20_Open sungery tm Remove tones: Whenand How? 595 ‘The loop around the ureter prevents small stones from ‘nigating into the ureter, The slones are withdrawn from the ronal pelvis with freopa. Afi removing all ccessble cul cali, @ Mexible nephrascope ean he insered to inspeet the collecting ystem and remove remainingstones, Alternative. the “coagulum pyelolithotomy” has heen described, in whieh a coagulum mixture is injected into the closed renal pelvis. There ie forms a cast comtining the stones and can he extracted vin a pyclotoms, Thorough inigation of the collect- ing system is required. An 8 F catheter can be passed down, the ureter to ensue tha iti clear of stones. A nephrostomry tube may be placed and brought out thiough the lower pole, but is not necessary in an uneomplicated procedure, The pyelotomy is closed with running 4-( sbsorbable sucues 49.4.4 Extended Pyelolithotomy (Gil-Vernet) Indication: Staghor Stones For extended pyelotthotomy, complete mobilization of the kidney is necessary to contro she ena artery ad fae tate radiogcaphy. After removal of extessfaty tissu, the renal pelvis is completely dissected onthe adventitia enter ing the renal hilum, The pelvis is separated bluntly fom the hilum with mist cotton strips wo expose the ealyceal necks. ‘The pelvis is then incised with Potts scissors in an open Usshape lengthened to reach the lowest and the highest — Fig. 49.2 FERAL pellitotony. Extctioe of renal pelvic stone wilhsoneloeeps pelvic urothetiom and ix pulled owt with forceps under rotating movemenss (see Fig, 49.3), Where possible, the stone should he removed in single piece. Irnevessury, the stone ean he fragmented with cutting forceps, hone savy, or rill, Calicel extensions of staghoen stones can be extracted ‘with vig be laible mephavecopes Radial ueplvoloniied (see below) may be used for complete stone removal sf an extraction of caliea! stones with a nephroscope is not pose sible. After thorough irrigation af the collecting system, intraoperative radiography is used to document complete stone-free status, An 8 P eutheter can be passed down the ureter fo ensure tha its clear of stones, A_nephrostomy The posi Ir thon tnelod wih Pots esors Inn op Ute # cesow tart Ie cen of stones. A neproriomy bat noe nasemary in at uncompleted procedure. The thine the @usaad pyctoanenamy wih ene oe everal ral 49.4.5 Pyelonephrolithotomy49. Open Sugery ta Remave Stone: When and How? 509 11 years eater may be regarded as an indication that the Skil 0 perfor open sone surgery is desing, However, as the dats ofthe 2008 metuamalsis deve fom only three Patient groups ineluding 51 pins, his epraach may not be contpletelyjusitiod, Today, a combination of PNL and SW. is considered treamentof choice for mos staghorn calculi However, whereas the stone-fesrate of thisaproach ‘was 8156 in 1994, iLulso dropped tn 66% in 2005." Jow tratmentftcacy suggests that ody complex cases are valteae by minimally invasive technology and that in such cases, open stone surgery might o'fer a better alterna tive (compare Figs. 49.1a, b and 49,128, bi. Generally, complex stone sivations involving a large weripheral stone mass can be handled either by anatrophie iceman of by eatded pyelothotomy combined with one or several radial nephnotomies, Both procedures require the complete mobilization of the kidney and the exposure of fe renal vessels, Whereas ae Tithotomy routinely requires ischemic conditions, pyelolithotomy and ultasund-guided radial nephroiomies as deerbod previously canbe performed without clamping the renal artery ia most situations. As transient ischemia bears the risk of further impairing the often alteady reduced renal function, this approach seems advantageous. Furthermore, as the res vascular anatomy is very arable, may become fino clearly identify a complete avasulrareuin which ‘the longitudinal nephrotemy far anatrophie nephralithatomy is pocormed AS daige 10 intapaeashyaalameril ‘races regulary lead oss. of nephron Suction, such an approach may further duce the ofen alte impaired real function, Tn soarast to this, extended pyeolitetomy and ltt sound guided radial nepbrotumies ean be performed without applying ischemia in most situations, The exact position of the rail nephotomy canbe identified by asng intaope tive uirasonography to reliably localize the stone-baring cealyxand assess the shortest access to the stn, Furthermore, the Doppler function of modesn duplex soaagraphy probes visualizes intraparenchyral ld vessels helps t iden tifyanavascular area i which the incision can be performed. with nial harm othe kidney, Although the points mentioned previously seem to favor the conbination of extended pyelolthotomy over anatrophic rephrlithotomy, both procedures are equally performed leaving ito the individual urologist to decide which approach he prefers,