الفهرس 
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Abstract
The percutaneous nephroscopy, signifies a revolution in kidney atone surgery. A large organ, which up till now could only be operated on by extensive surgical measures, can now be treated by endoscopic diagnosis and therapy. Just. a few years ago this was unthinkable.
The kidney will no longer be surgically exposed in making differential diagnosis. The percutaneous approach will make it possible to provide sample excisions for histologic diagnosis.
It will no longer be necessary to use a 20 Cm. incision to remove a small ureteral stone or a simple renal stone. Large stones can also be removed by the percutaneous techniques
Percutaneous nephroscopy makes it possible to operate on older and poor risk patientsc,
In 1948, Trattner described an instrument designed for examination of the interior of the renal pelvis Advances in fiberoptics, have increased the realm and effectiveness of nephroscopy. (Trattner H.R., 1948).
In 1950, Leadbetter improved on Trattner’s idea by developing a 22 Pr. rigid endoscope with a viewing arm fixed at a right angle to the instrument’s, shaft. (Leadbetter, W..F., 1950).
In the early 1970, the Storz and Wolf Companies developed fiberoj5tic, rigid, right—angled nephroscopes,
In 1979, ACMI introduced flexible fiberoptic nephr— oscope. Through a 200° arc with one hand while using the other to maneuver biopsy forceps or a stone grasper through a 5 Pr port in the instrument. (Clark, P., 1975 — Pearson, B., 197.5 — Stuart, A.E., 1974).
Bush has detailed his work with an 8 Pr, 36—inch— long ureterorenoscope, with which the ureter and renal pelvis can be examined. :(}?alph V. Clayman, Robert P. Miller, Donovan B. Reinke, and Paul B. Lange, 1982).
Renal Anatomy
The advent of urologic endoscopy in 1876 heralded a new era in medicine, With Nitzes cystoscope, the physician could traverse the urethra and directly examine the lower urinary tract. Over the ensuing 100 years, endoscopic instrumentation underwent myriad improvements, however, the anatomic area available for examination remained un changed, namely the urethra and bladder. Then, with Goodwin and his colleagues’ initial report of percutaneous nephrostomy in 1954, the foundation was laid for endoscopic evaluation of the upper urinary tract. During the later part of the 1970’s Smith, Miller, Lange, and Fraley explored the potential of the nephrostomy tract as an access route for the diagnosis and treatment of upper urinary tract pathology,
Although the percutaneous nephrostomy tract has been likened to the urethra in the access it provides, the int— rarenal anatomy is much more complex and difficult to master than the simple ballon—like interior of the bladder,
The coronal plane of each kidney divides it into anterior and posterior segments, Their coronal planes lie 30 — 50° behind the coronal plane of the body. The upper poles lie more medial and posterior than the lower poles.
There are four coverings of the kidney : the true
capsule, perirenal fat, renal (Gerota’s) fascia, and the pararenal fat. When performing a percutaneous nephrostomy, two areas of resistance are felt. The first is at the lumbodorsal fascia, the second is at the true renal capsule. The renal capsule is richly innervated, accordingly, puncture or dilation of an unanesthetized renal capsule causes considerable discomfort.
The Gerota’s fascia consists of two layers: a well developed posterior layer and a less well developed anterior layer (Toldt). Laterally these two layers fuse. Medially the posterior layer fuses with the fascia over the vertebral bodies, the anterior layer merges with the adventitia of the great vessels. The superior fuses with the infradiaph— ragmatic fascia, while the inferior edge ends as an open ended cone along the mid ureter.. Thus, perirenal spaces rarely inter connect.
The classic human kidney contain 14 lobes,each lobe consists of a central core of medullary tissue surrounded by a cortical layer except in the region of the papilla. The cortical covering of each lobe intermingles and fuses with its neighbor, The intermedullary extensions of cortex (Columns of Bertin), are the more vascular areas of the renal parench.yrna.
The papilla has multiple small ducts (Flap valves), which close off whenever the intrarenal pressure rises. The papillary ducts in the compound papilla are often gaping., The diuresis may decrease the degree of intrarenaly reflux. In the polar regions, the anterior lobes may fuse with one another as well as with the posterior lobes.
In the mid—zone of the kidney, much less fusion occurs , hence, the classic 14—lobed kidney usually has only 8 calyces.
Calyceal Arrangement :
The 14 renal lobes are initially arranged into anterior and posterior rows. The upper and lower pole calyces are usually compound . The remaining calyces are arranged in two distinct rows : anterior and posterior. The anterior form an angle of 7Q0 with the frontal plane,the posterior calyces .form an angle of 20° with the frontal plane. On occasion, the converse applies. The posterior and anterior pair of calyces do not lie directly opposite one another.
The lateral kidney margin is 30 — 50° behind the coronal plane of the body. This swings the anterior calyces laterally and the posterior calyces medially. The anterior calyces are seen “ side on “ the posterior calyces are medial.
The renal artery enters the renal hilum between the renal vein anteriorly and the renal pelvis posteriorly. The renal artery usually divides into five segmental arteries , each supplying a major segment of the kidney. There is no cross circulation from one renal segment to another , so occlusion of one segmental artery leads to necrosis of the renal segment it supplies.
The posterior division is the first branch crosses the posterior portion of the upper part of the renal pelvis.
The four branches of the anterior division: apical, upper anterior, middle anterior, and lower.
The junction between the anterior and posterior divisions results in an avascular plane (Brodel’s line of incision).
Brode].’s white line is I — 2 Cm. anterior to the lateral renal margin. This surface indentation overlies a broad column of Bertin formed by the fusion of renal cortex from the anterior and posterior lobes, this is a hypervascular area and should not be mistaken for the avascular plane. To enter the collecting system, the patient is
placed in a 300 prone—oblique position, causing the posterior calyces to project almost perpendicular to the fluoros— copy table.
The safety and efficacy of all endourological procedures are dependent on the physician’s understanding of practical renal anatomy. (Keith W. Kaye, M.D., 1984).