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39

3 T HE M ETHOD OF A NATROPHICN EPHROLITHOTOMY U SED INC ALCULUS R EMOVAL AND

PARTIAL N EPHRECTOMY

With the widely used extracor-poral lithotripsy, percutaneousnephrolithotomy, and endouro-logic methods for kidney stone

surgery, the clinical use of the ana-trophic nephrolithotomy proce-dure has diminished. However,

because this operation clearlyshowed the advantages of usinghypothermia in extensive kidneysurgery and demonstrated maxi-mal parenchymal preservation, itcan still be useful. Anatrophicnephrolithotomy not only can beused for full staghorn calculussurgery but also can be adaptedfor complex kidney reconstruc-

tions and partial amputations in asolitary kidney. If the surgeon chooses to in-

duce kidney hypothermia for theoperative procedure, intravenous

infusion of mannitol (12.5 g) pre-operatively as well as immedi-ately before clamping the renalvasculature will allow the maxi-

mal ischemic time with the leastrenal damage. 1,2

OPERATIVE PROCEDURESlush Preparation

FIG. 3-1. Slush should be usedimmediately after renal vascula-ture occlusion and is preparedeasily by the following method 3,4:

1 Dry ice is placed in a large basin.

2 An empty stainless steel

bowl is placed in the middleof the large basin such that itis surrounded up to the rimwith the dry ice (A).

A B C

From Cromie WJ, Streem S:Urology 19(1):85, 1982.

3-1

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40 Critical Operative Maneuvers in UrologicSurgery

Coagulum Cast of Renal Pelvis and Ureter with Stones Entrapped

Cast

Stone

3-2

3 When the inside of the stain-less steel bowl becomesf rosty, normal saline solu-tion is slowly poured inwhile the solution is stirred(B).

4 Within 5 minutes, slush willform and will be ready for

use (C). Coagulum Preparation

The use of the most popularcoagulum for trapping kidneystones was curtailed by the reportof the associated development ofa pulmonary embolus. The throm-

bin was identified as the culpritfor the cascade of the fatal event. 5

FIG. 3-2. A simpler method offorming a coagulum cast withoutthrombin was described by Ka-

lash, Campbell, and Young. 6 Al-though this formula is rarelyused, we have found it to be themost consistent and easiest to use:

1 Cryoprecipitate (250 mg/U)(12 U 100 ml) is orderedthe day before surgery.

2 The cryoprecipitate first is al-lowed to thaw in a 37 C bathand then is left at room tem-perature for 30 to 40 minutes

before use. 3 Using a 10% solution of cal-

cium chloride (10 ml ampule,Elkin), the surgeon mixes avolume ratio of 1:20 of cal-cium chloride to cryoprecipi-tate (e.g., 1 ml of calciumchloride solution to 20 ml ofcryoprecipitate). One to twodrops of methylene blue can

be added to distinguish thismixture from the stones. 2

4 Either by estimating or by di-rectly applying a No. 18 an-giocatheter into the renalpelvis, the surgeon with-draws the volume of urinewithin the pelvis.

5 Correspondingly, the surgeondraws the same or greatervolume of the cryoprecipitatemixture and injects it into therenal pelvis after the proxi-mal ureter is temporarily ob-

structed with a vessel loop.The injection should fill therenal pelvis such that the mix-ture can flow into the multi-ple calyces. However, the sur-geon should not overdistendthe collecting system becausethis could lead to venous ex-

travasation.5

6 The surgeon injects 5 ml ofthe mixture into a medicinecup to observe for coagula-tion to take place. It requires 15 to 20 minutes for the coag-ulum to form.

7 The surgeon then opens therenal pelvis and calyx and re-moves the solidified coagu-lum with the stone trappedwithin it.

Arterial and VenousIsolation FIG. 3-3. To find the true avascu-

lar plane between the anterior andposterior renal arteries, Smith andBoyce7 first described isolating therenal artery from the renal veinand then occluding the anterior orposterior branch of the artery witha bulldog vascular clamp. An ob-vious avascular line can be de-fined if methylene blue is injected.

However, because this methodis cumbersome and also has led toirreversible arterial injury, a sim-pler method described by Red-man, Bissada, and Harper 8 ismore commonly used.

With this simpler method, thesurgeon estimates the location ofthe avascular plane, which isslightly posterior to the midpor-tion of the kidney. The surgeon oc-cludes the renal artery and veintogether as one unit instead ofseparating the artery, vein, and

branches. We prefer using vessel loops

wrapped around twice and tied(en bloc ligation) rather than us-ing bulldog vascular clamps. Thisvessel loop method lessens thevascular trauma and also permitsthe surgeon to loosen the loops in-termittently to allow flow-throughduring the operation.

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Chapter 3 AnatrophicNephrolithotomy 41

Anterior Posterior

Kidney

Renal artery and veinligated separately by bulldog clamps

or vessel loops

En bloc ligation

Actualavascularplane

Estimatedavascularplane

3-3

Bowelbag

A Kidney

Bowelbag

B

Slush

Renal vein and artery Ureter

3-4

Possible leakageof slush

Bowel BagPlacement FIG. 3-4. After the vessel loops

have been placed loosely aroundthe entire vascular pedicle, a bowel bag is placed over the kid-ney. Wrapping the kidney downto its pedicle, the surgeon ties um-

bilical tape around the base (A). A small slit is made so the kid-

ney can be extruded. The object ofthis maneuver is to prevent exces-

sive leakage of slush into the ret-roperitoneum. Fluid in direct con-tact with the body may lead toexcessive body hypothermia (B).

Once the renal vasculature has been occluded, slush is pouredinto the bowel bag (C).

No leakageof slush

Reflectedbowelbag

C

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Kidney

Staghorncalculus

3-5

Renalpelvis

Blunt endof knifehandle

Renal capsule

FIG. 3-5. Using the simpler meth-od of this operation, the surgeonfirst divides and preserves asmuch of the renal capsule as pos-sible and then bivalves the kidneywith a blunt knife handle alongthe estimated avascular line.

If coagulum is used, the precip-

itate is injected before opening theparenchyma. After the surgeon has removed

the bulk of the stones and has ir-rigated and flushed out each ca-lyx, the most difficult part of thesurgery is undertaken: the re-moval of residual stones.

The recurrence rate of infec-tious stones is proportionally re-lated to the number of stones re-maining in the kidney.

FIG. 3-6. With a needle placed on

either pole, the surgeon can defineremaining stones in the anterior aswell as the posterior leaf of the

bivalved kidney with the use of jaw or dental film. 9 We prefer thismethod over the use of neph-roscopy or sonography.

Jaw or dental film (Kodak cata-log number 1566389) or 5 12inch panoramic film is placed be-tween intensifying screens (LanexRegular; Kodak) and then placedwithin a pliable Gendex cassette.The cassette is covered with adhe-sive sterilized plastic or placedwithin a sterile plastic bag. Thesurgeon places the cassette be-tween the bivalved kidney and ob-tains a radiograph of the stones inthe anterior leaf. A second film isplaced posterior to the whole kid-

ney to define stones in both leavesof the kidney. By counting thestones in the first film and sub-tracting the number from the totalnumber of stones detected in thesecond film, the surgeon can de-fine the stones in the posterior leaf.

FIG. 3-7. A nephrostomy tube and

a small-caliber irrigating stent areplaced after the stones are re-moved (1 and 2).

Obvious, large defects of thecollecting system and dividedvasculature are closed with an ab-sorbable stitch (4-0 chromic) (3),

but it is not necessary to reap-proximate all divided vessels orcollecting systems.

The importance of reapproxi-mating the renal capsule to createa tamponade cannot be overem-

phasized. When the kidney is rewarmedand the vessel loop around thevasculature is released (4), there isusually minimal bleeding.

PARTIAL NEPHRECTOMY FORRENAL CANCER IN SOLITAR YKIDNEY

If partial nephrectomy is indi-cated, whether for cancer in a soli-tary kidney or for other reasons,the objective is to remove the dis-eased segment of the kidney andto preserve as much residualparenchyma as possible.

A preoperative selective arteri-ogram is useful.

In rare cases in which a branchof the renal artery corresponds to

Portable Radiograph for Residual Stones

Needle

Superior View

X-rays

LateralView

Anterior leaf X-rays

Needle

Anterior leaf

Needle Cassette

3-6 Cassette

Posteriorleaf Posterior

leaf

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Renal pelvisand calyx

3 Renal capsuleclosure

Inflow stent

2

4

Nephrostomy tubefor outflow

1

3-7 Kidney

Partial Nephrectomy

Renal cancer

En blocligation ofrenal vein

and ar ter y Renalcapsule

Kidney

3-8

the segment to be resected, thesurgeon can simply ligate the

branch and perform partial neph-rectomy. In the majority of cases,however, this is not so. En bloc li-gation of the renal artery and veinshould be performed and then hy-pothermia should be induced.

FIG. 3-8. The capsule is opened,and the amputation of the kidneysegment for a partial nephrec-tomy can be performed using the

blunt end of a knife handle to di-vide the parenchyma.

The calyceal systems should beclosed with a running stitch (2-0

or 4-0 chromic), and large-calibervessels should be closed with fig-ure-of-eight stitches.

The assistant should nowloosen the vessel loop around therenal pedicle while the surgeonsearches for obvious venous andarterial bleeding sites that requireocclusion.

The argon beam coagulator(Birtcher/Solos, Irvine, Calif.) canprovide excellent hemostasis ofthe raw surfaces of the amputatedkidney. 9 The coagulator can also

be used to obtain hemostasis ofthe spleen and liver.

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FIG. 3-9. Mild hemorrhage can betamponaded by pieces of fat orSurgicel with Avitene compressedwithin the reconstructed renalcapsule.

The use of fibrin glue (Hemae-dics, Inc., Malibu, Calif.) is alsohelpful.

FIG. 3-10. If there is still bleedingafter the kidney is rewarmed andthe temporary vascular ligation isreleased, the Teflon felt pledgetsandwiching technique is another

alternative for achieving hemo-stasis.

Using two Teflon felt pledgets(1 2 cm), the surgeon passes amattress stitch (0 chromic) throughthe pledgets with the kidney in

between as a sandwich. TheTeflon pledgets prevent the stitch

from tearing through becausepressure is applied to compressthe kidney. The same technique isused to repair lacerated spleensand livers.

Closure of renal capsule

Fat and Surgicel

Partially amputated kidney

Nephrostomy tube

3-9

Closure of calyx

3-10 Teflon felt sandwichcompression stitch

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K E Y P O I N T S

ANATROPHIC NEPHROLITHOTOMY

Mannitol (12.5 g) is administered intravenously. A vessel loop is twice wrappedaround the renal artery and veintogether. Alternatively, a singleloop with a Rummel vasculartourniquet can be applied to therenal vessels. A bowel bag is placed around thekidney. Slush is poured into the bowel

bag to induce hypothermia. The divided renal capsule is pre-served for closure. The need for the use of coagulumshould be considered. The renal stone is removed andthe calyceal branches are irri-gated. Cassette film radiographs of theanterior and posterior leaves ofthe bivalved kidney are obtained. A nephrostomy tube (Malecot 18 Fr) and stent (6 or 8 Fr) are placed for possible irrigation. Large open defects of the collect-ing system are closed and large

vessels are reapproximated withan absorbable stitch. Capsular reapproximation iscompleted. The kidney is rewarmed and thevessel loops around the renalpedicle are released.

PARTIAL NEPHRECTOMY

Vascular control is obtained witha vessel loop double-loopedaround the renal artery and vein

together.

Hypothermia is induced with thekidney in a bowel bag. Capsular division and kidneyamputation are performed. A nephrostomy tube is placed. Open defects of the collectingsystem are reapproximated.

Stitch ligation of large blood ves-sels is performed. ( Partial loosen-ing of the vascular occlusion willreveal bleeding sites.) The argon beam coagulator isused to obtain hemostasis of rawsurfaces following amputation. A tamponade effect of capsularclosure is achieved with Surgicelor fat compressed within the re-nal capsule or with fibrin glue(Hemaedics, Inc.,) applied to thewound. The Teflon felt sandwich tech-nique can be used to control

bleeding.

P O T E N T I A L P R O B L E M S

ANATROPHIC NEPHROLITHOTOMY

Inability to remove small residualstones after radiographic location:Perform nephrostomy leavestent near the area of the stone toserve as the inflow port for laterirrigation Excessive bleeding after rewarmingof kidney and releasing vessel looparound renal pedicle: Use Teflonpledget sandwich technique to

compress the bleeding site

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REFERENCES 1 Wickham JEA, Coe N, Ward JP: One

hundred cases of nephrolithotomyunder hypothermia, J Urol 112:702, 1974.

2 Finlayson B: Anatrophic nephrolithotomy [letter to the editor], J Urol 122:428, 1979.

3 Cromie WJ, Streem S: Rapid and sim- ple slush preparation for hypother- mic renal surgery, Urol/Urotech, 19:1, 1982.

4 Stanisic TH, Horan P, Silvert MA: Normal saline slush preparation for renal surgery, J Urol 122:287, 1979.

5 Pence JR et al: Pulmonary emboli associated with coagulum pyelolithotomy, J Urol 127:572, 1982.

6 Kalash SS, Campbell EW, Young JD: Further simplification of cryoprecipitate coagulum pyelolithotomy without thrombin, Urology 22(5):483, 1983.

7 Smith MJV, Boyce WH: Anatrophic nephrotomy and plastic calyrraphy, J Urol 99:521, 1968.

8 Redman JF, Bissada NK, Harper DL: Anatrophic nephrolithotomy: experi- ence with a simplification of the Smith and Boyce technique, J Urol 122:595, 1979.

9 McHold DS, Yu GW: Intrarenal radio- graphy for localization of residual struvite stones, Cont Urol 7:2 58, 1995.

SUGGESTEDREADINGS Assimos DG et al: A comparison of ana-

trophic nephrolithotomy and percu-taneous nephrolithotomy with andwithout extracorporeal shock-wavelithotripsy for management of pa-tients with staghorn calculi, J Urol 145:710, 1991.

Boyce WH: The localization of intrarenal calculi during surgery, J Urol 118 (part 2):152, 1977.

Brodel M: The intrinsic blood vessels of the kidney and their significance in nephrotomy, Johns Hopkins Hosp Bull 118:10, 1901.

Kalash SS, Campbell EW, Young JD: Sources of fibrinogen for coagulum pyelolithotomy without thrombin, J Urol 12:486, 1983.

Kalash SS, Young JD Jr, Harne G: Modi- fication of cryoprecipitate coagulum pyelolithotomy technique, J Urol 19:467, 1981.

Roth RA, Finlayson B: Stones: clinical management of urolithiasis. In Roth RA, Finlayson B, editors: International

perspectives in urology, vol 6, Balti- more, 1983, Williams & Wilkins, pp 358-360.

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Yu Chap 03 (39-46)