Surgery of the Kidney and Ureter Flashcards
What lies medial to the kidneys?
Aorta + vena cava
What lumbar vertebrae is the:
A) L kidney?
B) R kidney?
A) 1-3
B) 2-4
Where is the renal vein and artery found?
Renal hilus
Which kidney is more likely to have multiple arteries within?
Left
Is a Non obstructive calculi, especially if they are not associated with a pelvic dilation, an indication for nephrotomy?
no!
What are the indications for nephrotomy? (2)
Exploration of the renal pelvis (e.g. for masses or to identify causes/location of renal haematuria)
Retrieval of partially or completely obstructive calculi (renolith).
Why does a nephrotomy not effect renal function?
Minimal changes to GFR
How should nephrotomy be approached if a bilateral intervention is needed?
Staged proceedure
What 2 reasons would mean that a nephrotomy should not go ahead? (even if the patient meets the textbook criteria)
- If the renolith(s) is/are thought to be associated with recurrent urinary tract infection;
- If, in the presence of a renolith, renal function deteriorates despite adequate medical management - this is more common when renoliths are bilateral.
Which of the following is an indication for a nephrotomy?
A circumscribed renal sarcoma
An obstructive renolith
A localised renal infarct
An obstructive renolith
What needs to be occluded in a nephrotomy? How is this done?
Renal vessels;
- vasc clamps, tourniquet or finger pressure
What is the safe warm ischaemia time for renal vessels?
20 mins
What are the 2 access approaches to the renal pelvis?
Bisection approach
Intersegmental approach
What is the bisection approach?
The kidney is incised on its convex surface (bisection approach) and parenchyma is bluntly dissected towards the pelvis.
What is the intersegmental approach?
A scalpel handle is used to bluntly dissect the renal parenchyma, and the blood vessels are identified and ligated prior to transection. This reduces haemorrhage and parenchymal damage, though glomerular filtration rate studies have found no advantage over the bisection technique. This technique also takes longer than the bisection approach.
What instrument is used to explore the renal pelvis in bisectional approach?
Right angled forceps
How should the ureters be assess with bisectional nephrotomy?
By passing a urinary catheter and gently flushing the ureter normograde.
How is the kidney first layer closed?
Digital pressure is applied to appose the cut surfaces of the kidney for 1-5 minutes to allow a fibrin seal to form
How is the renal capsule closed
The renal capsule is apposed using a continuous and/or horizontal matters pattern.
What layer of the kidney should sutures NOT enter?
Deep into the cortex to avoid excessive tissue damage.
What suture pattern/s for closure of nephrotomy? (3)
- combination of mattress and simple continuous
- simple interrupted
-pledgeted sutures
What sutures are goo for friable nephrotomy?
pledgeted sutures (buttressed or supported by a small flat non-absorbent pad)
What could happen if the kidney has become detached in a nephrotomy? How can this be prevented
torsion around the vascular pedicle, it is advised to nephropexy (to body wall)
What is a pyelolithotomy?
alternative to the nephrotomy for treatment of obstructions located in the proximal ureter/renal pelvis if the proximal ureter and renal pelvis are significantly dilated, and avoids the parenchymal damage associated with nephrotomy.
