Percutaneous Stone Removal
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Transcript of Percutaneous Stone Removal
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Percutaneous Stone Removal-PCNL-
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History
• The first description of percutaneous renal access was by Goodwin et al in 1955
• The first PCNL procedure performed by Fernstrom and Johannson 1976
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Indications and contraindications
Indications– radiopaque or cystine renal stones with a diameter of
>20 mm– lower-pole stones, the procedure competes with
shock wave lithotripsy (SWL) and ureterorenoscopy – For stones <20 mm, SWL shows lower morbidity but
"mini-perc" is recommended as an alternative and has a higher stone-free rate.
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The only absolute contraindications1. uncorrected coagulopathy
2. an untreated urinary infection.
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Preoperative diagnostics
• A detailed medical history of the patient
• Radiologic definition of the stone size and the anatomy of the collecting system
• plain abdominal film of the kidney, ureters, and bladder (KUB) in combination with intravenous urography
• Ultrasound • computed tomography (CT) scans
• Laboratory • coagulation parameters and electrolytes• urine culture - is strongly recommended
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• prone position - The traditional way of performing PCNL, as described by Alken et al
• supine position - The new way of performing PCNL by Valdivia (combined approach with simultaneous ureteroscopy is easy to perform)
Positioning of the patient
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Anesthesia
1. general anesthesia - mostly
2. spinal-epidural anesthesia – very good report cost efficacy and safety
3. local anesthesia - seems to be a feasible in selected group of patients
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Renal access
Renal access is divided into two main parts: – puncture of the collecting system – dilation of the tract.
• most urologists from EU puncture the collecting system themselves (90.1%)
• in the US - 11% of urologists obtained the renal access on their own
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Puncture of the collecting system Access type
– Radiological - radiographic guidance alone the “bull's eye” technique and the triangulation technique
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The dorsal calyx of the lower pole is the usually acces site
Supracostal access to an upper calyx due to stone location in the upper pole.
10th-rib supracostal approach is prohibitive - 63% risk of puncturing the lung
After puncture will are passing the papilla in the long axis of the target calyx avoids contact with large vessels
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Ultrasonographical - ultrasonography-guided access in experienced centers, is safe and efficient,
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The dilation of the tract tehnique
• metallic telescope dilator system and placement of a metallic sheath – Alken
• serial plastic dilators and then placement of a plastic sheath (Amplatz sheath)
• tract dilation using a balloon Clayman
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Disintegration
• the stones are usually disintegrated mechanically with a lithoclast device or a holmium laser.
• Ultrasonic disintegration • Fragments can usually be flushed out through the
access sheath or recovered with a stone basket or with special forceps
Operation time seems to be dependent on stone size.
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Standard PCNL - a nephrostomy tube is inserted after the PCNL with the intention of both draining the urine and tamponading the access tract
Tubeless PCNL – intern ureteral drainage
Totally tubeless PCNL - without any drainage
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Complications
Organ injury • Colonic injury < 1 %• Lung injury• Spleenic and hepatic injury
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Bleeding complications • In most, it is limited • selective arteriography with
embolisation is feasible 1%• Nephrectomy 0.2%
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Infectious complications 30% • Fever • Sepsis
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