Special Surgical Procedures II
LESSON 3: Procedures in Genitourinary Surgery
Section Iii: operations on the kidney, ureter, and adrenal glands
3-16
3-16. PROCEDURES FOR OPENING THE KIDNEY
a. Definitions.
(1) Nephrotomy is an incision into the kidney. A simple incision and drainage may be required for hydronephrosis, cyst, or perinephritic abscess.
(2) Pyelotomy is an incision into the renal pelvis.
(3) Pyelostomy is an incision into the renal pelvis to establish drainage or to permit irrigation of the renal pelvis.
(4) Pyelolithotomy is the removal of a stone or stones through the opening made in the renal pelvis.
(5) Nephrostomy is an opening into the kidney to maintain temporary or permanent drainage. A nephrostomy is used to correct an obstruction of the urinary tract, conserve and permit physiological restoration of renal tissue that has been impaired by disease, provide permanent drainage when a ureter is unable to function, treat anuria as an emergency measure, or drain a kidney during the postoperative period following a plastic repair on the kidney or renal pelvis.
(6) Nephrolithotomy and pyelonephrolithotomy are essentially the same, since one is simply an extension of the incision. This is done in order to remove a large stone intact or to explore a calyx where a small stone or fragment has slipped. The presence of a staghorn calculus is an indication for this procedure.
b. Operative Procedure.
(1) For opening. The kidney is approached as described for nephrectomy, using the desired incision. The renal pedicle is identified; the ureter is identified and retracted as necessary. The kidney is mobilized to permit approach to the aspect desired.
(2) For pyelotomy or pyelostomy. The pelvis of the kidney is incised with a small blade. Traction sutures of number 3-0 black silk on French eye or swaged-on needles may be placed at the edges of the incision to hold it open while the pelvis and calyces are explored. In pyelostomy, the catheter is placed through the incision directly into the renal pelvis.
(3) For nephrostomy. A curved clamp or stone forceps is passed through a pyelostomy incision into the renal pelvis and then out through the substance of the renal paren-chyma via a lower pole minor calyx. The tip of a Malecot or Pezzer catheter is then drawn into the renal pelvis, and the pyelotomy incision is closed. The distal end of the tube is brought out through the flank incision. Penrose drains are placed, and the incision is closed in the regular manner.
(4) For pyelolithotomy. The renal pelvis is opened, and the ureter may be probed for stones or strictures by passing a ureteral catheter and irrigating. Stones are removed. A multieyed catheter-- Pezzer, Malecot, or Foley type--is placed. The catheter is secured with sutures. A purse-string suture may be placed around the nephrostomy tube. After removal of a staghorn calculus, mattress sutures are usually tied over a pad of renal fat to support the long parenchymal incision.
(5) For closure. An incision in the renal pelvis may be closed with fine chromic-gut swaged on needles or left unclosed. The wound is drained and closed, as for nephrectomy. Reinforced absorbent dressings or special wound decompression apparatus is required for draining wounds.
