Update on PCNL technique: Tips to optimize outcomes

Percutaneous access has revolutionized stone surgery. Although percutaneous nephrolithotomy (PCNL) has been around for decades, continual improvements and refinements have helped optimize outcomes. These videos demonstrate significant advances in technique that can serve to optimize outcomes, reduce OR time, and help achieve optimal results.

Commentary on the videos is provided by Seth K. Bechis, MD, MS, assistant professor of urology, and Roger L. Sur, MD, professor of urology, University of California, San Diego, and 'Y'tube Section Editor James M. Hotaling, MD, MS, assistant professor of surgery (urology) at the Center for Reconstructive Urology and Men's Health, University of Utah, Salt Lake City.

Continue to the next page to watch the videos.Prone, split-leg, fluoroscopic-guided access for PCNL - Rajat Jain, MD, and Sriharan Sivalingam, MD

In this video, Cleveland Clinic urologists describe their technique for prone, split-leg, fluoroscopy-guided percutaneous access for nephrolithotomy. This technique removes the need to reposition the patient, thus increasing efficiency. It also allows for simultaneous antegrade and retrograde lithotripsy.

Dr. Bechis/Dr. Sur: By performing flexible cystoscopy through the split-leg table after the patient has been positioned prone, this approach eliminates the need to reposition the patient between retrograde ureteral access and percutaneous renal access. PCNL is an equipment-intensive procedure requiring multiple connections for endoscopic equipment, so minimizing changes in patient position should increase operating room efficiency. We find the bulls-eye technique in fluoroscopy for needle targeting of the calyx, as shown here, is easy to teach and reproduce, and is our preferred technique. The authors use a 21-gauge needle to reduce the risk of renal injury and bleeding in the setting of multiple accesses, but we find the 18-gauge to be acceptable as well. The authors highlight the importance of serial fluoroscopy to confirm wire placement and advancement of dilators and sheaths so as to avoid wire buckling or inadvertent injuries to the urothelium.

Dr. Hotaling: The need to not reposition patients is a significant improvement in PCNL technique. Moving patients from lithotomy to the prone position will typically add 10-15 minutes to a case, depending on how efficient the OR team is. The bullseye technique is easily reproducible and yields good outcomes. This video shows an excellent example of a reproducible and efficient technique that can be employed by urologists to safely perform this surgery.

Rajat Jain, MD

Sriharan Sivalingam, MD

Dr. Jain is an endourology fellow at Cleveland Clinic and Dr. Sivalingam is director of the Center for Endourology & Stone Disease at Hillcrest Hospital and assistant professor of laparoscopic and robotic surgery at Lerner College of Medicine, Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland.Prone percutaneous access with retrograde guidance - Brenton B. Winship, MD, Daniel A. Wollin, MD, and Michael E. Lipkin, MD

There are multiple methods of access for percutaneous nephrolithotomy including various positioning practices and means for visualizing the calyx of interest. In this video, we describe a method of prone percutaneous nephrolithotomy with concurrent retrograde ureteroscopic access that allows for a safe entrance into the kidney and enables simultaneous ureteroscopic manipulation.

Dr. Bechis/Dr. Sur:Use of retrograde ureteroscopy to facilitate targeting and guide needle placement is a potentially useful addition to the procedure. Instead of relying on a retrograde pyelogram with contrast and/or air to differentiate anterior from posterior calyces, retrograde ureteroscopy provides direct visualization to identify which calyces are aligned in the proper orientation. In addition, the ureteroscope serves as an obvious target during needle access. Preplacing a ureteral access sheath under fluoroscopy on every patient enables simultaneous ureteroscopy, which can be useful to reposition large stones for percutaneous removal. In cases with complex anatomy such as large upper pole stone burden but overlying pleura that precludes upper pole percutaneous access, or cases involving stones in anterior calyces that are not directly targetable percutaneously, simultaneous ureteroscopy allows for laser lithotripsy and relocation of stone fragments to an area that is accessible for percutaneous removal. It may also provide enhanced irrigation and drainage via two channels. This procedure may require an additional surgeon to perform ureteroscopy as some facilities can utilize a surgical assistant to hold the scope.

Dr. Hotaling: This technique, which enables simultaneous access through use of an access sheath, has several advantages. First, it allows real-time manipulation of both the ureteroscope and the access needle to facilitate entry into the collecting system. Second, it allows manipulation of stone fragments to facilitate fragmentation or percutaneous removal, thus increasing efficiency.

Brenton B. Winship, MD

Daniel A. Wollin, MD

Michael E. Lipkin, MD, MBA

Dr. Winship and Dr. Wollin are endourology fellows and Dr. Lipkin is associate professor of urologic surgery at Duke University Medical Center, Durham, NC.Prone, ultrasound-guided access for PCNL - Seth K. Bechis, MD, MS

There are many techniques for obtaining access for percutaneous nephrolithotomy. In the era of reducing fluoroscopy exposure, ultrasound has emerged as an excellent alternative for targeting renal calyces for percutaneous nephrolithotomy. In this video, we present our approach for prone, ultrasound-guided percutaneous access for nephrolithotomy. We also briefly discuss equipment and patient positioning.

Dr. Hotaling: Here, Dr. Bechis and colleagues show how ultrasound-guided percutaneous access can be used to obtain safe and efficient entry into the collecting system. This simple technique can be used to reduce fluoroscopy exposure in patients, many of whom will require multiple stone surgeries over their lifetime.

Dr. Bechis is assistant professor of urology at the University of California, San Diego Comprehensive Kidney Stone Center.Ultrasound-guided PCNL access - Roger L. Sur, MD

Despite its widespread use throughout the rest of the world, ultrasound-guided percutaneous nephrolithotomy has not been commonly performed in the US due to lack of familiarity with the approach. In this video, we describe our technique for using ultrasound to perform an initial survey of the kidney, identify targetable calyces (with or without hydronephrosis), and subsequently obtain access into the collecting system during percutaneous nephrolithotomy. Familiarity with the steps in ultrasound use should allow for quick adoption of this technique and reduction in radiation exposure to patients during stone surgery.

Dr. Hotaling: Here, Dr. Sur and colleagues demonstrate obtaining access with ultrasound. Ultrasound, a technology that all urologists are familiar with, has not been routinely used for PCNL access in the United States. Dr. Sur demonstrates a safe, reproducible technique to visualize access in real time and avoid complications.

Dr. Sur is director of the Comprehensive Kidney Stone Center and professor of urology at the University of California, San Diego.

'Y'tube Section Editor James M. Hotaling, MD, MS, is assistant professor of surgery (urology) at the Center for Reconstructive Urology and Men's Health, University of Utah, Salt Lake City.