(Ki22-534 7/ 81 / 1254-046 / $0'2.
00 / G
THZ ,]CURN.A.L OF UROLOGY
Copyright© 1981 by Ths V!illia:ns & Vhlkin.s Co.
EXTENDED PYELOLITHOTOiv.1:Y: THE USE 01_1· RENAL ARTERY
CLAMPING AND REGIONAL HYPOTHERMIA
MENDLEY A. WULFSOHN
From the Department of Urology, Mount Sinai Hospital, New York, New York
ABSTRACT
Extended pyelolithotomy is a technique applicable for removal of most staghorn, and large pelvic
and caliceal calculi. Nephrotomy incisions can be avoided in many cases. The efficiency of extended
pyelolithotomy in difficult cases can be improved by renal artery occlusion combined with regional
renal hypothermia. Devascularizatio:n of the kidney produces softening of the renal substance, which
facilitates stone removal. The operative method is described and 5 cases are presented.
Extended pyelolithotomy is an operative technique suitable
for the removal of staghorn calculi, and large renal pelvic and
multiple caliceal stones. 1 - 4 This method, as popularized by Gil-
Vernet in 1965, 3 has become well established and consists of
deep dissection into the renal sinus along the avascular plane
immediately superficial to the renal pelvic musculature. The
operation, correctly performed, furnishes excellent exposure of
the interior of the renal pelvis and permits exploration of the
major and individual minor calices. However, the presence of
complicating factors, such as a small intrarenal pelvis, a pre-
vious renal pelvic operation or numerous peripheral calculi,
may persuade the surgeon to do a nephrolithotomy for fear that
a pelvic approach may not provide adequate exposure.
Anatrophic nephrolithotomy may be used for the removal of
staghorn calculi5- 7 but requires extensive incision into the renal
substance. The same holds true for pyelocalicotomy, when
extension of a pyelotomy incision into the lower calix assists in
intrarenal exploration. 6 · 8 Many surgeons prefer to complement
extended pyelolithotomy with separate radial nephrotomies to
remove peripheral stones, particularly when mushroom-shaped
stones are too large to deliver through the caliceal neck. 9 • 10 This
type of nephrotomy is probably the least traumatic to the
kidney since the overlying parenchyma usually is scarred and
atrophic.
Although nephrntomy is of undoubted value in the manage-
ment of renal calculi, some loss of functioning renal tissue can
be expected with the healing process. Therefore, a procedure
that diminishes the necessity for incision of the renal paren-
chyma is desirable. For this reason it is believed that occlusion
of the renal artery with protection of renal function renal
hypothermia should be considered in selected cases since this
procedme expands the of extended
facilitating dissection into renal smus
the exposure of the interior of the collecting system.
METHOD
The kidney is approached through a flank incision, usually
through the bed of the 12th rib. The kidney is mobilized
completely so that it can be delivered into the wound. At this
stage it is advisable to obtain an x-ray of the kidney to establish
the location and appearance of the stones to be removed and
also to confirm that the radiological technique is correct. The
small, flexible, sterilizable, contact x-ray plates are used. The
main renal artery then is isolated and held by an umbilical tape.
The dissection into the renal sinus for extended pyelolithotomy
proceeds on the posterior surface of the renal pelvis. If, at any
stage, difficulty is encountered as a result of a narrow renal
sinus, adhesions or bleeding a small bulldog clamp is placed on
the renal artery and hypothermia is instituted using iced saline
Accepted for publication July 14, 1980.
467
Val. 125,
Printed in
slush, cooling the kidney to between 15 and 20C.
As soon as the clamp on the renal artery is applied all blood
drains from the kidney, producing a dramatic change in the
consistency of the renal tissue. The kidney decreases in size and
the normally turgid renal parenchyma becomes soft, pliable
and supple (fig. 1). The renal sinus relaxes, retraction and
manipulation of the renal parenchyma are improved markedly
and blunt dissection to the infundibula of the minor calices is
accomplished more easily. It also is possible to palpate small
calculi through the collapsed renal substance, which would not
have been possible through the normally engorged tissues. The
pelvis is opened by a curved transverse incision, which extends
from the lower to the upper calix and has its apex just proximal
to the ureteropelvic junction. Because of the more complete
sinus dissection and easier retractibility of the renal tissue as
well as the bloodless field, exploration of the renal pelvis is
improved markedly and it is possible for the minor calices to be
visualized for removal of stone fragments. Identification and
removal of stones from the calices are further facilitated by the
use of a small illuminated suction, as well as the short Turner
Warwick stone forceps. 8 Gentle dilation of a caliceal neck may
be accomplished separating the blades of the stone forceps
to remove some of the bigger stones but the tissue must not be
lacerated. Only stones that are considered too large for this
route of removal should be extracted through small individual
radial nephrotomies. Once all stones are believed to have been
removed fmther intraoperative x-rays are obtained to deter-
mine whether there are any residual calculi. If no residual
the interior of the pelvis and the calices
are irrigated ,n-.,wrmon~ and the pelvis is closed with
interrupted absorbable sutures. The vascular clamp is removed
and the renal pa.recncJllym is observed to be certain
that total revascularization has occmTed.
Throughout the '-'"'vc,cn,~ the kidney is cool but it is
preferable not to work in the presence of ice rather to re-
cool the approximately every half hour to maintain the
hypothermia. An ideal time to re-cool the is while x-ray
plates are being developed,
Renal artery occlusion and kidney cooling were required in 5
cases of extended pyelolithotomy.
ILLUSTRATIVE MATERIAL
A 33-year-old man had passed kidney stones when he was 10
and 21 years old, and had undergone left ureterolithotomy
when he was 30 years old. A plain x-ray of the abdomen revealed
a large radiopaque compound pelvic stone on the right side
with several medium and small-sized stones within the calices
(fig. 2, A). An excretory urogram (IVP) showed satisfactory
bilateral function, with moderately severe hydronephrosis on
the right side associated with the pelvic calculus (fig. 2, B). The
renal pelvis was small and intrarenal in position.
468 WULFSOHN

The stones were removed via an extended pyelolithotomy.
Despite the intrarenal position of the pelvis and narrow renal
sinus it was possible to remove all pelvic calculi with renal
artery occlusion without difficulty and also to explore each calix
individually, removing all smaller stones. Intraoperative x-rays
showed that all calculi had been cleared. In all, 13 stones were
removed (fig. 3). An IVP 10 days postoperatively confirmed
that there were no visible residual calculi and revealed resolu-
tion of the hydronephrosis (fig. 4).
Three patients underwent removal of staghorn calculi by
extended pyelolithotomy. Difficulty was encountered in each
case because of a small renal sinus. After renal artery occlusion
the staghorn calculi were extracted and all caliceal fragments
were cleared without nephrotomy. One additional patient had
8 small symptomatic caliceal stones removed with this tech-
nique. The kidney had a bifid pelvis that was entirely intrarenal.
Only after the renal artery was occluded was it possible to
visualize the calices sufficiently to extract all calculi.
DISCUSSION
stone operation has been appreciated previously. 2 · 11 - 15 Some
investigators have reported that the renal vasculature needs
to be clamped only when nephrotomy is contempla-
ted.2-4'8'9' 12 • 16 • 17 Although many urologists prefer to remove cal-
culi via the renal pelvis, without resorting to nephrotomy inci-
sions, they may be unaware of the advantage of operating on
the devascularized kidney, particularly when there is a small
intrarenal pelvis, and they are forced to resort to nephrolithot-
omy. The safety of temporary ischemia combined with local
hypothermia is well established. Stubbs and associates operated
on solitary kidneys with renal preservation, using hypothermia
with an average occlusion time of 126 minutes, and showed no
1cm 1

The advantage of renal artery occlusion during a kidney

FIG. 1. Diagrammatic representation of renal sinus dissection for

extended pyelolithotomy after occlusion of renal artery. There is loss
of renal tissue turgor with diminution of size of kidney and widening of FIG, 3. Calculi removed through extended pyelolithotomy. Same
renal sinus. patient as in figure 2.

FIG. 2. A, plain film of right renal area shows large pelvic stone with extensions into calices. Several separate small and medium size peripheral
stones. B, IVP shows small intrarenal pelvis containing calculus and moderately severe hydronephrosis.

FIG. 4. Ten days after extended pyelolithotomy in same patient as in figure 2. A, plain film shows no evidence of residual calculi. B, IVP shows
resolving hydronephrosis.
statistical difference in the preoperative and renal
function studies. 18 Postoperative renograms have shown no
diminution in function and no decrease in blood flow. 15 In fact,
hyperemia often occurs initially.
The renal artery should be exposed and dissected off the
renal vein early in the operation, and it should be isolated with
an umbilical tape. A vascular clamp then can be applied at any
time during the operation if required for bleeding or if exposure
is inadequate. '\/\Tilson suggested that the renal vein also should
be clamped after the renal artery. rn Generally, however, trou-
blesome back-bleeding from the renal vein is unusual. James
and associates suggested that the patient should be hydrated
preoperatively and, also, intravenous mannitol should be given. 5
Several successful methods of cooling have been established,
including the use of the St. Peters cooling coils 20 and various
methods of application of saline ice slush. 6' 15 ' 21 Constant irri-
gation of the interior of the kidney with cold saline is preferred
by some. 11 Direct infusion of the renal artery to cool the kidney
has been done with either a cannula inserted into the renal
artery or a transfemoral balloon catheter. 22 However, these
methods involve the risk of damage to the endothelial lining
and subsequent thrombosis.2'l Whereas a warm ischemic time
of 20 minutes temporary reduction in renal func-
tion and ischemia 60 minutes pennanent
damage to the much of ischemia can be
withstood if the kidney is cooled to a temperature of between
15 and 20C. 23 At this level of hypothermia metabolism of the
renal tubular cells virtually ceases. The method of intermittent
clamping of the renal artery at IO-minute intervals used
Kerr 14 generally has not found favor. Recently, the use of
nucleotide inosine has been shown to protect the kidney against
warm ischemia for up to l hour. 24 ' 25 Whatever method of
lithotomy is used it is important that a maximum effort be
made to remove all stone fragments. The use of intraoperative
x-ray is mandatory in determining whether stones still are
present after the main bulk of calculous material has been
removed and, also, to determine in which part of the kidney
these stones are located to facilitate removal. The small, flexible
x-ray plates that can be sterilized and used in the wound are,
by far, the best available method at the present time. The
Polarex 2C arm image intensifier also has been used in an
attempt to localize caliceal stones under vision. 26 However,
469
there are technical problems. In particular, the machine is
cumbersome and results in excessive radiation exposure to the
kidney and the surgeon.
Various techniques to visualize the interior of the calices to
identify and remove peripheral calculi without nephrotomy
have been used in the past. These techniques include the
insertion of an illuminated nasal speculum 10 or, more recently,
the use of operative nephroscopy with either a rigid instru-
ment27 or a flexible fiberoptic nephroscope. 28 The intraoperative
use of ultrasound scanning also is extremely useful in identifying
and localizing elusive stones. 29 Small stones may be flushed out
of the calices with a high pressure water jet1 7 and some success
also had been achieved with coagulum pyelolithotomy. 30·:n
With extended pyelolithotomy and renal artery occlusion
exposure of the calices usually is so adequate that the afore-
mentioned -------, _____ are required rarely. However, it is advis-
able to have a of techniques available for difficult stones.
In particular, ultrasonic localization of retained stones may well
prove to be the most important adjunct to this operation and,
may intraoperative
CONCLUSION
is the preferred
"'··-·"·~·- caliceal calculi.
calculi can be removed this
Vl:'ULt,WJH and Vn.Ot!hP,cmrn are USed.
This maneuver removes the normal tissue turgor and
causes the kidney to collapse, thereby allowing more thorough
exploration of the kidney. Although it is not being advocated
routinely for all cases of extended pyelolithomy it is recom-
mended for the difficult case, particularly when there is an
intrarenal pelvis, or scarring from a previous operation or during
the course of pyelolithotomy, when technical difficulty is en-
countered because of bleeding or anatomical factors.
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of removal of staghorn calculi by extended pyelolithotomy with-
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2. Resnick, M. I. and Grayhack, J. T.: Symposium on renal lithiasis.
470 WULFSOHN
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