GI and GU
Right Percutaneous Nephrolithotomy
PREOPERATIVE DIAGNOSIS: Right staghorn calculous.
POSTOPERATIVE DIAGNOSIS: Same.
PROCEDURE: Right percutaneous nephrolithotomy.
SURGEON: T H, MD.
ASSISTANT SURGEON: G H, MD.
ANESTHESIA: General endotracheal.
EBL: 100 cc.
DRAINS: Nephrostomy tube left, and the right kidney Foley catheter to gravity.
SPECIMENS: Stones sent to pathology for evaluation.
COMPLICATIONS: None.
DISPOSITION: In the PACU stable.
INDICATIONS FOR PROCEDURE: This is a 46-year-old female that had a right upper and mid-pole staghorn calculous. She went to interventional radiology in the morning to have a percutaneous assess obtained, and comes to the OR for definitive treatment of her stone disease.
OPERATIVE PROCEDURE: The patient was brought to the cystoscopy suite and general anesthesia induced. A Foley catheter was then placed in the bladder and then she was flipped prone on the cystoscopy table. Her back was then prepped with Betadine, dried and a craniotomy drape was placed over the access sheath from the previous percutaneous access. At this point, an implant extra stiff wire was placed through the sheath and seen curling in the urinary bladder under fluoroscopic visualization. Once this was done, a second wire in the form of a 0.038 Teflon-coated wire was passed through the access sheath as well, and this was also seen curling in the bladder. Once both wires were placed, the access sheath was removed. A small incision was made and the 0.038 Teflon-coated guide wire was secured to the drape to act as a safety wire. Once this was done, the NephroMax dilating balloon was placed over the working wire. A 30 French sheath was also placed with a NephroMax balloon. The balloon was advanced, and under fluoroscopic guidance placed within the renal pelvis and dilated to 12 atmospheres of pressure for 5 minutes. Once this was completed the access sheath was slid over the balloon, and under fluoroscopic guidance, positioned into the renal pelvis. At that point, the balloon was let down and the balloon was removed off the wire. The wire was then secured to the drape. At this point, a rigid nephroscope was passed through the sheath and into the renal pelvis. Nephroscopy was performed and the large stone was identified in the upper pole. Suction was used to remove any blood clots that impaired vision. With the irrigation consisting of warm saline, the ultrasonic lithotripter was placed through the nephroscope and the stone was engaged. The lithotripter was used to fragment the stone in several small pieces. A grasping forcept was then used through the nephroscope to take these pieces and remove them from the renal pelvis. The stone fragments were sent to Pathology for evaluation. Quite an extensive amount of time was used breaking the stone up, approximately 40 minutes to 45 minutes. All stone fragments were removed. Fluoroscopy did not, at the conclusion of the process of lithotripsy, did not reveal any stone fragments in the renal pelvis. There was one small area that was parallel to the access sheath that may be a stone, but it was unclear at that time. Once all of the fragments were removed, the sheath was backed out of the kidney under direct vision. Attempts were made to identify this radiolucent area in line with the access sheath, but this was unsuccessful. With the access sheath and nephroscope removed, the wire was secured again to the drape. A 20 French nephroureteral catheter was then passed over the wire and seen opening in the renal pelvis. The catheter flushed and irrigated easily. Dye was introduced through the catheter, revealing no filling defects in the renal pelvis. At this point, the catheter was secured to the skin with 2 number 0 silk sutures, and the catheter connected to a drainage bag. A pressure dressing was then applied and the patient was then returned to the supine position, where she was extubated and transferred to the PACU in stable condition, tolerating the procedure, without any complications.
Dr. H was scrubbed and present during the entire procedure.