PCNL – Tips and Tricks for a Good Puncture Ho Siew Hong Consultant Urologist S H Ho Urology and Laparoscopy Centre Gleneagles Hospital

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

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

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

End on puncture of the calyx

Along axis of calyx, leading into infundibulum

Decrease risk of injury to segmental vessels, calyceal perforation or tear

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

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

Planning a Puncture

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

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

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 ?

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 ?

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

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

End on puncture with straightest path along stone axis Puncture along stone axis

Puncture along stone axis

End on puncture with straightest path along stone axis

Dilated calyx If everything is equal, chose a dilated calyx Easier to puncture Easier access to stone

If everything is equal, chose a dilated calyx

Easier to puncture

Easier access to stone

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

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

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

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

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

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

Opacifying the collecting system

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

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

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

Largest possible retrograde catheter, e.g. open ended #7

No actual need for UPJ catheter

Connected to mixture of contrast and methelene blue

Puncturing Techniques

Positioning of patient Prone on pillow or frame support Small foam support under the intended kidney

Prone on pillow or frame support

Small foam support under the intended kidney

Positioning of patient and surgeon Irrigation, Contrast Nurse Surgeon Fluoro Fluoro view Camera

Puncture needle 18 G two part trocar needle 22 G Chiba needle less preferred - only with u/s guided, double puncture technique

18 G two part trocar needle

22 G Chiba needle less preferred - only with u/s guided, double puncture technique

Puncture and dilate in 2 planes AP for direction Oblique for depth End-on puncture Dilate on oblique – depth appreciation is essential

AP for direction

Oblique for depth

End-on puncture

Dilate on oblique – depth appreciation is essential

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

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

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

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

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

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 Guidewire placed under II Flexi-tip (5-7cm) and stiff body Coil in pelvis, advance beyond flexi component of wire

Guidewire placed under II

Flexi-tip (5-7cm) and stiff body

Coil in pelvis, advance beyond flexi component of wire

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

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

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 – 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

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

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

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

Special Situations

Non opacification of collecting system Puncture to stone Ultrasound guided puncture 1. Direct puncture 2. Double puncture technique

Puncture to stone

Ultrasound guided puncture 1. Direct puncture 2. Double puncture technique

Undilated system Seldom required to chose undilated system Complete staghorn maybe associated with minimal dilatation of collecting system

Seldom required to chose undilated system

Complete staghorn maybe associated with minimal dilatation of collecting system

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

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

Securing a good puncture

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

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

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

Plan the puncture / punctures

Opacify collecting system

2-plane technique for lower pole

Bull’s eye technique for upper pole

Secure puncture well

Thank you