Surgical Anatomy of the Kidney in the Prone, Oblique, and Supine Positions

Abstract

This chapter describes the anatomy of the main renal structures encountered in the endourologic kidney procedure. Regardless of the degree of respiration (mid or full), the risk of injury to the lung from a 10th or higher intercostal approach to the kidney is prohibitive. When the patient is in the prone position, the surgeon must expect to find a retrorenal colon in 10% of cases, especially in the area of the inferior pole of the kidneys, and especially in women, the old, and those who are thin. Percutaneous nephrostomy through an infundibulum of a calyx is an unsafe route because it poses a significant risk of bleeding from interlobar vessels. Also, infundibular puncture creates the hazard of through-and-through (two-wall) puncture of the collecting system. Intrarenal puncture through a calyceal fornix is harmless and associated with few risks of vascular lesions. In 65% of cases there is a prominent artery and/or vein in close relationship with the ventral surface of the ureteropelvic junction (UPJ). In 45% this vessel is the inferior segmental artery. During an endopyelotomy, the deep incision along the UPJ stenotic wall must be made just laterally to avoid important vessels. In most patients, an access through a lower-pole calyx enables frontal visualization of the UPJ. The access shall be selected based on the angle that is formed between the calyceal infundibulum and the UPJ. © 2012 Blackwell Publishing Ltd.