ANATROPHIC

NEPHROLITHOTOMY
Cold Ischemia Time
• Time of cold storage with or without perfusion with
a storage solution
• Up to 24 hours
Warm Ischemia Time
• The period between the circulatory arres and
beginning of the cold storage
• Up to 20 minutes are well tolerated by the kidney
Preoperative Planning and
Preparation
• All patients should be evaluated with three-
dimensional reconstruction of noncontrast
computed tomography of the abdomen to
understand the spatial orientation of the renal
anatomy and stone

Hinman’s Atlas of Urologic Surgery (Smith, 2018)

Patient Positioning and Surgical
Incision
• The patient is placed in the 90-degree flank

Hinman’s Atlas of Urologic Surgery (Smith, 2018)

• A flank incision is used to access the kidney
• An 11th or 12th rib incision is made depending on
the location of the kidney
• The pleura and diaphragm are mobilized cranially,
and the peritoneum is mobilized medially
• Resection of the 11th rib may be necessary if the
kidney is located high in the retroperitoneal cavity

Hinman’s Atlas of Urologic Surgery (Smith, 2018)

Operative Technique
• The Gerota fascia is encountered and opened in a
cranial-caudal fashion over the posterior aspect of
the kidney to allow for cover- ing at the time of
closure
• Perinephric fat is dissected off the kidney taking
care not to enter a subscapular plane
• Superior dissection must be performed gently to
separate and free the adrenal gland and inferior
dissection to separate the lower pole

Hinman’s Atlas of Urologic Surgery (Smith, 2018)

• Each renal pole should be free to facilitate
dissection and further manipulation of the renal
hilum

Hinman’s Atlas of Urologic Surgery (Smith, 2018)

• At this point, an intraoperative plain film or
fluoroscopy can be performed to help with planning
the optimal location for nephrotomy
• The posterior segment is then temporarily clamped
with a bulldog clamp or rubber shod, and the patient
is given 10–20 mL intravenous methylene blue
• This will result in blanching of the posterior segment
of the kidney, the blue-colored parenchyma allowing
delineation of the avascular intersegmental plane, that
is, the Brodel line
• Once marked, the clamp on the posterior segmental
artery is removed

Hinman’s Atlas of Urologic Surgery (Smith, 2018)

Hinman’s Atlas of Urologic Surgery (Smith, 2018)
• The kidney is then surrounded by a plastic drape,
12.5 g of mannitol is given intravenously, and 10
minutes later the renal hilum is clamped using
bulldog clamps or a vascular clamp
• Once clamped, the kidney is covered in ice slush for
10 minutes to achieve a parenchymal temperature
of 15° C. Ice slush should be replaced at least every
30 minutes while clamped

Hinman’s Atlas of Urologic Surgery (Smith, 2018)

Hinman’s Atlas of Urologic Surgery (Smith, 2018)
• Incise the capsule sharply along the previously
marked line
• Make the incision as short as deemed necessary, it
can always be opened up later
• Using a Penfield dissector or the back of a scalpel,
bluntly separate the parenchyma until the
collecting system is encountered
• Sharply transect any interlobar vessels
encountered; few should be seen if in the
appropriate avascular plane

Hinman’s Atlas of Urologic Surgery (Smith, 2018)

Hinman’s Atlas of Urologic Surgery (Smith, 2018)
• Open the collecting system sharply with a Potts
scissor and expose the stone

Hinman’s Atlas of Urologic Surgery (Smith, 2018)

• Once the stone is exposed, gently free the stone
with a blunt Randall forceps

Hinman’s Atlas of Urologic Surgery (Smith, 2018)

• Complex stone ramifications or stones located in calices
with stenotic infundibulum may require a separate
nephrotomy incision directly over the moiety where the
stone is located

Hinman’s Atlas of Urologic Surgery (Smith, 2018)

• Inspect each calyx in succession and gently palpate
the renal parenchyma to ensure all stone is
removed
• Once the bulk of the stone has been removed from
the renal pelvis, an antegrade ure- teral stent is
placed over a glide wire to help prevent any
migration of stone particles

Hinman’s Atlas of Urologic Surgery (Smith, 2018)

Closure
• All transected vessels are oversewn with 4-0
absorbable polyglactin suture
• The collecting system is then closed in a running
fashion using 5-0 polyglactin suture
• Calicoplasty is per- formed by either suturing the
mucosal edges of the infundibulum to the adjacent
renal pelvis or by suturing the mucosa of two
adjacent infundibula together

Hinman’s Atlas of Urologic Surgery (Smith, 2018)

Hinman’s Atlas of Urologic Surgery (Smith, 2018)
• The remainder of the collecting system is closed
with a running suture

Hinman’s Atlas of Urologic Surgery (Smith, 2018)

• The renal capsule is closed using either a running 4-
0 polyglactin suture or horizontal mattress stitches
over a fat bolster to prevent tearing of the capsule

Hinman’s Atlas of Urologic Surgery (Smith, 2018)

• The ice slush is removed, and the bulldog clamps are
removed
• The patient is given another dose of 12.5 g of mannitol to
decrease renal reperfusion injury
• The kidney is then bathed in warm saline with rapid return
of good turgor
• Any bleeding encountered from the nephrotomy site can be
controlled with light pressure to the incision
• If high-volume bleeding ensues, the incision should be
reopened and a search should ensue for an actively
bleeding vessel
• The Gerota fascia is then reapproximated over the incision
using 2-0 polyglactin sutures
• A Jackson Pratt drain is placed posterior to the kidney and
brought out through a separate stab incision
• The fascial layers and skin are closed in a standard fashion

Hinman’s Atlas of Urologic Surgery (Smith, 2018)

Postoperative Care and
Complications
• Hemoglobin and creatinine are closely monitored
for hemorrhage and renal insufficiency
• The urethral catheter is removed on the second or
third day if no significant urine leak is evident
• The Jackson Pratt drain is removed when output is
less than 50–100 mL over 24 hours
• The patient is discharged with oral antibiotics for 5–
7 days and the ureteral stent is removed 4 weeks
postoperatively

Hinman’s Atlas of Urologic Surgery (Smith, 2018)