Urolithotomy

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. I nstrumentation 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