Urolithiasis management- pcnl

Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
1

MODERATORS:
Professors:
 Prof. Dr. G. Sivasankar, M.S., M.Ch.,
 Prof. Dr.A. Senthilvel, M.S., M.Ch.,
Asst Professors:
 Dr. J. Sivabalan, M.S., M.Ch.,
 Dr. R. Bhargavi, M.S., M.Ch.,
 Dr. S. Raju,M.S., M.Ch.,
 Dr. K. Muthurathinam, M.S., M.Ch.,
 Dr. D.Tamilselvan, M.S., M.Ch.,
 Dr. K. Senthilkumar, M.S., M.Ch.
DEPT OF UROLOGY, GRH AND KMC, CHENNAI. 2

INTRODUCTION
 Fernstrom and Johansson first reported the technique of establishing a percutaneous
track specifically to remove a stone in 1976 .`
 PNL as a routinely used technique to treat patients with large or complex calculi
(Alken et al, 1981 ;Wickham and Kellett, 1981 ; Segura et al, 1982 ; Clayman et al,
1984)
3
DEPT OF UROLOGY, GRH AND KMC, CHENNAI.

INDICATIONS
 Large stone burden >2 cm or 1.5 cm for lower calyceal stones.
 Staghorn stones.
 Stones that are difficult to disintegrate by ESWL (calcium-oxalate
monohydrate,brushite,cystine).
 Stones refractory to ESWL or ureteroscopy.
 Urinary tract obstructions that need simultaneous correction (e.g. PUJ obstruction).
 Malformations with reduced probability of fragment passage after ESWL (e.g.
horseshoe or dystopic kidneys, calyceal diverticula. , infundibular stenoses .)
 Obesity 4

CONTRAINDICATIONS
 Uncorrected coagulopathy
 Untreated UTI
 Tumour in the presumptive access tract area
 Potential malignant kidney tumour
 Pregnancy
 Within 12 months of drug eluting stent / within 3 months of bare metal stent
Patients with bleeding diathesis or receiving anticoagulant therapy
must be monitored carefully pre- and post-operatively.
5

INVESTIGATIONS
 A complete blood count
 Serum electrolytes
 Renal function tests
 Urine culture is mandatory for all patients
 Perioperative antibiotics can be appropriately tailored to culture-specific organisms
 Typing and screening of the patient's blood
 Imaging – Xray KUB, IVU / CECT KUB with 3D reconstruction
6

CONSENT
 For multiple access
 Bleeding & blood transfusion
 Staged / Repeat endoscopic procedures
 Need for auxillary treatment – ESWL,Angioembolisation
 Renal function loss & late complications
7

ANATOMIC CONSIDERATIONS
 Familiarity with basic renal anatomy is essential for access to be obtained safely
 Vascular Anatomy
 Pelvicalyceal Anatomy
8

SURGICAL ANATOMY
Longitudinal axes of the kidneys are oblique
Parallels to psoas major muscle
Superior poles more medial than the Inferior poles.
Usually the posterior surface of
 Right kidney is crossed by the 12th rib
 Left kidney by the 11th and 12th ribs.
9

TRANSVERSE SECTION
Renal frontal axis angles 30-50 degree
to the frontal axis of the body
10

INTRARENAL ARTERIES
InterlobarA
InterlobularA
ArcuateArtery
Afferent arteriole of the glomerulus
11

12

BRODEL’S PLANE
 Ideal point of renal entry.
 The avascular field between the
anterior and posterior divisions,
known as Brödel's bloodless line
 Because of the orientation of the
kidney in the body, entry through a
posterior calyx usually traverses this
line
13

BRODEL & HUDSONTYPES
Brodel type - Right Hudson type - Left
14

20 degrees
70 degrees
Brodel type Hudson type
15

INTRARENAL
VEINS
Stellate veins arcuate veins
interlobar veins  RV, renal
vein.
Three orders of arcades: 1,
first‐order arcade; 2, second‐order
arcade; 3, third‐order arcade
16

PELVICALYCEAL SYSTEM
 Pyramid  collecting duct  papillary
ducts  renal papilla  minor calyx
 major calyx / infundibulum  renal
pelvis
 Minor calyces: 5 to 14 (mean, 8)
17

SIMPLE / COMPOUND CALYX
 Single / Simple calyx drains only one
papilla
 Compound calyx drains two or three
papillae
 The polar calyces are often compound,
markedly in the superior pole
18

CLASSIFICATION OF PELVI CALYCEAL SYSTEM
 Sampaio Classification - based on superior pole, inferior pole, and kidney midzone
(hilar) calyceal drainage.
19

GROUP A – 62.2%
 Midzone calyceal drainage dependent on superior/inferior calyceal groups
 Type A‐I (45%): the kidney midzone is drained by minor calyces that are dependent
on the superior and/or inferior calyceal group
 Type A‐II (17.2%): the kidney midzone is drained simultaneously by crossed calyces,
one draining into the superior calyceal group and the other draining into the
inferior calyceal group
20

Type A 1 Type A 1I
Interpelvioca
lyceal space
21

IMPORTANCE OF IPC SPACE
 Detection of an inter-pelviocalyceal region on the pyelograms is an indirect sign of
crossed calyces in the kidney midzone.
 Crosses calyces  Inferior calyceal group – ventral in 87.5%
 Even when radiographically the calyx draining into the inferior group was apparently
in the dorsal position, its ventral position is verified on the endocast
22

TYPE B (37.8%)
 Midzone (hilar) calyceal drainage independent of both the superior and inferior
calyceal groups
 Type B‐I (21.4%): the kidney midzone is drained by a major calyceal group
 Type B‐II (16.4%): the kidney midzone is drained by minor calyces (one to four)
entering directly into the renal pelvis
23

TYPE B
24

FAVOURABLE
CALYX
 Unfavourable - long
and thin calyceal
infundibulum
 Favourable - short and
thick calyceal
infundibula
Favourable Unfavourable 25

POSITION OF CALYCES
 First choice of access to the collecting
system is through a posterior calyx
 Determine preoperatively
 Large variation of position of the
calyces (>50% in different positions)
26

POSITION OF THE CALYCES RELATIVE TO THE
POLAR REGIONS
 Superior pole was drained by a midline calyceal infundibulum in 98.6%
 Midzone (hilar) was drained by paired calyces that were arranged in two rows
(anterior and posterior) in 95.7%
 Inferior pole was drained by -
 paired calyces arranged in two rows (57.9%)
 single midline calyceal infundibulum (42.1%)
27

INFERIOR POLE – SINGLE INFUNDIBULUM
INFERIOR POLE – PAIRED CALYCES
28

ANTERIOR CALYCES – LATERAL & PERIPHERAL
29

POSTERIOR CALYCES – LATERALAND PERIPHERAL
30

The calyces in the
anterior plane
(arrows) are
located alternately
relative to the
lateral margin of
the kidney
In one
region they are
more lateral and in
another they are
more medial.
ALTERNATIVELY LOCATED CALYCES
31

PERPENDICULAR
MINOR CALYCES
 Inferior pole is drained
by paired calyces in
57.9%
 This anatomic detail
must be kept in mind,
both to plan and
perform the intrarenal
access and endoscopic
procedures in the
inferior pole
32

PCNLTECNIQUE
33

PERIPROCEDURAL ANTIBIOTICS
 Urine culture & therapeutic course to sterilise the urine
 AUA recommendation – Periprocedural antibiotics for all cases of percutaneous
renal surgery
 Antimicrobial
 Coverage – E.coli, Proteus, Klebsiella, Enterococcus;Skin – Staph.Aureus, coag
negative Staph., group A Streptococcus
 First & 2nd generation Cephalosporins,Amino glycosides/Aztreonam +
Metronidazone/clindamycin;Ampicillin/sulbactum; Fluroquinolone
 Immediate perioperative period <24 hrs before surgery & short course at the
time of nephrostomy removal
34

MANAGEMENT OF ANTICOAGULATION
 Preoperative Cessation Periods
 Herbal medicines – 1 week
 Aspirin – 1week
 Warfarin – 5 days
 Clopidogrel – 5 days
 NSAIDS – 3- days
 Bridging with heparin derivatives
 Resumption of oral anticoagulant or antiplatelet agents as soon as possible 35

OR SETUP
36

PATIENT POSITIONING
 Prone
 Supine
 GMSV
 Lateral
37

PRONE
 Arms
(a) “superman” position
(b) tucked at the patient’s sides.
The neck is in neutral position
Thorax and abdomen are placed on
bolsters
Knee & Hip slightly flexed
Pressure points are padded
38

PRONE POSITION
 Accidental extubation and kinking of the endotracheal tube during positioning
 Hampered ventilation – Decreased pulmonary capacity
 Altered circulation – decrease in cardiac index
 Torsion of the neck
 Pressure and transient ischemia of the eyeballs
 Overstretching, and pressure injuries of the peripheral plexuses
39

PRONE POSITION
40

SUPINE
 Dr. Jose GabrielValdivia Uria
 Supine position with an air bag under the flank
 MODIFICATIONS:
 Supine modified - modified supine
 Galdakao modified supineValdivia
 Semisupine & supine‐oblique positions
41

GMSV
 Galdakao‐modified supineValdivia (GMSV) position
 Combination of the supineValdivia position with a modified lithotomic arrangement
of the lower limbs.
42

Flank to be operated near to the border
Elevated 20–30
Extended,and only slightly abducted
Contralateral one is lifted, flexed,and well abducted
Arm on the side to be operated is bent at the thorax
Contralateral one lies abducted less than 90
43

SUPINE POSITIONS - ADVANTAGES
 Easy simultaneous combined antegrade and retrograde approach to the upper
urinary tract for stone treatment with both rigid and flexible endoscopes
 Optimal cardiovascular and airway control
44

SUPINE POSITIONS - DISADVANTAGES
 Unfamiliar
 Reduced pressure in collecting system
 Less room for visualisation and manipulation
 Upper pole calyceal access is more difficult
 Longer percutaneous tract length
45

LATERAL DECUBITUS POSITION
 Less commonly used
 Allows simultaneous access to anterior & posterior calyces
 Useful for morbidly obese & spinal deformity
46

INTRARENAL ACCESS
 ? PELVIS
 ? INFUNDIBULUM
 ? CALYX
47

ACCESSTHROUGH PELVIS
 SHOULD NEVER BE PERFORMED
 Difficult to reintroduce during the
operative maneuvers
 Unnecessary risk of injuring a
retropelvic vessel
 Nephrostomy tube inserted at this
site is easily dislodged
48

ACCESSTHROUGH INFUNDIBULUM
 Puncture through an infundibulum (in any region of the kidney) presents clear
hazards
49

UPPER POLE INFUNDIBULUM
 Most dangerous
 Surrounded almost completely by large vessels
 Infundibular arteries and veins course parallel to the anterior and posterior aspects
of the upper pole infundibulum.
 Injury to an interlobar (infundibular) vessel – 67%
 Injured vessel was an artery in 26%
 Most serious vascular accident - posterior segmental artery
 Crossed by and is related to the posterior surface of the upper
infundibulum in 57% 50

UPPER POLE PUNCTURE THROUGH INFUNDIBULUM
Upper infundibulum almost completely
encircled by infundibular arteries and
veins.
This anatomic arrangement makes
upper pole infundibular puncture
especially dangerous
51

UPPER POLE PUNCTURE THROUGH INFUNDIBULUM
Posterior segmental artery (retropelvic artery) crossing
the posterior surface of the upper infundibulum (arrow).
May supply up to 50% of the renal parenchyma
Injury to it may result in significant loss of
functioning
renal tissue, as well as causing hemorrhage
52

ACCESSTHROUGH IP INFUNDIBULUM
 Arterial lesion in 23% of the kidneys studied.
 Most commonly injured vessel – Middle branch of posterior segmental artery
 Through and through perforation of the collecting system
53

THROUGH &THROUGH PERFORATION
 Marked hemorrhage may occur as a
result of an anterior
through‐and‐through perforation.
 Effective tamponade of injured
anterior vessels is difficult because
they lie distantly in the nephrostomy
tract
54

ACCESSTHROUGH LP INFUNDIBULUM
 Posterior aspect of the lower pole infundibulum is widely presumed to be free of
arteries.
 Considered to be a safe region through which to gain access to the collecting system
and to place a nephrostomy tube.
 However
 About 38% - an infundibular artery was found in this region
 Arterial injury – around 13%
55

ACCESS THROUGH LP INFUNDIBULUM
Large venous anastomoses
Puncture through the lower pole
infundibulum risks injury to a venous
arcade
A venous lesion usually heals
spontaneously, but consequent
hemorrhage may be problematic
during the procedure.
56

ACCESSTHROUGH INFUNDIBULUM
 Not a safe route
 Poses an important risk of significant bleeding from interlobar (infundibular) vessels
 Through and‐through (two‐wall) puncture of the collecting system
 Infundibular access is feasible in some circumstances and must be considered in
specific situations (e.G. Some difficult anatomic cases)
 Must evaluate the risk of an arterial lesion, primarily in the superior pole and in the
mid kidney
57

ACCESS THROUGH A CALYCEAL FORNIX
 Safe and should be the site chosen by
the operator
 Even in the superior pole, intrarenal
puncture through a calyceal fornix is
harmless
 Injury is always to a peripheric vessel,
such as a small venous arcade
58

59

?IDEAL CALYXTO PUNCTURE
? UPPER POLE
? LOWER POLE
? INTER POLE
? ANTERIOR
? POSTERIOR
• ? MEDIAL
• ? LATERAL
60

IDEAL CALYX
 Careful appreciation of the collecting system anatomy and the position of stone/ s
within it.
 Should allow easy and maximal visualization of the pelvis/upper ureter and as many of
the calyces as possible.
 At the end of the PCNL all or the maximum amount of the stone should have been
retrieved without losing fragments down the ureter.
61

IDEAL CALYX
 Easier to access endoscopically a polar region drained by a single infundibulum, which
usually has suitable diameter, rather than a polar region drained by paired calyces.
 For best access to the pelvic-ureteric junction (PUJ) one should choose a pole whose
calyx forms an angle of 90° or more with the PUJ
 Select a pole for puncture which provides the straightest path along the stone axis
62

IDEAL CALYX
 A lower pole, postero-Iateral puncture of the centre of the calyx is theoretically the
safest.
 The upper pole is more posterior and allows for easier navigation but has to be
approached with due care.
63

POSTERIOR CALYCEAL PUNCTURE
Closer to the skin surface in the prone
position.
Lies in Brodel’s avascular plane
Route from a posterior to an adjacent
anterior calyx or the renal pelvis is more
or less in a straight line forward.
Easier to negotiate a wire out of the
calyx and into the ureter
64

TO IDENTIFY A POSTERIOR CALYX
 Air pyelogram  Posterior calyces are
opacified
 Along the renal axis – End on view –
calyx appears short and wider
 Away from the calyx – lateral view –
appears longer
65

RENAL ACCESS
Posterior calyces allow access to anterior
calyces
Anterior calyceal entry poorer for intra renal
navigation
66

UPPER POLE PUNCTURES
 More posterior
 Entry is easier
 Navigation down to the PUJ simple and even the upper half of the ureter is accessible
as the navigation route is more or less 'downhill’.
 Disadvantages
 Intercostal puncture is often necessary with the risk of pleural or intercostal
artery damage
 Possibility of puncturing the posterior division of the renal artery,
 Postoperative pain from pleural and intercostal muscle irritation 67

RENAL ACCESS
Upper pole – allows deep access of PUJ / Upper ureter; Injury to
posterior division artery,pleura
LOWER POLE – Ideal and most commonly used
INTERPOLE – Rarely used;AdditionalTract / Anatomic abnormalities
68

RENAL ACCESS
 Lateral or Medial?
 Lateral – As it traverses the Brodel’s
avascular plane
69

SAFEST SITE OF INTRARENAL ACCESS
CENTRE OFTHE CALYCEAL FORNIX
70

IDEAL CALYX
 Posterior
 Inferior pole
 Lateral
71

IDEAL PUNCTURE
 Performed from a posterolateral position
 Performed through the renal parenchyma thick enough to
maintain a stable path
 Toward the center of the calyx posterolaterally
 Toward the center of the renal pelvis
As a result of these four conditions, the trajectory does
not damage any major blood vessels.
72

PRE REQUISITE
 0.035 inchTeflon-coated guidewire / Terumo glidewire into the upper collecting
system.
 When the guidewire is in position, 5/6 Fr open end ureteral catheter passed into the
collecting system.
 Rigid cystoscope (with the patient in lithotomy position)
 Flexible cystoscope (with the patient prone)
73

RETROGRADE PYELOGRAM
 Retrograde pyelogram
 Ureteral occlusion balloon / open end ureteric catheter is then inserted over a
guidewire & positioned at the ureteropelvic junction
 Ureteral catheter / occlusion balloon is secured externally to a foley catheter
 Using a tegaderm™ (3 m) to allow for easy separation
 Tied with 2‐0 silk to secure them in place.
 And wrapped in sterile towels where is exits from the urethra
 Allowing for sterile insertion of a double J stent on a tether in a retrograde fashion
at the end of the procedure 74

 A three‐way valve is attached and connected to a 10 ml syringe and intravenous
tubing leading to a bottle of contrast.
 This allows aspiration and infusion of additional contrast as needed during the
case..
 Flow of contrast under gravity distends the collecting system, providing a larger
target for access.
75

INTRA RENAL ACCESS
 Fluroscopic
 Ultrasound guided
 CT guided
 Laparoscopic guided
76

FLUROSCOPIC ACCESSTECHNIQUES
 Bull’s eye technique
 Triangulation technique
 Hybrid technique
77

BASIC C – ARM
POSITIONING
78

C ARM AT 90
DEGREE
79

C ARM AT 30
DEGREE
TOWARDSTHE
SURGEON
80

C ARM AT 30
DEGREE
TOWARDSTHE
OPERATOR
81

C ARM AT 30
DEGREE
CEPHALAD
82

C ARM AT 30
DEGREE
CAUDAD
83

PCNL ACCESS
TECHNIQUES
84

TECHNIQUES FOR RENAL ACCESS
 ANTEGRADE
 RETROGRADE
85

INITIAL PUNCTURE NEEDLE
 The standard choices for the needle are
 21-gauge needle (relatively minor injury)
through which is passed a 0.018-inch
guidewire
 18-gauge needle through which is passed a
standard 0.035-inch guidewire.
 Both needles have a blunt sheath, a sharp
obturator
86

ANTEGRADE ACCESS
 Site of entry
 Angle of entry
 Depth of the puncture
87

SITE OF SKIN ENTRY
 Depends on the fluoroscopic technique used
 Bull’s eye – direct under fluoroscopy
 Triangulation technique – puncture along the stone axis i.e in alignment with the
infundibulum
 Hybrid technique – Mathematically calculated
88

SITE OF SKIN ENTRY
 Reference lines
 Posterior axillary line
 Costal margin
 Iliac crest
 Mid scapular line
89

SKIN ENTRY
 Too medial or lateral – tract of variable length and angle of entry
 Medial to posterior axillary line – avoid injury to colon
 Too medial – traverse paraspinal muscles  increased postoperative pain, direct
puncture to pelvis
 Too close to the rib – intercostal nerve & vessel injury, pleural injury
90

BULL’S EYE TECHNIQUE
 Site of skin entry – Directly towards the target calyx
 Angle – Angle at which the needle forms bull’s eye
 Depth – at 0 degrees
91

92

TRIANGULATION TECHNIQUE
 Skin puncture – Along the stone axis in alignment with the infundibulum
 Withdraw the needle laterally (around 4 cms) along its axis
 Angle – 30-45 degree from frontal plane
 Depth – 30 degrees CC/towards the surgeon
 Fluroscopic view
 Mediolateral axis – 0 degree
 Depth - 30 degrees
93

94

HYBRID
TECHNIQUE
SITE OF SKIN
ENTRY
95

ANGLE OF PUNCTURE
 Angle of puncture – 30 degrees at
Point B
96

DEPTH OF THE PUNCTURE
 Calculated mathematically
 One side of triangle – AB
 One angle – 90 degree with Carm at 0 degree
 Another angle – Measured using the protractor at point
B
B A
C 97

UNIVERSAL LAW OF SINES
C
A
B
98

99

RETROGRADE ACCESS
 Indications
 Surgeon has limited experience with antegrade percutaneous
 Morbid obesity
 Hypermobile or abnormally situated kidney
100

LAWSON RG NEPHROSTOMY WIRE PUNCTURE SET
 7-Fr Torcon catheter (actively deflectable from 0 to
140 degrees)
 3-Fr polytetrafluoroethylene (PTFE) sheath containing
the 0.017-inch stainless steel puncture wire
Cook Urological,Spencer,IN
101

 Torcon catheter passed through the guide wire and
into the desired calyx
 Insert the puncture wire through the Torcon catheter.
 Advance the puncture wire through the kidney and
body wall under fluoroscopic control
102

 Make a small skin incision and grasp the wire
externally.
 Use the fascial dilators in an antegrade fashion until
theTorcon catheter can be advanced through the
tract.
 Once the end of the catheter exits the skin, exchange
the puncture wire for a standard 0.035 inch guidewire,
thus attaining through-and-through access.
103

CONFIRMATION OF PUNCTURE OF
POSTERIOR CALYX
104

PASSAGE OF GLIDE /GUIDE WIRE
 0.035 inch GW initially hydrophilic  replaced with 0.035 zebra or Amplatz super
stiff GW
105

SECURING THE INTRARENAL ACCESS
 Stiff,straight wire path makes dilatation much easier.
 Time spent in securing a stiff wire is always rewarded.
 The hydrophilic wire should be exchanged for an amplatz super-stiff wire.
 Rigid wire will orientate the calyx, infundibulum, the renal pelvis and the ureter
into a straight path without acute angles.
 Avoids kinking of the wire during dilatation.
 A stiff wire down the ureter and curled in the bladder is the most secure for
dilatation
106

SECURING THE INTRARENAL ACCESS
107

INCISING SKIN & FASCIA
 Using the knife along the needle under fluoroscopic control
 Incised at two planes at right angles to each other
 Can also use 18G coaxial fascial incising needle
 Care ! – subcostal / intercostal neurovascular bundle on the inferior rib margin
108

GW & SAFETY WIRE
 Pass the GW all the way to the bladder
 Placement of second safety GW to access the tract in event of inadvertent slipping
out of working GW
 Safety GW – introduced alongside the initial wire using a dual lumen catheter or
8/10 Fr coaxial dilator of the dilatation canula
109

TRACK DILATATION
 Tract size – 24 – 30 in most cases
 Dilators
 Sequential teflon
 Single step
 Telescopic Alken’s metal dilators
 Amplatz dilators
 Balloon dilator
110

111

TRACK DILATATION
 Adequate skin incision for safe dilatation
 Every step monitored on fluoroscopy
 Collecting system should be kept distended
 Tract should be dilated only till the minor calyx
 If the infundibulum is narrow do not advance the dilators/ sheath across the
infundibulum
 Dilate using a rotatory motion with slow advancement
 Do not push a dilator over a kinked guidewire - tear the collecting system 112

AMPLATZ SHEATH
 Maintains the tract
 Tamponade of the tract & reduces bleeding
 Beveled end uses to tamponade a part of renal parenchyma
 Protects parenchyma from injury by the instruments used
 Maintains low pressure system – reduces fluid intravasation, sepsis in infected calculi
113

TROUBLE SHOOTING
IN PCNL
114

FAILURETO OPACIFY THE SYSTEM
CAUSE REMEDY
Ureteric catheter slipping out while positioning Fix to the per urethral catheter
Placing GW across the calculus
Tightly impacted calculus preventing passage of
contrast
Head low position
Diluting the contrast
USG guided puncture & opacify the
system
115

EXTRAVASATION OF CONTRAST
CAUSE REMEDY
Large volume of contrast instilled at high
pressure
Inject small amount of diluted contrast
slowly with ureteric catheter in pelvis
Extravasation through improperly placed
ureteric catheter (large impacted calculus
with infection)
1. Give diuretic & wait for 15 mins
2. Use concentrated contrast to identify
PCS
3. USG guided access
4. Air pyelogram
5. Ureteroscopically assisted percutaneous
access
6. Angled tip angiographic catheter
7. Rarely – stage the procedure & re-
attempt after 48 hrs
Non-satisfactory first attempt at puncture
116

INABILITY TO PUNCTURE
Cause Remedy
Inexperience & Incorrect choice for
puncture
Presence of more experienced surgeon
Non dilated system PCS adequately filled & distended
Continuously flush saline in ureteric
catheter
Add a drop of methylene blue / betadiene
to the contrast
Use of 21 gause needle for initial puncture
USG / CT guidance
117

BLOOD ATTHE TIP OF THE NEEDLE
CAUSE REMEDY
• Needle at blood vessel or renal
parenchyma
• Ensure proper posterolateral calyceal
puncture
• Adjust the depth of the needle –
withdraw outside the parenchyma
• Multiple attempts • Use of 21 G needle
• Flush the ureteric catheter with saline –
clears  PCS access confirmed
118

MULTIPLE PUNCTURES?
 Large & complex stones & staghorn calculi
 Percutaneous calyceal lavage to flush the calculi to be picked through primary tract
 Flexible nephroscopy with laser
 Ist tract – most stone bulk removed
 Accessory tract – mini PCNL tracts for peripheral small calculi
 Upper calyx advantageous – direct access to upper calyx, pelvis, lower calyx, upper
ureter
 If a second tract is anticipated – place the guide wires in the calyces where the
second tract is expected before dilatation of primary tract 119

TRACT DILATATION
 Dense scar tissue – Collings knife or plasma vaporization for tract making
 Largest Amplatz dilator without initial small dilators – rapid, easy & less blood loss
 Radially expanding single step dilator– advantage of not removing the needle;
dilatation over rigid system
120

KINK IN GUIDEWIRE
CAUSE REMEDY
Forceful dilatation in wrong direction / against
resistance
Placement of guide rod
Dilatation in correct direction & adequate force
• 2/3 of progress by rotational screwing
movements
• 1/3 by force
Usually kinks at thoracolumbar fascia Fascia to be incised well before starting dilatation
Exchange for a new wire
Advance the kink down the ureter / pull the kink
externally
Use of super stiff wire for dilatation
121

LOSS OFTRACT
CAUSE REMEDY
Slipping of guide wire before dilatation Adequately park the guide wire in the collecting system
Use of safety guide wire
Use of super stiff wire
If the amplatz sheath not held properly Follow the GW with Nephroscope till it is positioned in
PCS
AdvanceAmplatz sheath over the nephroscope
Under dilatation Flushing saline during dilatation
Over dilatation (traversing opposite wall of PCS) No forceful dilatation
Dilatation till the calyx & not till the calculus
Withdraw the sheath to get back in PCS
Large perforation/significant bleeding  abandon & place
large bore nephrostomy tube;stage after 3-4 days
122

MOBILE KIDNEY
 Place a bolster underneath the patient to fix the kidney.
 Use a stiff wire.
 Use a balloon dilator
123

STAGHORN / TIGHT SYSTEM
 Use the ureteric catheter to distend and a hydrophilic wire.
 If wire will not advance past the stone, coil tip in the calyx if possible and dilate with
care
124

STONE TIGHTLY WITHIN CALYX
 Use the ureteric catheter to distend and a hydrophilic wire.
 If wire will not advance past the stone, coil tip in the calyx if possible and dilate with
care
 Puncture another calyx and approach the stone internally
125

PELVIC / INFUNDIBULAR TEAR
 There is a danger of absorption or retroperitoneal collection of irrigant.
 Procedure can continue with care but proper post-operative drainage should be
ensured
126

BRISK BLEEDING
 Place a balloon and tamponade the track.
 If bleeding continues consider open surgical repair or embolisation
127

HORSESHOE KIDNEY
 Under-rotated and malascended kidney, with numerous accessory arteries.
 Relatively immobile,which hinders intrarenal navigation
 Pre-operative 3D CT is of particular help here for access planning.
 As a general rule the upper pole, medial calyces are preferred,and the use of double-
contrast pyelography is very useful in identifying the most posterior calyces.
 Long sheaths may be necessary as the horseshoe is usually more deeply located
128

MAL-ROTATED KIDNEYS
 Mal-rotated kidneys: a kidney may be over- or under-rotated with the posterior
calyces facing medially or laterally.
 There may also be anomalous vessels present.
 CT scan with 3D volume reconstruction - Helps to clarify the calyceal anatomy and
its relationship with the vessels
129

CALYCEAL DIVERTICULUM
 Calyceal diverticulum: most are stone packed and in the upper pole.
 Needle can be readily targeted onto the stone
 Wire will either not enter the diverticulum, because of lack of space, or if it does it
cannot be manipulated across the tight calyceal neck and down the ureter
 Firm retrograde injection can help to distend both the neck and the diverticulum
 If the wire could not be passed through the neck, then it should be coiled firmly
within the diverticulum and dilatation carried out with the utmost care and slowly
130

BIFID / DUPLEX SYSTEM
 The importance here is to recognize these anomalies and that navigation will be
restricted.
 Such systems are also overall 'small' and prone to calyceal tearing during dilatation.
 Entry should be directly onto the stone-bearing calyx
131

PELVIC / THORACIC KIDNEYS
 Pre-operative CT is a must
 Percutaneous entry may require CT guidance or laparoscopic assistance to move
away interposed bowel loops or lungs.
132

COLONIC INJURY
 1%
 Retrorenal colon
 More common on left side
 Risk factors: thin, elderly, dilated colon, prior colon surgery or disease, horseshoe
kidney
 Prevention: Preoperative CT,Awareness of colonic gas bubble on fluoroscopy,USG
guided punctures
 Management :Abandon & place NT in colon and RP drain
133

LIVER & SPLENIC INJURY
 With supracostal access if above 10 th rib in normal individual
 Hepatomegaly / splenomegaly – preoperative CT to decide a safe access, CT guided
access
134

PLEURAL INJURY
 Asssociated with supracostal access
 12th rib access – 4%
 11th rib access – 20%
135

PLEURAL INJURY
 Parietal pleura crosses the 12th rib
 Medial half covered by pleura
 Mid scapular line – Parietal pleura
at 12th &Visceral Pleura at 10th rib
 Both rise cranially and laterally on
ribs
 Further rise in deep expiration
 Tracts below 11th rib made lateral
to mid scapular line 136

PLEURAL INJURY
 Make the tract lateral to mid scapular line
 Stay below 10th rib
 Perform puncture in deep expiration
 Minimize size of the tract as possible
 Check Costo-phrenic angle at the end of
supra costal access
 Pleural fluid collection if occurs – Chest
drain at the end of the procedure
 Thoracoscopically guided access superior
to 10th rib
137

EXIT STRATEGIES IN PCNL
 Externalised nephrostomy tube
 Nephroureteral stent
 Tubeless with ureteral stent
 No drainage tube
138

NEPHROSTOMY TUBES
 Foley and council catheters
 Malecot / malecot re entry catheter
 Cope catheter with retention string
 Nephroureteral stent
139

NEPHROSTOMY TUBES
 Advantages
 Good drainage
 ?Tamponade the tract & reduce haemorrhage
 Maintains percutaneous access for additional procedures
 Disadvantages
 Pain
 Urinary leak
Use smaller calibre tubes
140

URETERAL INTUBATION
 Greatest control & assurance of drainage
 Only be used when needed
 Morbidly obese
 Ureteral obstruction
 Ureteral injury
141

TUBELESS WITH URETERAL STENT
 Advantages
 Decreased pain & analgesic use
 Shorter hospital stay
 Decreased cost
 Should not be advocated in
 Significant bleeding
 Perforation of PCS
 Second percutaneous procedure anticipated 142

TOTALLY TUBELESS
 Selected patients with low volume stones
 Atraumatic single access
 No haemorrhage/perforation/obstruction
143

ADJUNCTS TO DRAINAGE WITHOUT
NEPHROSTOMY TUBE IN BLEEDING FROM TRACT
 Placing a fascial suture
 Direct monopolar cauterisation of the tract
 Cryotreatment of tract
 Insertion/instillation of hemostatic agents – surgicel, gelatin sponge/granules, fibrin
glue, collage matrix coated with fibrin glue
 Systemic enhancements to hemostasis – oral tranexamic acid
144

COMPLICATIONS
 Acute haemorrhage – 0.5 – 4% transfusion rate
 Delayed haemorrhage – 1% - AV fistula, arterial pseudoaneurysm
 Collecting system injury
 Visceral injury – colon, small bowel, hepatic & splenic injuries
 Pleural injury
 Postoperative fever – 15 -30%
 Sepsis – 0.5-2.5%
 Loss of renal function – 1.6%; negligible long term loss 145

COMPLICATIONS
 Extravasation of large amount of saline  respiratory distress, cardiac failure from
volume overload
 Venous gas embolism – air pyelography
 DVT – early ambulation; no prophylaxis for PCNL
 Collecting system obstruction – ureteral edema, clot retention
 Death – extremely rare ; reported in underlying cardiovascular conditions
146

THANKYOU
147

Urolithiasis management- pcnl

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