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Common Urological Problems

Urinary Stone Disease Intervention

  • - General Urology - Common Urological Problems - Urinary Stone Disease
  • Jul 25, 2010
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I. ANATROPHIC NEPHROLITHOTOMY
Anatrophic nephrolithotomy is used with complex staghorn calculi. A complete staghorn calculus is a cast of the renal pelvis and calyces (Figure 16–21). A partial staghorn calculus involves the renal pelvis and extends into at least 2 infundibula. To gain access to the entire collecting system, a longitudinal incision is made on the convex surface of the kidney just posterior to the line of Brödel,  taking advantage of the converging anterior and posterior renal blood supplies. Occlusion of the renal artery followed by renal cooling with slushed ice gives a relatively bloodless surgical field. A nerve hook is helpful to tease out calculi.

Careful inspection of the entire collecting system helps remove all stones.  Repair of narrowed infundibula helps reduce stone recurrence rates.  The collecting system is closed followed by the renal capsule. Intraoperative placement of a nephrostomy tube for possible follow-up irrigations or endoscopic inspection or stone retrieval makes hemostasis difficult. Open stone surgery becomes progressively more difficult after the first procedure owing to reactive scar tissue.

J. RADIAL NEPHROTOMY
Radial nephrotomy gives access to limited calyces of the collecting system.  An appropriate approach to localized calculi, it is frequently used in blown-out calyces with thin overlying parenchyma. Intraoperative ultrasound helps to localize the calyx and the calculi. Once the kidney has been opened, the introduction of air can make interpretation of subsequent ultrasound scans confusing. A shallow incision of the renal capsule can be followed by puncture into the collecting system. Brain retractors provide excellent exposure.

Urinary Stone Disease

Urinary Stone Disease

Care should be taken not to force stones through narrow infundibula. Stones may be cut with heavy Mayo scissors, and remaining fragments can be retrieved. Inspection with flexible endoscopes is helpful.  Intraoperative radiographs help document a stone-free status.

K. OTHER RENAL PROCEDURES
Partial nephrectomy is appropriate with a large stone burden in a renal pole with marked parenchymal thinning.

Caution should be taken with a simple nephrectomy even with a normal contralateral kidney, as stones are frequently associated with a systemic metabolic defect that may recur in the contralateral kidney. What may seem prudent and simple today may be regretted tomorrow.

Other unusual procedures include ileal ureter substitution performed with the hope of decreasing pain with frequent stone passage.  Autotransplantation with pyelocystostomy is another option for patients with rare malignant stone disease.

L. URETEROLITHOTOMY
Long-standing ureteral calculi-those inaccessible with endoscopy and those resistant to ESWL-can be extracted with ureterolithotomy.  Again,  a preoperative radiograph documents stone location and directs an appropriate incision.

The proximal ureter may be approached with a dorsal lumbotomy. An incision lateral to the sacrospinalis muscles allows medial retraction of the quadratus lumborum. The anterior fascicle of the dorsal lumbar fascia must be incised to gain proper exposure despite the appearance of potentially opening the peritoneum. Once the ureter is identified, a vessel loop or a Babcock clamp should be placed proximal to the stone to prevent frustrating stone migration. Extension of this incision is limited superiorly by the 12th rib and inferiorly by the iliac crest. A longitudinal incision over the stone with a hooked blade exposes the calculus. The nerve hook is excellent to help tease out the stone.  A flank or anterior abdominal muscle splitting incision gives excellent exposure to mid- and distal ureteral stones.

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Marshall L. Stoller, MD

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REFERENCES

  1. Ackermann D et al: Influence of calcium content in mineral water on chemistry and crystallization conditions in urine of calcium stone formers. Eur Urol 1988;14:305.
  2. Allie-Hamdulay S et al: Prophylactic and therapeutic properties of a sodium citrate preparation in the management of calcium oxalate urolithiasis:  Randomized,  placebo-controlled trial.  Urol Res 2005;33:116.
  3. Bilezikian JP et al:  Primary hyperparathyroidism:  New concepts in clinical,  densitometric and biochemical features.  J Intern Med 2005;257:6.
  4. Fellstrom B et al: Dietary habits in renal stone patients compared with healthy subjects. Br J Urol 1989;63:575.
  5. Gentle DL et al: Geriatric nephrolithiasis. J Urol 1997;158:2221.
  6. Heller HJ et al: Effect of dietary calcium on stone forming propensity. J Urol 2003;169:470.
  7. Langley SE, Fry CH: The influence of pH on urinary ionized [Ca2+]:

Full References  »

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