You are in: eMedicine Specialties > Urology > Stones PyelolithotomyArticle Last Updated: Jun 12, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Martha K Terris, MD, FACS, Professor, Department of Surgery, Medical College of Georgia Martha K Terris is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Institute of Ultrasound in Medicine, American Society of Clinical Oncology, American Urological Association, New York Academy of Sciences, and Society of University Urologists Coauthor(s): Subbarao V Cherukuri, MD, Consulting Staff, Department of Urology, St Joseph Regional Health Center; Richard H Jadick MD, Staff Physician, Section of Urology, Medical College of Georgia Editors: Bradley Fields Schwartz, DO, FACS, Associate Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Martin I Resnick, MD †, Former Lester Persky Professor and Chair, Department of Urology, Former Professor, Department of Oncology, Case Western Reserve University School of Medicine; J Stuart Wolf, Jr, MD, FACS, David A Bloom Professor of Urology, Director, Division of Minimally Invasive Urology, Department of Urology, University of Michigan Medical Center; Stephen W Leslie, MD, FACS, Founder and Medical Director of the Lorain Kidney Stone Research Center, Clinical Assistant Professor, Department of Urology, Medical College of Ohio Author and Editor Disclosure Synonyms and related keywords: kidney stone, stone removal, kidney stone removal, renal pelvic stone, renal stone, Gil-Vernet procedure, large stone removal, renal surgery, kidney surgery, extracorporeal shock wave lithotripsy, extracorporeal shock-wave lithotripsy, extracorporeal shockwave lithotripsy ESWL, percutaneous nephropyelolithotomy, PCN INTRODUCTIONSection 2 of 11
  The term pyelo means renal pelvis, and the term lithotomy means removal of stone. Because of the advent of extracorporeal shockwave lithotripsy (ESWL) and percutaneous nephropyelolithotomy (PCN), pyelolithotomy is becoming an uncommon surgery in most developing countries. However, before these newer technologies, pyelolithotomy was the procedure of choice for stones within the renal pelvis, including stones that demonstrated minimal invasion into calyces and infundibulum. Pyelolithotomy differs from an anatrophic nephrolithotomy, as the anatrophic nephrolithotomy allows for greater access to calyces and allows for repair of infundibulum and calyces. Anatrophic nephrolithotomy is indicated for large multiple-branched staghorn calculi with infundibular stenosis. ESWL is clearly noninvasive, but it may necessitate (1) a cystoscopy and the insertion of a stent to drain the kidney or (2) a nephrostomy in some cases involving infection. ESWL is associated with less morbidity than pyelolithotomy, but the overall failure rate and the amount of residual stone fragments are higher. Lower pole stones fragments do not flush out of the renal unit as readily as midpole and upper pole fragments. PCN is a highly technical procedure and requires some experience for optimal results. At some facilities, these procedures require the teamwork of a radiologist and a urologist. Morbidity is higher than with ESWL, but residual stone fragments are less common. The stone-free rate associated with percutaneous nephrolithotomy (PNL) is 78%; ESWL, 54%. The 2004 American Urological Association (AUA) guidelines recommend that staghorn smaller than 2500 mm2 with normal renal anatomy should be treated with PNL as first-line treatment and with ESWL as a follow-up procedure. Pyelolithotomy continues to have a role in the management of renal pelvic stones in areas where ESWL and PNL are not feasible because of the lack of equipment or expertise. Pyelolithotomy is also indicated in situations in which the patient's condition does not permit transfer. Indications for pyelolithotomy include minimally branched staghorn stones in the renal pelvis of complex collecting systems and excessive morbid obesity. Pyelolithotomy is also appropriate in patients who are undergoing major open abdominal or retroperitoneal surgical procedures for other indications; the most common concomitant procedure is open pyeloplasty for ureteropelvic junction (UPJ) obstruction. History of the ProcedureOn October 8, 1872, Ingalls performed a nephrotomy at Boston City Hospital. In 1880, Henry Morris, an English surgeon, performed the first pyelolithotomy on a 31-year-old woman. Vincenz Czerny also performed a pyelolithotomy in 1880. These initial operations were performed without regard for renal vasculature, anatomy, and functionality. The technique was refined after Gil-Vernet better described renal vascularity and function of the collecting system musculature. The incision of the renal pelvis was initially taken vertically but, after Gil-Vernet's description, became a transverse incision, therefore preserving anatomic musculature and blood supply. ClinicalPatients may be asymptomatic or may present with symptoms that include renal colic, flank pain, sepsis, and/or hematuria. In addition, incidental findings of stones on CT scan or during laboratory workup studies that demonstrated an elevated creatinine level have followed with a finding of partially obstructive stones within the renal pelvis. INDICATIONSSection 3 of 11
Pyelolithotomy is an open surgical procedure in cases involving a stone in the renal pelvis. This was a common procedure until the development of extracorporeal shockwave treatment, PNL, and ureteroscopic laser lithotripsy. However, pyelolithotomy continues to be performed when other modalities fail or when proper facilities are unavailable. Although it is now considered overly invasive for routine use, pyelolithotomy continues to have a role in certain cases. Criteria include the size of the stone, the need for concomitant open surgery, and an inaccessibility to ESWL or PCN. Current guidelines advocate pyelolithotomy or anatrophic nephrolithotomy when stone burden is greater than 2500 mm2, in cases of extreme morbid obesity, or when the patient presents with a complex collecting system. Indications for stone removal (possible pyelolithotomy) include sepsis, severe flank pain, obstruction with impending parenchymal renal loss, and hematuria. Patients who present for pyelolithotomy also meet the criteria as outlined above. RELEVANT ANATOMYSection 4 of 11
The renal pelvis is posterior to the hilum of the kidney. From anterior to posterior, the relationship of the structures is renal vein, renal artery, and pelvis. The pelvis can be extrarenal or intrarenal. In an intrarenal pelvis, the pelvis is embedded in the parenchyma of the kidney. An extrarenal pelvis is exposed outside of the parenchyma and is easily reachable. The renal pelvis joins the ureter at the UPJ. Normal pelvis volume is 3-5 mL. On the left side, the ovarian vein or testicular vein is adjacent to the ureter and pelvis. Recognize and identify these veins during surgery to avoid injury and bleeding. The renal pelvis is easily approachable from a posterior subcostal incision or through the 12th rib bed. CONTRAINDICATIONSSection 5 of 11
Pyelolithotomy is absolutely contraindicated in patients in a poor general medical condition or those with severe kyphoscoliosis. Only consider this surgery when all other options fail. Relative contraindications include branched staghorn calculi with infundibular stenosis and stones in the calices. These conditions may be approached using the Boyce anatrophic nephrolithotomy or calycelectomy. WORKUPSection 6 of 11
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TREATMENTSection 7 of 11
Medical therapyPrior to surgery, if the nature of the infecting organism is known, use the appropriate intravenous antibiotic based on culture results. If culture results are not available, use a broad-spectrum antibiotic. Assume all candidates for open pyelolithotomy are or will be infected at the time of surgery because renal pelvic stones tend to harbor bacteria. Surgical therapyThe goal of the preoperative evaluation includes improving the patient's general condition as much as possible, especially in a septic patient. In a septic patient, drain the kidney using a stent or via nephrostomy. Let the kidney rest for 48-72 hours, if possible, so that the inflammation from the infection subsides. A less inflamed kidney is less friable and bleeds less. The ureter is easier to recognize if a stent is in place. Also, a stent prevents stone fragments or debris from blocking the ureter. Even though the renal pedicle is generally anterior to the renal pelvis, at times a posterior branching blood vessel may be present. Approaching the renal pelvis posteriorly is easier. Infected urine can be drained posteriorly using a retroperitoneal drain. The left-sided testicular or ovarian vein may resemble the ureter. When in doubt, feel for the stent or aspirate with a 22-gauge needle and syringe. Properly positioning the patient is key for easy surgery. Be prepared to perform an extended pyelotomy. Always dissect the upper and lower poles of the kidney and renal pedicle or, at least, be prepared to do so. Incision The pyelolithotomy surgical approach is generally through the flank but also may be via a transabdominal approach (in children when concomitant UPJ obstruction repair is planned) or through a posterior lumbotomy. Use endotracheal general anesthesia. Insert a Foley catheter. Position the patient in a jack-knife kidney position with the table flexed so that the flank muscles are tight. The kidney bridge may be raised, but the author does not use it often. Take precautions to protect the auxiliary nerve plexus by placing soft towels under the armpit. Also, do not flex the contralateral knee joint more than 50° to avoid deep vein thrombosis. Finally, apply knee-high stockings preoperatively or use mechanical calf compression devices in order to prevent deep vein thromboses and phlebitis. The surgeon should position the patient and not rely on the nurse or assistant. The incision may be costal, intercostal, or subcostal, but remember that the kidney is always higher than estimated. Incise the skin over the 12th rib or between the 11th and 12th ribs. Be generous in the skin incision. Start the incision 3 inches from the spine to the xiphisternum. Do not angle towards the umbilicus, but keep it close to the costal margin. Cut the subcutaneous fat with electrocautery current, which helps limit bleeding. Approach the 12th rib. The intercostal vessels are at the inferior margin of the rib. Incise the periosteum longitudinally with diathermy current or a knife. Elevate using the periosteal elevator. Resect the rib from the tip to the base of the rib with a rib cutter. The rib may be cut without dissecting the periosteum. Use bone wax to seal the proximal end of the rib, which otherwise tends to slowly ooze. If bleeding occurs, do not cauterize. If necessary, dissect the subcostal nerve and ligate the intercostal vessels. Incise the periosteum. The pleural cavity may be entered, but if this occurs, do not panic; ask the anesthesiologist to help hyperinflate the lungs after suturing the pleura (with a watertight closure). Incise the abdominal muscles by diathermy current over the 2 fingers inserted inside, pushing the peritoneum medially. Do not curve the incision towards the pubis; incise towards the xiphisternum (ie, because kidney is always higher than estimated). Palpate the kidney inside the Gerota fascia. Lift the kidney from the psoas muscle. Identify the ureter lying over the psoas muscle and posterior to the peritoneum. The spleen and liver are intraperitoneal organs. If they are visualized, close the tear in the peritoneum. Incise the Gerota fascia vertically; diathermy may be used. Dissect the kidney upper pole, lower pole, and posterior aspect. Trace the ureter upwards (a stent is useful). If the ureter is not found, examine the peritoneum from the pelvic brim upwards. Often, the ureter is pushed with the peritoneum. Also, gonadal vessels may be easily mistaken for the ureter; aspirate when in doubt. Dissect the ureter, and place umbilical tape or a vessel loop behind it. The renal pelvis can be reached by following the ureter upwards. Look for vessels crossing the UPJ. Expose the posterior aspect of the pelvis using sharp and blunt dissection. Remain in the renal capsule when dissecting the kidney. Do not use blunt dissection because adhesions can tear the renal capsule and cause more bleeding, which obscures the operative field. The renal pelvis may be intrarenal or extrarenal. For an extrarenal pelvis, insert 2 stay sutures of 3-0 chromic catgut or 5-0 synthetic absorbable suture. Make a transverse incision with a knife between the stay sutures. The incision can be extended into the calyx or, if needed, can be converted into a T incision by crossing the UPJ. If the stone is very large, a Gil-Vernet procedure can be performed (extended pyelolithotomy). The dissection is continued into the sinus by Kuttner (peanut). A vein retractor is very useful for lifting the kidney margin and exposing the infundibulum in the sinus so that the incision can be extended into the calyx. This allows a bigger stone to be removed, especially if the stone extends into a calyx. The stone can be removed using stone forceps (Turner-Warwick straight or curved stone forceps). Count the number of stones and compare the total with the number of stones observed on the x-ray film. Irrigate the renal pelvis with a red rubber Robinson catheter, and flush out any small fragments. Coagulum pyelolithotomy Coagulum pyelolithotomy is used when multiple small stones are present and are scattered throughout the calyceal system. Coagulum or a clot envelops the small stones, and fragments are removed with it. Into the renal pelvis through a 19-gauge needle, inject cryoprecipitate and 1 mL methylene blue and inject 1 mL of thrombin and calcium chloride. Do not overdistend the renal pelvis. Block the ureter with a noncrushing bulldog clamp. Thrombin and calcium chloride solution can be made by adding 5000 U of thrombin to 5 mL of saline and adding 10 mL of 10% calcium chloride. Another method to make coagulum is to inject the necessary volume of cryoprecipitate (ie, volume equal to that of the renal pelvis) and inject 1 mL of 10% calcium chloride. After 5-7 minutes, the clot is formed. The thromboplastin from the renal pelvis is used. Pyelolithotomy is then performed, and the clot, along with the stones, is removed. The procedure is usually safe, but pulmonary embolism and hepatitis are possibilities. This procedure is rarely performed in the United States because of concerns about possible infectious agents in the materials used. Avoid overdistension of the renal pelvis or ureter. Contact x-ray films can be used to localize the stone. The author uses a flexible nephroscope, but a rigid nephroscope or even a simple cystoscope can be used if needed to inspect, locate, and retrieve a stone or fragment from a calyx. Pyelotomy may be closed with 4-0 chromic or 5-0 synthetic continuous suture. Try to create a watertight closure, but this is not essential. Insert a drain through a stab incision to drain the pyelotomy site. Close the wound in 2 layers, transversalis and internal oblique fascia, with 0-0 synthetic absorbable suture. Suture the external oblique fascia with interrupted sutures of the same material. Unflexing the table and lowering the kidney bridge help greatly in closing. Skin can be closed with 3-0 monofilament nylon mattress sutures or staples. Summary
Preoperative detailsA plain x-ray film of the abdomen (KUB) is essential because kidney stones are notorious for moving. Kidney position is always higher than visualized on the x-ray film; always incise above the site noted. Always assume more than one stone is present in the renal pelvis. Make a bigger incision to gain better exposure. Be prepared to take intraoperative x-ray films. Intraoperative detailsRecognize the left testicular vein or ovarian vein on the left side and on the right side of the vena cava. Gonadal veins may be sacrificed with impunity if the need arises. Always mobilize the entire kidney, both upper and lower poles. Be prepared to extend the pyelotomy incision. The UPJ is not inviable; make sure it is not narrowed when closing. If necessary, perform an extended pyelolithotomy to remove a larger stone. Always use stone forceps to remove the stones, not regular forceps. When in doubt, perform a nephroscopy or obtain an intraoperative x-ray film. When a caliceal stone is present, incise the calyx and the infundibulum and then remove the stone with the stone forceps. If several small stones are present, consider the use of a coagulum pyelolithotomy. Postoperative detailsPain is less severe if bupivacaine (Marcaine) is injected, but be absolutely sure that the bupivacaine is not accidentally injected into a vessel because it can cause cardiac arrhythmias. Drains may be removed in 24 hours if the drainage is less than 25 mL. Ureteral stents can be removed after 2 weeks. If a ureteral catheter is used as a stent, it can be removed after 5 days. Follow-upPerform an imaging study to confirm the removal of all stone particles. Patient Education: For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center and Procedures Center. Also, see eMedicine's patient education articles Kidney Stones, Intravenous Pyelogram, and Cystoscopy. COMPLICATIONSSection 8 of 11
As with all renal stone procedures, a urinary tract infection or pyelonephritis may occur. Perinephric abscesses may require percutaneous drainage. Retained stone fragments, ureteral/renal pelvic scarring, and obstruction are possibilities that may require additional open or endoscopic urological surgery. As with any surgery, atelectasis is the most common complication of stone surgery. Aggressive incentive spirometry and patient ambulation assist in treating this. Some advocate a brief period of hyperventilation with vigorous lung expansion immediately postoperatively while the patient is supine and just prior to extubation. Flank hernia/laxity due to intercostal nerve injury or disruption of the fascial closure are usually benign but very bothersome to patients. An adequate cosmetic result is difficult with this repair. Stone formation on the sutures used to close the renal pelvis incision has been reported. Other complications include urine leak or urinoma, urinary fistula (to skin or bowel), bleeding, arteriovenous malformations, pseudoaneurysms, and injury to pleura/lung with pneumothorax. The vast majority of cases with urinary leakage and fistula between the collecting system and skin can be treated with a ureteral stent; percutaneous placement of a perinephric drain may be needed if an intraoperative drain was not placed or has already been removed at the time the leak is recognized. An indwelling urethral catheter may also be needed to divert the flow from the fistula tract and allow it to seal. A small pneumothorax without respiratory distress due to an iatrogenic pleural injury can usually be treated conservatively and monitored. Larger air pockets can be treated with aspiration or a chest tube. If a lung injury is also present, a chest tube should be the initial therapy. Fistula with the bowel can sometimes be managed with a stent, urethral indwelling catheter, bowel rest, and parenteral nutrition. If the fistula does not respond to this conservative management, surgical repair and possible nephrectomy and/or bowel resection may be necessary. Bleeding, arteriovenous malformations, and pseudoaneurysms can be severe problems that may require embolization, emergent surgical intervention, transfusion, possible loss of the kidney, and even loss of life in extreme cases. OUTCOME AND PROGNOSISSection 9 of 11
While the stone-free rates after pyelolithotomy are excellent for solitary renal pelvic stones, the morbidity is so much greater than even multiple percutaneous, ureteroscopic, and/or extracorporeal shockwave approaches that this procedure is rarely used. Urologists practicing before the advent of these technologies or in areas with little access to the complex instrumentation for noninvasive stone management have the most experience and best surgical results. Note that these patients should be informed about kidney stone prevention metabolic analysis, including a 24-hour urine collection for calcium, citrate, oxalate, magnesium, phosphate, sodium, uric acid, and total volume analysis. Optimally, a screening blood test for hypercalcemia, hyperparathyroidism, and hyperuricemia should also be performed. Testing protocols are available commercially from Dianon Systems (Stratford, Conn), UroCor Labs (Oklahoma City, Okla), and LabCorp (Burlington, NC), among others. FUTURE AND CONTROVERSIESSection 10 of 11
Because of the advent of ESWL and PCN, pyelolithotomy is becoming an uncommon surgery in most developed countries. Pyelolithotomy is invasive, but it continues to have role in certain cases due to the size or shape of the stone, inaccessibility to ESWL and PCN, or the need for concomitant open surgical intervention for related problems. Laparoscopic pyelolithotomy has growing support, especially when laparoscopic reconstruction of a UPJ obstruction is planned. REFERENCESSection 11 of 11
Article Last Updated: Jun 12, 2006 |
