20. Grasp the stone with Randall forceps. Gently rock and rotate it to extract its caliceal extensions . Extricate the shortest branch first. If absolutely necessary, fracture the neck of one or more of the branches and remove the clubbed ends via transverse nephrotomies . Often an infundibulum can be dilated with forceps sufficiently to allow an extension of the main stone to be extracted. If the renal hilum is large enough, a vertical incision along the involved infundibulum ( cali - cotomy ) may assist in the removal of large caliceal stones. Remove the stone and fit the pieces together to be sure all were retrieved. Send the stone for culture and analysis.

21. Inspect the interior of the calyces, using a flexible nephroscope if necessary, and remove any remaining calculi, usually with stone forceps or Mixter clamp. If the stones are too large to pass through an infundibulum, gently dilate the opening with a clamp. Try not to use a finger or high pressure. Irrigate each calyx in turn, using a large syringe and a cut-off 18 F red rubber catheter.

22. Make a radial nephrotomy over clubbed caliceal stones too large to extract through the infundibulum . Locate the site of the stone by pushing it toward the capsule with a clamp or finger in the infundibulum and palpating it through the cortex. If it cannot be felt , probe for it with a milliner's needle.

23. Sharply incise the capsule circumferentially for a distance equal to the diameter of the stone; then bluntly separate the kidney parenchyma down to the stone, which is supported by a clamp or finger in the infundibulum . Extract the stone with forceps inserted into the nephrotomy . If the cortex is thick, it is helpful to place a bulldog clamp on the renal artery to soften the kidney long enough to locate and remove the stone. If these manipulations are to be prolonged, cool the kidney and give mannitol intravenously. Irrigate the calyx thoroughly with saline. Avulsion of the ureteropelvic junction is possible. With a segment made ischemic by chronic impaction of a relatively large stone, avulsion can occur during dissection. Repair and intubation are necessary), even though the tissue has the quality of wet paper.

24. Close the nephrotomy with 3-0 CCG mattress su - tures over fat bolsters. If the pelvis lies principally inside the sinus, exposure can be improved by inserting a grooved ( Gouley ) sound along the outside of the inferior pelvis and lowest calyx and out through the lower-pole parenchyma. Cut into the groove and divide the renal cortex. Alternatively, pass successive pairs of sutures, tie them, and cut between them. Perform radiography A straight milliner's needle thrust through the cortex can be useful to locate residual stones, and two needles provide a landmark on the roentgenogram. Intraoperative nephroscopy and sonography are the best techniques to detect and clear remaining stones. Coagulum can be used if the pelvis is closed first. Pass an 8 F catheter down the ureter to be sure it is clear.

25. A nephrostomy tube made from perforated silicone tubing may be brought out through the lower pole but is necessary only when stone removal is incomplete and irrigation postoperatively with hemiacidrin ( Renacidin ) must be resorted to . Close the pelvis with a running 5-0 SAS, occasionally locked . If reaching either end of the incision for suturing is difficult, start and finish the closure at convenient sites because the parenchyma falls over the suture line and prevents leakage. Irrigate the wound copiously. Tack a Penrose drain near the pelvis with the long suture technique, although urinary leakage is unusual . Fasten Gerota's fascia over the kidney with 3-0 plain catgut sutures. Close the wound

26. At a secondary operation, the kidney is found firmly attached to the transversalis fascia and is readily entered inadvertently. Identify the capsule early, and dissect it carefully from the fibrous bed. Enter the sinus anteriorly and inferiorly, at a site- distant from that for the initial pyelolithotomy .