PCNL - the Perfect Puncture

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  • + ashwent ashwent 5 months ago
    Superb presentation - please send link
  • + LIGONGHUI LIGONGHUI 10 months ago
    GOOD
  • + guestf3d9e3 guestf3d9e3 11 months ago
    very good presentation.please give link for download
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PCNL - the Perfect Puncture - Presentation Transcript

  1. PCNL – Tips and Tricks for a Good Puncture Ho Siew Hong Consultant Urologist S H Ho Urology and Laparoscopy Centre Gleneagles Hospital
  2. What is a perfect puncture ?
    • Minimal risk of injury - avoid major vessels, bowel, lungs - shortest distance may not be the best
    • Allows easiest access to the stone, lithotripsy and complete stone clearance
  3. Minimize injury to kidney
    • End on puncture of the calyx
    • Along axis of calyx, leading into infundibulum
    • Decrease risk of injury to segmental vessels, calyceal perforation or tear
  4. Obtaining a good puncture
    • Planning the puncture
    • Opacification of collecting system
    • Technique of puncturing
    • Special situations – non opacified system, non dilated system
    • Securing a good puncture and establishing a working tract
  5. Planning a Puncture
  6. Planning the puncture - Imaging
    • IVU
    • CT IVP - with coronal reconstruction
    • CT KUB in patients with renal impairment - retrograde study required
    • CT abdomen – only in patients with previous open stone surgery
  7. Planning the puncture - Considerations
    • Posterior calyx
    • Straightest path to calyx with highest stone burden
    • Dilated calyx
    • Lower, upper or mid pole ?
    • Need to have access to upper ureter ?
    • Single or multiple punctures ?
  8. Posterior vs anterior calyx
    • Only puncture on posterior calyx
    • Ant / post calyx recognised on C-arm
    • Upper and lower poles are usually complexes
    • Pure ant / post calyx in mid pole
    • Ant calyx stone accessed via post calyx
    Anterior middle Posterior middle
  9. End on puncture with straightest path along stone axis
    • Puncture along stone axis
  10. End on puncture with straightest path along stone axis
  11. Dilated calyx
    • If everything is equal, chose a dilated calyx
    • Easier to puncture
    • Easier access to stone
  12. Mid pole puncture
    • Not good as single puncture to access renal pelvis and PUJ (better access with upper pole puncture)
    • Usually part of multiple punctures for isolated stones or branch of staghorn
    • Puncture posterior to access anterior
  13. Single or multiple punctures
    • Plan before starting
    • Puncture, dilate tract, lithotripsy and puncture
    • 1 st puncture along axis of maximal stone burden or
    • Lower pole to distract upper pole to a more favorable position (below 11 th rib)
    • Multiple punctures almost always required to clear a complete staghorn stone
  14. Single or multiple punctures
    • Leave sheath in situ as more tracts are created
    • No limit to number of tracts
    • Nephrostomy tube for every tract
    • Usually stent in view of complexity of stone
  15. Opacifying the collecting system
  16. Retrograde catheter
    • Increases OR time, need for repositioning
    • But worth the effort
    • Advantages: 1. Retrograde study 2. Real time imaging of the collecting system 3. Induced hydronephrosis 4. Methelene blue dye to confirm puncture
  17. Retrograde catheter
    • Largest possible retrograde catheter, e.g. open ended #7
    • No actual need for UPJ catheter
    • Connected to mixture of contrast and methelene blue
  18. Puncturing Techniques
  19. Positioning of patient
    • Prone on pillow or frame support
    • Small foam support under the intended kidney
  20. Positioning of patient and surgeon Irrigation, Contrast Nurse Surgeon Fluoro Fluoro view Camera
  21. Puncture needle
    • 18 G two part trocar needle
    • 22 G Chiba needle less preferred - only with u/s guided, double puncture technique
  22. Puncture and dilate in 2 planes
    • AP for direction
    • Oblique for depth
    • End-on puncture
    • Dilate on oblique – depth appreciation is essential
  23. Lower pole puncture – 2 plane technique
    • Needle at 40 degree against patient
    • Post axillary line
    • Forcep over tip of post calyx, as a target
    • Mental estimation of depth of calyx
    • II at AP position
  24. Lower pole puncture
    • Needle transverses skin, subcut, stopping short of renal capsule
    • Cephalo-caudal movement of II to confirm depth
    • Minor adjustment in angle of puncture by withdrawing needle almost to skin
    Kidney Kidney
    • Confirmation of position - CC and AP - gentle rocking of kidney
    • Single decisive push of needle to perforate renal capsule
    • Advance into lower calyx
    Lower pole puncture
  25. Lower pole puncture
    • Guidewire placed under II
    • Flexi-tip (5-7cm) and stiff body
    • Coil in pelvis, advance beyond flexi component of wire
  26. Upper pole puncture - bull’s eye technique
    • Upper calyx is more posterior pointing
    • Cephalic space restriction – pleura and lungs
    • Vertical puncture to upper calyx
    • Depth of puncture determined on CC
    • Vertical puncture over upper calyx
    • Puncture on expiration
    • Depth of puncture determined by CC
    • Return of contrast and blue dye on entry
    Upper pole puncture Calyx Kidney
  27. Upper pole puncture – how to avoid injury
    • Tip of 12 th rib, or infra 11 th rib
    • Avoid supra 11 th rib – lung injury
    • Puncture in expiration - kidney is higher but lungs are away
    • More medial, shorter distance and straighter path to PUJ
    Post axilla line 11 12
  28. Pleura injury
    • Recognised during surgery - nephroscope in pleura cavity - hydrothorax (on C-arm) - advance sheath in to collecting system and complete lithotripsy - chest tube placement at end of surgery
    • Erect CXR in recovery - chest tube
    • Keep chest tube for few day, monitor effusion with CXR
  29. Special Situations
  30. Non opacification of collecting system
    • Puncture to stone
    • Ultrasound guided puncture 1. Direct puncture 2. Double puncture technique
  31. Undilated system
    • Seldom required to chose undilated system
    • Complete staghorn maybe associated with minimal dilatation of collecting system
  32. Undilated system
    • Use of ureteric catheter and injection of contrast +/- methylene blue
    • UPJ catheter to provide more dilatation in very tight system
    • Manipulation of guide wire - ‘Terumo’ glide wire to find space between stone and mucosa before placing stiffer guide wire for dilatation
  33. Securing a good puncture
  34. What to do after a good puncture ?
    • Only the first step in PCNL, but probably the most important
    • Dilated to #8 or #10 to place 2 nd guide wire
    • 2 nd guide wire – softer and possibly passed into ureter
    • Dilate on stiffer wire
    • Dilate under II / CC for depth appreciation
  35. Take home message
    • Plan the puncture / punctures
    • Opacify collecting system
    • 2-plane technique for lower pole
    • Bull’s eye technique for upper pole
    • Secure puncture well
  36. Thank you

+ Siewhong HoSiewhong Ho, 2 years ago

custom

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