Introduction
Since the advancement of techniques such as extracorporeal shockwaves lithotripsy and percutaneous nephropyelolithotomy, the frequency of pyelolithotomy has reduced in developing countries. Pyelolithotomy is indicated in minimally branched staghorns stones in individuals with excessive morbid obesity and complex collecting systems.
Pyelolithotomy is also performed in individuals with complex open abdominal surgery or retroperitoneal surgery. Pyelolithotomy is often accompanied by open pyeloplasty for ureteropelvic junction obstruction. ‘Pyelo’ refers to ‘renal pelvis,’ and ‘lithotomy’ means removal of stone. Before the emergence of advanced techniques, pyelolithotomy was the treatment of choice.
A pyelolithotomy is performed in three ways:
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Open.
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Laparoscopic.
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Robotic.
There are two types of pyelolithotomy:
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Transperitoneal.
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Retroperitoneal.
What Is the Presentation for Pyelolithotomy?
The individual may present with the following signs and symptoms:
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Flank pain.
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Hematuria.
Individuals may even be asymptomatic. For example, there may be incidental findings during a computed tomography with elevated creatinine levels with partially obstructed stones within the renal pelvis.
What Is the Indication for Pyelolithotomy?
Even though there are advanced technologies present at the moment, pyelolithotomy remains the choice when other options fail or there are no choices left. As a routine pyelolithotomy may be considered an invasive procedure, there are particular cases in which the procedure is performed.
The cases selection criteria involve the following:
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Size of the stone.
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Need for an associated open surgery.
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When extracorporeal shockwave, lithotripsy, and percutaneous nephropyelolithotomy can not be performed.
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When the stone is more prominent than 2500 millimeters squared.
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Cases of extensive obesity.
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Complex collecting system.
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Failure of stone clearance through percutaneous nephropyelolithotomy.
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The stone composition is usually cysteine.
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Anatomy includes horseshoe, pelvic, or ectopic.
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At times performed in combination with pyeloplasty.
Other indications involve:
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Sepsis.
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Obstruction cases with approaching parenchymal renal loss.
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Hematuria and sepsis.
What Is the Contraindication of Pyelolithotomy?
Pyelolithotomy should not be considered in individuals with poor medical health and should be performed when no other reliable procedures are left.
Other contraindications include:
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Branches staghorn renal calculi.
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Infundibular stenosis.
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Renal calculi are present in the calyces.
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Severe kyphoscoliosis.
These conditions may be treated with calculectomy or Boyce, atrophic nephrolithotomy.
What Are the Diagnostic Tests Done for Pyelolithotomy?
The usual laboratory tests include:
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Complete blood count (CBC).
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Blood urea nitrogen.
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Blood creatinine.
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Blood type.
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Electrolytes.
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Activated partial thromboplastin time and prothrombin time.
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Urinalysis with culture and sensitivity tests.
Imaging tests include:
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Radiologic tests usually confirm the diagnosis.
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Radiograph of the ureters, kidney, and bladder. Around 90 percent of renal calculi are opaque.
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Computed tomography (CT) helps in quantifying the mass of the renal calculi. This test also helps in detecting radiolucent stones. It assists in the identification of vascular anatomy.
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Intravenous pyelogram gives information about demonstrating filling defects where the stone burden is present and also about the collecting system anatomy. An intravenous pyelogram is also able to detect uric acid stones.
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Retrograde pyelogram or cystoscopy provides similar outcomes as intravenous pyelogram and is performed in individuals with renal failure. Individuals with a creatinine level greater than 1.8 grams per 24 hours are also indicated.
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Renal scintigraphy is performed in individuals with long-standing obstructions and large stone burdens. In this clinical scenario, kidney function is usually extremely poor. In these cases, a renal scan can be performed.
How Is the Pyelolithotomy Procedure Performed?
Management Before Surgery:
If the infecting organism is known, it is treated by intravenous antibiotics based on the culture and sensitivity tests. Broad-spectrum antibiotics are recommended when culture results are not available. Individuals who are candidates for pyelolithotomy are most likely to have an infection because pelvic renal calculi harbor bacteria.
Surgical Approach:
The preoperative examination is done to improve the individual's general health. In sepsis, the kidney is drained using a stent or nephrostomy. The inflammation from the infection is left to subside for 48 to 72 hours. This is advised because an inflamed kidney is brittle and susceptible to bleeding. In addition, stent placement may help in ureteral identification and prevent debris or stone fragments from blocking the ureter.
The renal pedicle is anterior to the renal pelvis, but a posterior branch blood vessel may occasionally exist. Infected urine is drained using a retroperitoneal drain. The testicular or ovarian vein often resembles the ureter and can be distinguished by aspirating the stent with a needle or syringe.
The procedure is performed using general endotracheal anesthesia followed by the insertion of a foley catheter. The procedure can be open, robotic, or laparoscopic with a retroperitoneal or transperitoneal approach. During renal pelvis dissection, the renal pelvis should be adequately exposed, and all the vascular branches with ureteropelvic junction should be identified.
Coagulum Pyelolithotomy:
This procedure is used when numerous stones are present in the calyceal system. Around these stones, a coagulum or clot envelops them, and these fragments are removed. The renal pelvis is injected with cryoprecipitate, one milliliter of methylene blue, one milliliter of thrombin, and calcium chloride. Care is taken to not over-distend the renal pelvis. The ureter is blocked with a non-crushing bulldog clamp. The coagulum is prepared by adding chloride solution and 5000 units of thrombin to five milliliters of saline and adding ten milliliters of ten percent calcium chloride. After ten minutes, the clot is formed, followed by pyelolithotomy, and the clot is removed along with the stones.
Postoperative Details:
The drains may be removed after a day or so if the drainage is less than 25 milliliters. Ureteral stents are removed after one to two weeks.
What Are the Complications of Pyelolithotomy?
The complications involve:
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Urinary tract infection or pyelonephritis.
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Perinephric abscess.
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Retained stone fragments, renal pelvic scarring, or obstruction.
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Atelectasis.
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Urinoma or urine leak.
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Arteriovenous malformation.
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Pseudoaneurysms.
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Pneumothorax with lung injury.
What Is the Prognosis After the Procedure?
Pyelolithomy stone-free rates are excellent in cases of solitary renal pelvic stones. However, this procedure's morbidity rates are high and rarely used.
Conclusion
Pyelolithotomy is a surgical procedure used in removing renal calculi from the renal pelvis. Although this procedure has been replaced with several advanced minimally invasive techniques, there are times when the case criteria may require the need for pyelolithotomy. However, the procedure has high morbidity rates and is hence rarely used.
