What Is Pyelolithotomy?
Pyelolithotomy is a procedure employed in patients with a stone in the renal pelvis of the kidney. Indications for pyelolithotomy include minimally branched stones in the renal pelvis of collecting systems and excessive morbid obesity. Pyelolithotomy is also relevant in patients who are experiencing major open retroperitoneal or abdominal surgical procedures for other indications; the most common coexisting procedure is open pyeloplasty for ureteropelvic junction obstruction. A pyelolithotomy can be performed as a laparoscopic, open, or robotic method.
What Is Open Pyelolithotomy?
Open pyelolithotomy surgery is usually applied for difficult and complex stones which are resulting in blockage or the presence of symptoms such as recurrent infection, pain, and stones that are incapable of being removed using less invasive treatments. The procedure is generally done through a flank incision that permits the best feasible access. With the ureter and kidney being exposed, the surgeon is able to locate the stones by using X-ray imaging which can also be used to locate their exact position. Once the stones are found, an incision is made into the ureter or the kidney so the stone can be extracted. Once the stones are removed, all the incisions are stitched and secured. The surface skin layers are sealed with either dissolving stitches or with surgical staples.
A wound drain is placed to drain any fluid from the area, and a nephrostomy tube can also be inserted. A drain is positioned into the kidney called a nephrostomy tube through the same incision operated to remove the stone. It is stitched into position and is attached to a drainage bag that drains any blood, urine, or stone fragments from the renal pelvis of the kidney. If the ureter is to be incised during surgery, a ureteric stent may be positioned. This is a soft and thin tube that sits within the ureter. Both ends of the stent are spiraled, and one loop sits within the kidney and the other within the bladder. The stent permits healing and drains urine and any stone fragments from the kidney.
A catheter is also placed through the urethra to drain the urine from the bladder into a bag. Depending on the area and number of stones, surgery can take two to four hours to complete and can involve a two to four days of hospital stay.
What Is the Procedure for Open Pyelolithotomy?
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During admission into the hospital, the approximate time and preparation for the surgery are informed by the physician.
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An intravenous line is obtained through circulation, preventing blood clots.
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A shave of the surgical site is done just prior to the surgery.
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An anesthesiologist obtains anesthesia once ready for the surgery.
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After the surgery, blood pressure and pulse are checked. The wound is drained and checked for any bleeding, and the urine output from the nephrostomy tube and catheter are monitored closely.
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The intravenous line is still maintained in order to provide enough nutrients after the surgery. It is removed once the person is able to drink water normally.
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One can drink on the first day of surgery as advised by the surgeon.
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The next day after the surgery, the person will be able to wake up from bed and can eat and drink normally.
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Until one is able to eat and drink properly, the intravenous line is still kept to keep them hydrated and provide nutrients as required.
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Antibiotics and painkillers will be advised by the physician to prevent infection and reduce the pain from the surgery.
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The surgeon advises regular deep breathing and leg exercises after the surgery until one is fully mobile.
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The physiotherapist can come and advise the person on leg exercises and give further instructions.
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If the wound drainage is minimal on the second or third day, then it will be removed. Also, the catheter is removed if the urine output is sufficient.
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If the nephrostomy tube has been kept, it is also removed when the urine outflow is normal, as it would lead from the kidneys down to the bladder.
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If there is no pain or leakage from the nephrectomy tube, it can be removed.
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The length of treatment and need for antibiotics is different in each individual and can usually require two to three days.
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Generally the second or third day after the surgery, all the drainage and nephrostomy tubes are removed.
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If the suture placed is a dissolving one, then it need not be removed however if staples are used to stitch the wound, then they need to be removed within 7 to 10 days.
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Once the nephrostomy tube, catheter, and wound drainage have been removed and the person is able to eat and drink on their own, then they will be able to go home.
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If all the stone treatments have not been removed and further surgery is required, one will be sent with nephrectomy tube still on.
What Are the Risks Associated With Open Pyelolithotomy?
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There is always a risk of infection and blood loss associated with surgery. Sometimes, a blood transfusion is necessary to compensate for the blood loss during surgery.
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In some cases, the ureter needs to be incised during the surgery if a stone fragment is lodged firmly within the ureter causing scarring.
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These ureteral strictures are usually treated with minor surgery that opens up the narrowing.
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If a larger number of stones need to be removed during surgery, sometimes not all of them are removed and can require another surgery for the removal.
Conclusion
Open pyelolithotomy is a stone-removing procedure from within the renal pelvis part of the kidney (the funnel-shaped area for urine collection within the kidney) or from the ureter. The surgery is usually done through a 10 to 15 centimeter incision in the side of the body (flank) between the ribs and the hip, to expose the location of the stone. Open stone surgery, such as pyelolithotomy is generally reserved for the complex location of stones that causes blockage. Ongoing symptoms such as recurrent infection and pain also prevent the removal of stones using less invasive treatments.
