PYELOLITHOTOMY

It is the open surgery which uses the incision through the renal pelvis for removal of a stone.
Large renal stones are usually removed by percutaneous nephrolithotomy (PCNL) or ESWL. Pyelolithotomy is only rarely performed in recent times.

Indication

1. Failure or contraindication to both ESWL and PCNL.
2. Presence of an associated anatomic abnormality requiring open operative intervention such as PUJ obstruction.

Types
Standard pyelolithotomy
Extended pyelolithotomy
Coagulum pyelolithotomy



Radiological investigation :
X ray KUB
USG KUB
Intravenous Pyelography
Computerized tomography


Surgical procedure
Antibiotic
Injectable Cephalosporin group
Anaesthesia
Under general anaesthesia
Position
Lateral (Flank) position

Things :
1. BP handle –3,4,7 size
2. Forceps- Toothed -6”, 8”
Non Toothed –6”,8”
Vascular Forceps-6”-8”
3. Clamps:
• Mosquito curved artery forceps
• Mosquito straight artery forceps
• Medium curved artery forceps
• Medium curved artery forceps

4. Tissue Holding Forceps:
• Allis tissue holding forceps
• Babcock forceps
• Sponge holder
• Right angle forceps
• Stone holding forceps(Randall’s Forceps)
5. Needle Holder –6” and 8”
6. Retractors:
• Self retaining retractor
• Langenbeck retractor
• Deavers retractor
• Kellys retractor
• Morris retractor
• Eyelid retractor
4. Scissors:
• Metzenbaum scissor
• Mayo straight scissor
• Angle pott’s scissor
5. Suction yanker
6. Towel clips
7. Cautery bag
Sutures:
• 2-0,3-0 free ties
• 2-0,3-0 chromic
• 4-0 vicryl
• 1 vicryl
• 2-0 ethilon
Miscellaneous things:
• Periosteal elevator
• Doyens’ rib raspirator
• Liston bone cutter
• Swedish bone nibbler

Procedure
The standard Pyelolithotomy is generally performed through a flank incision along the 12th rib.
In this approach, the Retroperitoneum is entered and Gerota’s fascia opened posteriorly near the lower pole of the kidney.
The proximal ureter is identified and taped with a vessel loop to prevent distal migration of the stone during the subsequent dissection.
Then the dissection is carried proximally toward the renal pelvis along the posterior aspect of the ureter
The kidney need not be mobilized more than is necessary to provide adequate exposure of the renal pelvis. Excessive mobilization may result

in significant perirenal scarring
Once the renal pelvis is adequately exposed posteriorly, stay sutures are placed away from Pelvi ureteric junction.
The Pyelotomy is initiated with a curved banana blade and extended with a Potts scissor as for as necessary to extract the calculus under

direct vision.
The stone is then removed with a standard Randalls forceps and a 6fr catheter is passed antegrade to the bladder to ensure ureteral patency.
The catheter is left in place to prevent distal migration of any stone fragments and the renal pelvis is irrigated with saline. Then the

Pyelotomy is closed with interrupted 4-0 chromic sutures through the thick pelvic wall.
Internal stent is placed in case of the preoperated kidney (or) in the presence of infection.
External drainage is routinely provided with a penrose (or) closed tube drain placed in retroperitoneum and the wound is closed in a standard

fashion.

Post operative care
Post operative Xray KUB is required to ensure the complete clearance of calculi.
Biochemical analysis of the stone has to be performed
The drains are removed after 24-48hrs postroperatively.

Post operative medicines:
IV antibiotic
Analgesics
Inj Ranatc


Complications:
Bleeding
Stone migration
Post operative :
Infection