Incision and drainage of the kidney
Nephrotomy is the surgical incision of the renal parenchyma. This intervention is indicated for renal carbuncle, hydronephrosis, or pyonephrosis, as well as for staghorn and multiple small parenchymal stones. If the surgeon removes a calculus during the incision, this operation is called nephrolithotomy.
There are two main types of nephrotomy:
- Major (complete).
- Minor (partial) — considered a safer technique. The tissue is incised in a strictly limited area directly over the stone, which helps minimize bleeding.
Technically, the parenchymal incision is made along the long axis of the organ, 1 cm posterior to the middle of its convex border. After completing the main stage, the wound is closed with catgut sutures. It is important to note that high postoperative mortality, frequent complications, and a high risk of stone recurrence significantly limit the use of this surgery in modern practice.
Nephrostomy is a surgery aimed at temporary or permanent drainage of the kidney to improve its function. It is indicated for renal failure caused by pyelonephritis, as well as for severe calculous pyonephrosis in situations where organ removal (nephrectomy) is impossible. Currently, nephrostomy, like pyelostomy (creation of a fistula directly into the renal pelvis), is performed rarely and only under very strict indications.
Organ fixation and decapsulation
Nephropexy is the surgical fixation of the kidney. The main indication for it is nephroptosis (kidney prolapse) with significant displacement of the organ. The surgery is necessary if the prolapse is accompanied by severe complications: hematuria (blood in the urine), development of pyelonephritis, or persistent renal hypertension.
Renal decapsulation aims to reduce the interstitial pressure, which increases critically during inflammatory edema of the organ. The mechanism of action is as follows: stripping the dense fibrous capsule immediately improves intrarenal blood circulation, significantly reduces venous stasis, and thereby helps restore normal renal function. Despite its pathophysiological justification, the current state of the art is that decapsulation is used less and less frequently. This is due to the high efficacy of early hemodialysis, which successfully and less invasively eliminates uremia.
Kidney transplantation
Kidney transplantation is the most common procedure among all vital organ transplantations.
In topographical anatomy and operative surgery, two main types of transplantation are distinguished:
- Orthotopic transplantation — the donor organ is implanted into the anatomical site of the recipient's own removed kidney.
- Heterotopic transplantation — transplantation is performed to an atypical site: into the pelvis (iliac region) or the thigh.
In clinical practice, pelvic transplantation is usually preferred. This approach has two key advantages. First, the iliac region maintains the natural temperature regime required for normal organ function. Second, the anatomical proximity to the urinary bladder makes it much easier to implant a short segment of the donor ureter.
Briefly: answers to topical questions
What surgical approaches are used to expose the kidney?
Lumbar and extraperitoneal surgical approaches are used to expose the kidney.
- Fedorov incision — performed parallel to the costal margin.
- Bergman incision — the incision line runs along the bisector of the angle between the 12th rib and the outer edge of m. erector spinae.
- Israel incision — a modification of the Bergman incision extended downward parallel to the inguinal ligament.
- Kocher incision — performed parallel to the costal margin.
An extraperitoneal approach is also possible, in which the skin incision is made along the lower border of the 12th rib.
Which recipient vessels are used to form anastomoses during heterotopic kidney transplantation into the iliac fossa?
During heterotopic kidney transplantation into the iliac fossa, vascular anastomoses are formed with the recipient's iliac vessels.
- Arterial anastomosis — the donor kidney vessels are connected to the common iliac artery (a. iliaca communis) or external iliac artery. Most often, it is formed in an end-to-side manner.
- Venous anastomosis — the donor vein is anastomosed with the recipient's common iliac vein (v. iliaca communis) or external iliac vein. It is usually performed in an end-to-side manner.
What is the difference between nephrostomy and pyelostomy?
The difference lies in the anatomical structure on which the drainage fistula is created.
| Sign | Nephrostomy | Pyelostomy |
|---|---|---|
| Essence of the procedure | Temporary or permanent drainage of the kidney to improve its function | Creation of a fistula on the renal pelvis |
| Relevance | Performed rarely, under strict indications | Performed rarely, under strict indications |
The acronym "HPH" (Hematuria, Pyelonephritis, Hypertension) helps remember the indications for nephropexy in nephroptosis.
Class and exam questions
What is the difference between nephrotomy and nephrolithotomy?
Nephrotomy is the incision of the renal parenchyma for specific indications (e.g., carbuncle or pyonephrosis). If the surgery combines parenchymal incision with targeted stone removal, it is called nephrolithotomy.
Why is minor nephrotomy considered safer?
In minor (partial) nephrotomy, the renal tissue is incised in a limited area directly over the calculus. This avoids massive vascular damage and reduces the risk of severe bleeding.
Why is heterotopic kidney transplantation frequently performed in the pelvis?
Placing the graft in the iliac region provides a natural temperature regime for the organ. In addition, the close proximity to the urinary bladder facilitates the implantation of a short donor ureter.
What is the modern role of renal decapsulation?
Currently, decapsulation is used extremely rarely. Stripping the fibrous capsule to combat inflammatory edema and uremia has been successfully replaced by early hemodialysis procedures.
What else to study on this topic
- Topographical anatomy of the kidneys and ureters
- Surgical approaches to the kidneys (lumbotomy)
- Technique of renal suturing
- Types and grades of nephroptosis
- Indications and technique of nephrectomy
- Methods of hemodialysis in renal failure
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