The initial approach, retroperitoneal or transperitoneal, is the same as described for pyelolithotomy or ureterolithotomy. Subtle differences vary with the degree of perinephric inflammation encountered. In the absence of significant adhesions, we prefer to place the balloon inside Gerota's fascia because this allows rapid and easy dissection of the kidney. The hilum is then approached and the vessels clipped. Past history of pyelonephritis, evidence of renal scarring, perinephric adhesions, and pyonephrosis predominantly lead to dense perinephric adhesions which preclude safe and easy dissection, as the kidney is densely adherent to the posterior abdominal wall. Open conversions typically occur due to excessive bleeding and poor intraoperative progress. Because the adhesions are per-inephric, the space external to Gerota's fascia is still relatively clear. The hilar vessels are approached first to minimize bleeding during the subsequent dissection of the kidney. It is important to avoid puncturing the kidney during mobilization lest infected material soil the operating space. Although the spillage is confined to retroperitoneum, thoroughly irrigation with antibiotics solution is important (12). Rarely, due to severe fibrotic adhesions, one may intentionally or unintentionally enter within the renal capsule, and resort to retroperitoneal subcapsular nephrectomy to complete the operation.
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