Percutaneous Nephrolithotomy PCNL by Dr. Majid Kakakhel IKD, Peshawar.

Percutaneous Nephrolithotomy PCNL
Dr. S K Pal technique Gradual Descend technique

1. Percutaneous Nephrolithotomy PCNL By: Dr. Majid Jan Kakakhel PGR-Team C Institute of Kidney Diseases, Peshawar .

2. Learning Objectives Indications Procedure and Position Techniques Complications

3. By the end of this presentation our PG’s wil be able to know common indication , procedure and position , different techniques and complications .

4. Percutaneous N ephrolithotomy  is a   minimal-invasive procedure   to remove  stones  from the  kidney  by a small puncture wound (up to about 1 cm) through the skin. It is most suitable to remove stones of more than >2  cm in size and which are present near the  pelvic  region. PCNL attains stone free rates of upto 95% AUA guidelines recommend PCNL as a treatment of choice for staghorn calculi. It has been invented in 1976 by Fernstrom and Johansson [1]

5. INDICATIONS Percutaneous nephrolithotomy (PNL) is recommended by the Guidelines of the European Association of Urology for the following 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 ). • Urinary tract obstructions that need simultaneous correction (e.g. PUJ obstruction ). • Malformations with reduced probability of fragment passage after ESWL (e.g. horseshoe , calyceal diverticula ) • Obesity

6. PCNL is contraindicated if patient has uncorrectable coagulopathy . Antiplatelet medications like aspirin should be discontinued 7 days before operation.

7. Anaesthesia and Positioning Preferably performed under General Anesthesia Spinal or Local Anesthesia The positions generally preferred for puncture are: P rone Oblique Completely Prone Supine

8. Surgical Technique Pre-operative urographic assessment with computed tomography is helpful in planning the operation. Any urinary tract infection needs prior treatment with appropriate antibiotic, and a temporary percutaneous nephrostomy can be inserted to drain an obstructed and infected pelvicalyceal system beforehand.

9. FLUOROSCOPY GUIDED PUNCTURE Types of fluoroscopy guided puncture techniques are: Bull’s eye Triangulation Technique Gradual Descent Technique

10. BULL’S EYE TECHNIQUE also called the Eye of the Needle technique. The target calyx is identified with the C arm at 0° in the axial plane . Then the C arm is rotated 30° towards the surgeon and the calyx to be punctured would appear end on the fluoroscopy screen. A tilt of 5°-10° in the caudal direction for the lower pole or in the cranial direction for the upper pole may be necessitated to have a circular end on appearance of the target posterior calyx.

11. The position on the skin overlying the selected calyx is then marked and the puncture initiated. It is seen as a Bull’s eye (as a dot ) on the fluoroscopy screen It is then advanced to puncture the calyx.   Free efflux of urine confirms the position in the collecting system.

12. BULL’S EYE TECHNIQUE To perform the “ eye-of-the-needle ” technique, first inspect the kidney with the fluoroscopy unit directly above the patient (directed vertically 0 degree ) and select the desired calyx. Next, rotate the top of the fluoroscopic unit 30 degrees toward the operator , Place the tip of a hemostat on the skin and move it until it is directly over the desired calyx. Mark this site and make an incision. Place the tip of the access needle into this incision, and then move the shaft of the needle while keeping the tip in place until the needle is directly in line with the axis of the fluoroscopy unit; doing so gives the appearance of a “ bull’s eye ” with the hub of the needle (appearing as a circle ) around the shaft (which appears as a dot ).

13. TRIANGULATION TECHNIQUE technique of using two known points of reference to locate a third unknown point guided by biplanar fluoroscopy. The medial and lateral plane is assessed with the C arm at 0°.   The depth is assessed by rotating the C arm in the cranial or caudal direction by 30°. The target calyx is identified with the C arm at 0°. Then the line of puncture is aligned with the infundibulum With the C arm at 0° the needle is introduced through the skin incision. The left and right ,  i.e ., the mediolateral adjustments are made and the needle is aligned with calyx . Then the C arm is rotated 30°, towards the head end for lower pole punctures and towards the foot end for upper pole punctures. The needle is then oriented in the up and down,  i.e ., the cephalo -caudal position so that the orientation is again towards the desired calyx. 

14. If the needle position in the medial-lateral and cephalo -caudal planes is maintained, the needle should enter the targeted calyx. It is preferable to use the 18-gauge rather than a 21-gauge needle with the triangulation technique, as its stiffness provides better stability to help maintain angle of entry

15. The S tandard O perative T echnique of PCNL consists of Four main steps: 1 . Opacification 2. Percutaneous puncture of pelvi-calyceal system. 3. Development of track . 4. Fragmentation and/or removal of stone.

16. 1. OPACIFICATION of PCS Air , contrast or both can be used. These agents can be gradually established in PCS by antegrade or retrograde means. RETROGRADE UROGRAPHY: Contrast injected directly into PCS via Catheter . ANTEGRADE UROGRAPHY: A FINE GUAGE NEEdle ( Chiba) under local anesthetic inserted directly into PCS and contrast injected to visualize the calyces, pelvis and ureter .

17. Hydronephrotic collecting system can be punctured easily under realtime ultrasonographic guidance (Fig 5).

18. Initial exploratory puncture is performed with a 21G or 22G skinny needle from below the 12th rib , targeting a posterior calyx. A second definitive puncture is then performed with a larger 18G needle. Insertion of this needle into the target calyx enables subsequent introduction of a .038 or .035 working guidewire into the pelvi-calyceal system. 2. PERCUTANEOUS PUNCTURE OF PCS

19. A supracostal puncture provides upper pole renal access that is needed when there is substantial stone burden in the upper pole calyces , or in horseshoe kidneys .

20. 3.Development of Track The second step is to dilate a track from the skin through the renal parenchyma into the collecting system , and to place a working sheath. Over the guidewire , fascial dilators are inserted to serially dilate the track between the skin and the renal calyx to enable subsequent instrumentation. There are 3 types of fascial dilators : 1 . Amplatz teflon dilators , 2. Alken telescopic metal dilators , 3 . balloon dilator .

21. Under fluoroscopic guidance, fascial dilators are inserted along the extra-stiff guidewire until their tips enter well into the collecting system. The fastest method of track dilatation is to use a balloon dila tor, as it does not require serial insertion of multiple dilators of increasing size. Its only drawback is the cost of the balloon dilator.

22. After dilating the track to the desired size (generally 26 to 30 Fr), an Amplatz sheath is slipped over the dilator and manipulated into the collecting system. This Amplatz sheath provides tamponade to stop any bleeding from the freshly developed track, while at the same time serves as a conduit for introducing instruments and a channel for irriggation fluid to flow out easily.

23. 4. Nephroscopy and Stone Extraction The last step is to introduce a nephroscope via the Amplatz sheath into the pelvi-calyceal system to locate the stones (Fig 11).

24. Smaller stones can be retrieved with rigid stone forceps directly via the Amplatz sheath. Larger stones have to be fragmented first using either one of the following energies: 1. Ultrasonic lithotripsy . 2. Holmium laser lithotripsy. 3. P neumatic lithotripsy. Holmium laser is ideal for cutting harder stones into smaller pieces.

25. Complications Possible complications of PCNL include: Haemorrhage . Collecting System Injury Injury to adjacent bowel . F ailed access or failure of equipment. Pneumothorax and Pleural effusion (with supracostal punctures) Sepsis Major complications can occur in 1% to 7% of patients undergoing PCNL

26. COMPLICATIONS Acute Hemorrhage • The most common significant complication • Factors associated with hemorrhage during percutaneous surgery include: multiple access sites supracostal access increasing tract size tract dilation Prolonged operative time renal pelvic perforation

27. Delayed Hemorrhage Delayed hemorrhage is usually due to arteriovenous fistulas or arterial pseudoaneurysms (more common) The standard treatment of renal arteriovenous fistulae and arterial pseudoaneurysms is selective angio-embolization Nephrectomy may be required if selective angioembolization fails.

28. Postoperative Fever and Sepsis • Incidence: 15% to 30% • Risk factors for fever infectious stones preoperative urinary tract infection Hydronephrosis indwelling ureteral stent or nephrostomy tube • If pus is aspirated upon initial percutaneous to the upper urinary tract, the safest measure is to abort the procedure and leave a nephrostomy tube for drainage

29. Thank you

30. References Fernstrom I, Johansson B. Percutaneous pyelolithotomy : a new extraction technique. Scandinavian Journal of Urology and Nephrology, 10: 257, 1976. Alken P, Hutschenreiter G, Gunther R, Marberger M. Percutaneous stone manipulation. Journal of Urology, 125: 463- 466, 1981. Wickham JEA, Kellett MJ. Percutaneous nephrolithotomy . British Journal of Urology, 53: 297, 1981 Albala DM, et al. Lower pole 1: a prospective randomized trial of extracorporeal shockwave lithotripsy and percutaneous nephrostolithotomy for lower pole nephrolithiasis - initial results. Journal of Urology, 166: 2072, 2001. Segura JW, et al. Nephrolithiasis clinical guidelines panel summary report on the management of staghorn calculi. Journal of Urology, 151: 1648, 1994

31. Our experience at IKD

32. To use the “triangulation” technique, inspect the kidney with the fluoroscopy unit directly above the patient to select the desired calyx, and hold the needle in the approximate position of the desired angle of entry. Rotate the top of the fluoroscopy unit cephalad and lateral, and widen the field of view with the collimator such that mediolateral (left-right) movements of the needle are apparent. Move the shaft of the needle while keeping its tip in place until the needle is aimed toward the desired calyx (Fig. 8-20A). Then rotate the top of the fluoroscopy unit medially 45 degrees. While keeping the mediolateral orientation of the needle constant, move the needle in the cephalo-caudad (up-down) plane until the needle is again aimed toward the desired calyx (Fig. 8-20B). Resting the forearm on the patient’s back will help stabilize the needle in one plane while moving in the other. Move the fluoroscopy unit back and forth between these two positions until the needle remains aimed at the desired calyx on both views. Advance the needle under fluoroscopic guidance while monitoring the anteroposterior direction (depth) of the needle tip. If the needle position in the mediolateral and cephalo-caudad planes is maintained, the needle should enter the targeted calyx.

33. Gradual Descend Technique Always donein 30 degree C-arm