Pyelotomy

Indications for surgery

The operation known in topographical anatomy and operative surgery as pyelotomy (pyelotomia) is a direct surgical opening of the renal pelvis cavity. This intervention has a strict list of indications associated with mechanical obstacles or neoplasms in the pelvicalyceal system.

First, the most frequent reason for the surgery is renal pelvis stones. In a situation where a calculus is localized specifically in this anatomical zone, surgical opening allows for careful extraction of the stone. In surgical practice, this variant of the intervention often appears under the specifying term — posterior pyelolithotomy.

Second, an indication is narrowing of the initial part of the ureter. Strictures in the pelviureteric junction area disrupt adequate urine passage, and access directly through the pelvic wall is required to eliminate them.

Third, the surgery is indicated when benign pelvic tumors are detected. Opening the lumen provides an opportunity to visualize the neoplasm and perform the necessary surgical manipulations.

Selection of the anesthesia method and surgical access

The success of surgical intervention on retroperitoneal structures largely depends on the correct choice of anesthetic management and surgical access.

According to classical protocols of operative surgery, exclusively endotracheal anesthesia is used to perform a pyelotomy. When analyzing clinical problems (where students are offered alternative options: mask anesthesia, epidural or spinal anesthesia), the only correct choice is endotracheal anesthesia. It provides reliable control over the patient and the necessary relaxation of the lumbar region tissues.

To approach the kidney and its pelvis, surgeons use the classical oblique lumbar incision according to Fedorov. This access is considered optimal as it allows wide exposure of the retroperitoneal space and safe mobilization of the kidney for subsequent manipulations.

Step-by-step technique of opening the renal pelvis

The technique of performing pyelotomy requires a strict sequence of actions from the surgeon. The main stage of the operation — opening the pelvis — consists of the following regulated steps:

1. Exposure of the posterior wall of the pelvis. After performing Fedorov's access and isolating the kidney, the surgeon visualizes specifically the posterior wall of the pelvis. This is the most convenient zone for the incision.
2. Placement of provisional stay sutures. Two provisional traction threads are placed on the prepared pelvic wall. Catgut is used as the suture material here. These stay sutures will serve as instruments for safe traction.
3. Formation of a cone. The surgeon takes the placed catgut threads and pulls the pelvis anteriorly. Due to this tension, the pelvic wall is elevated, forming a characteristic cone shape.
4. Incision of the wall. The opening of the pelvic lumen itself is performed strictly in a longitudinal direction. The incision is made carefully between two tensioned catgut stay sutures at the apex of the formed cone.

Concluding stage: closure of the pelvic wound

After the main goal of the operation is achieved (e.g., a stone is removed or a tumor is excised), the stage of closing the surgical defect begins.

Suturing of the pelvic wall begins with working with the already existing threads. The surgeon tightens the previously placed provisional catgut stay sutures, bringing the edges of the longitudinal incision together.

However, stay sutures alone are not enough for reliable tightness. Therefore, the suture line is necessarily reinforced with additional interrupted catgut sutures.

A visual representation of this stage is often demonstrated in classical diagrams. For example, when illustrating the posterior pyelolithotomy stage, the closure of the pelvic wall incision is shown in detail. In such cases, the defect is reliably sutured with three interrupted sutures, which ensures adequate apposition of the wound edges.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Topographical anatomy of the renal pelvis and its syntopy with the elements of the renal pedicle.
• Features of the oblique lumbar incision according to Fedorov (layered tissue structure).
• Posterior pyelolithotomy as the most frequent specific case of pyelotomy.
• Properties of catgut and the reasons for its choice as a suture material on the urinary tract.

Other topics in the section «Operations on retroperitoneal organs»

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