Pyelolithotomy

Pyelolithotomy is a surgical procedure in which the renal pelvis is incised (pyelotomy) to remove renal calculi directly, without cutting into the renal parenchyma. It is one of the oldest approaches to renal stone disease and historically was a preferred alternative to nephrolithotomy because it avoided renal parenchymal incision and the associated hemorrhagic morbidity.

Historical Background

The operation evolved over centuries. Heinecke in 1879 first described a pyelotomy incision for calculus extraction. The technique was refined by Josef Hyrtl (1882) and Max Brödel (1902), who identified the relatively avascular plane near the midline of the convex border of the kidney. A landmark advance was the Gil-Vernet intrasinusally extended pyelolithotomy (1965), which allowed wide access to the collecting system with minimal morbidity, making it the dominant open surgical approach for renal calculi through the 1970s. Lower (1913) had previously revived interest in pyelolithotomy, noting it was safer and simpler than nephrolithotomy, though some series suggested a higher incidence of retained stone fragments with pyelolithotomy alone.

Campbell Walsh Wein Urology, p. 254-257

Current Indications

Modern endourology (PCNL, ureteroscopy, ESWL) has largely supplanted open surgery for most renal stones. As stated in Harrison's Principles of Internal Medicine 22e, "advances in urologic approaches and instruments have nearly eliminated the need for open surgical procedures such as ureterolithotomy or pyelolithotomy."

Pyelolithotomy (open or laparoscopic/robotic) is now reserved for:

Complex stones with anatomical abnormalities (e.g., horseshoe kidney, ectopic kidney, pelviureteric junction obstruction [UPJO])
Infected staghorn calculi not accessible by PCNL
Concomitant reconstructive procedures (e.g., pyeloplasty for UPJO with calculi)
Patients with prior failed endourological attempts
The procedure cannot be performed if the patient has an intrarenal pelvis (the pelvis must be extrarenal to allow safe incision)
Bailey and Love's Short Practice of Surgery 28e, p. 4232
Hinman's Atlas of Urologic Surgery, p. 221

Preoperative Preparation

Urine culture - treat any infection prior to surgery
Axial imaging (CT urogram) - define stone burden, collecting system anatomy
Basic labs - renal function, coagulation
Patient positioned in the flank position
A flank incision is made below the 11th or 12th rib depending on kidney position

Operative Technique

Step 1 - Exposure

Gerota's fascia is opened in a cranial-caudal direction. Perinephric fat is dissected off the kidney carefully, avoiding the subscapular plane. The proximal ureter is identified and dissected proximally to the renal pelvis.

Key anatomical caution: The posterior segmental artery crosses just inside the posterior renal sinus - avoid injuring it during dissection.

Ureter and renal pelvis exposed during pyelolithotomy

FIGURE 24.12: Ureter and renal pelvis exposed - Hinman's Atlas of Urologic Surgery

Step 2 - Pyelotomy Incision

A U-shaped incision is made in the renal pelvis over the stone using a hooked 12-blade scalpel or Potts scissors. The apex of the incision must be placed at least 1 cm away from the ureteropelvic junction to avoid UPJ stenosis.

FIGURE 24.13: U-shaped incision for pyelolithotomy - Hinman's Atlas of Urologic Surgery

If multiple small stones are present, an 8-French feeding tube is passed down the ureter to prevent stone migration distally.

Step 3 - Stone Extraction

The U-shaped ureteral flap is retracted to expose the stone. A blunt Randall forceps is used to gently grasp and extract the stone.

FIGURE 24.15: Stone extracted using blunt Randall forceps - Hinman's Atlas of Urologic Surgery

Extended Pyelolithotomy

If stone ramifications extend into a calyx making complete removal difficult through the pyelotomy alone:

The pyelotomy incision is extended superiorly into the respective infundibulum
The renal parenchyma is reflected away to expose the calyceal stone
If a calyceal stone still cannot be retrieved through the infundibulum: locate it by palpation, push it toward the capsule, sharply incise the capsule circumferentially, and bluntly dissect the parenchyma using a Penfield dissector
Extract via blunt Randall forceps through the resulting nephrotomy
Close the nephrotomy with horizontal mattress 3-0 polyglactin sutures over a fat bolster
If parenchymal incision is required and clamping will be prolonged: temporary renal artery bulldog clamp + cold ischemia + IV mannitol

Coagulum Technique

A useful adjunct for multiple small stones or when preventing stone migration during manipulation:

Two bags of thawed cryoprecipitate (~30 mL total, stained with methylene blue) are prepared
The ureter is occluded with a wrapped Penrose drain
Residual urine is aspirated from the pelvis via Angiocath
1 mL of 10% calcium chloride is mixed into the cryoprecipitate immediately before injection
The mixture is injected to fill (not overfill) the renal pelvis
After 5 minutes, the pelvis is opened with a U-shaped incision and the intact coagulum (with entrapped stones) is carefully extracted
The pelvis and ureter are then thoroughly irrigated

Closure

A nephroscope (flexible cystoscope or ureteroscope) is used to inspect all calyces for residual fragments
An antegrade double-J stent is placed for urinary drainage
The renal pelvis is closed with a running 5-0 polyglactin suture
Gerota's fascia is re-approximated with 2-0 polyglactin sutures
A Jackson-Pratt drain is placed posterior to the kidney through a separate stab incision
Standard fascial and skin closure

Postoperative Care and Complications

Postoperative care is similar to anatrophic nephrolithotomy, but pyelolithotomy carries significantly less risk of bleeding or transfusion since no parenchymal incision is required for straightforward cases. Acute tubular necrosis rates are also lower because renal blood flow is not interrupted.

Complication	Notes
Urinary leak	Drain output monitored; usually resolves with stent in place
Residual stone	Persistent infection signals retained fragments; treat with antibiotics + secondary PCNL/retrograde URS (wait ≥6 weeks)
UPJ obstruction	Rare late complication if incision is too close to UPJ
Hemorrhage	Less common than after nephrolithotomy
ATN	Rare unless prolonged ischemia required

Laparoscopic and Robotic Pyelolithotomy

Minimally invasive approaches are now available and well-described:

Laparoscopic pyeloplasty + concomitant pyelolithotomy: In a series by Ramakumar et al. (2002), 20 cases with UPJO + calculi were managed laparoscopically; 90% stone-free rate at 3 months, using laparoscopic graspers and a flexible cystoscope through a 10-12 mm port.
Robotic-assisted pyeloplasty + pyelolithotomy: Demonstrated in 8 patients by Atug et al. (2005), with one robotic arm temporarily undocked to facilitate stone extraction. Overall stone-free rate 80%.
A 2024 systematic review and meta-analysis on robotic pyelolithotomy (Wang et al., PMID 39120845) confirms its efficacy for large renal stone disease.
Laparoscopic pyelolithotomy is also listed among "miscellaneous" minimally invasive urological procedures for complex indications. - Smith and Tanagho's General Urology 19e
Campbell Walsh Wein Urology, p. 2611

Summary

Feature	Detail
Definition	Incision of renal pelvis to remove calculi
Access	Flank incision (below 11th/12th rib)
Incision	U-shaped pyelotomy, apex ≥1 cm from UPJ
Contraindication	Intrarenal pelvis
Key instrument	Blunt Randall forceps
Adjunct	Coagulum technique for multiple stones
Drainage	Double-J stent + Jackson-Pratt drain
Current role	Reserved for complex stones, anatomical anomalies, concomitant reconstruction
Advantage over nephrolithotomy	Less bleeding, no ATN risk (no vascular clamping needed for standard cases)

Primary sources: Hinman's Atlas of Urologic Surgery; Campbell Walsh Wein Urology 3-Volume Set; Bailey and Love's Short Practice of Surgery 28e; Harrison's Principles of Internal Medicine 22e

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