What is the role of anatrophic nephrostolithotomy in the treatment of nephrolithiasis?

Updated: Jun 21, 2018
  • Author: Chirag N Dave, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Answer

Anatrophic nephrolithotomy was classically an open procedure indicated for large staghorn calculi. It involved accessing the kidney through an open approach, identifying the avascular plane of Brodel, which is a relatively avascular plane in the posterior kidney, and then making an incision through this plane and subsequently removing the calculus.

During this procedure the renal artery is clamped, which raises the risk for ischemic injury, as well as reperfusion injury once the procedure is complete. To decrease the risk of those complications, hypothermia of the renal bed is initiated to prevent ischemic injury and intravenous mannitol is given to limit reperfusion injury, due to its ability to attenuate free radical scavengers. [83, 84] This procedure was successful in removing kidney stones, but due to its invasive nature it has been associated with significant morbidity related to the respiratory system (eg, atelectasis, pneumothorax), as well as renal hemorrhage. [84]

A laparoscopic version of this procedure has been developed in more recent years. It involves a three-port access system, similar to other renal procedures. The patient is placed into the flank position and once port access is obtained, the colon is reflected and the hilum is exposed. Intravenous mannitol is given prior to the induction of hypothermia.  Methylene blue is then give intravenously, which allows the surgeon to find the avascular plane of Brodel and then mark it using electrocautery. 

The renal artery is then clamped and hypothermia is achieved. Hypothermia can be achieved via ice-slush placed in a polythene bag.

Ultrasonography is then used to identify the location of the stones. Next, the incision is made at the previously marked area and the stones are removed. [85]

This technique minimizes the complications encountered in the open approach, while achieving stone-free rates of around 88%. [86] This procedure can be considered for difficult stones that require multiple access tracts throughout the kidney. {ref69)

Unsurprisingly, as robotic-assisted surgery becomes increasingly utilized, it has also been found useful in anatrophic nephrolithotomies.  A few small studies have attempted anatrophic nephrolithotomy using a robotic approach. So far it has been shown to be a safe and effective technique that can be used in the removal of large staghorn calculi, with little morbidity. [87, 88]


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