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PCNL A Global Perspective Dr CW Wong Division of Urology Department of Surgery Pamela Youde Nethersole Eastern Hospital.

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Presentation on theme: "PCNL A Global Perspective Dr CW Wong Division of Urology Department of Surgery Pamela Youde Nethersole Eastern Hospital."— Presentation transcript:

1 PCNL A Global Perspective Dr CW Wong Division of Urology Department of Surgery Pamela Youde Nethersole Eastern Hospital

2 Introduction and history Introduction and history PCNL: what is it? PCNL: what is it? Indications Indications Imaging modalities for percutaneous access Imaging modalities for percutaneous access Dilatation of the nephrostomy tract Dilatation of the nephrostomy tract Mini-perc technique Mini-perc technique Mode of stone fragmentation Mode of stone fragmentation Chinese MPCNL: PYNEH experience Conclusion

3 Introduction and history 1865Thomas Hillier described first percutaneous nephrostomy 1865Thomas Hillier described first percutaneous nephrostomy 1955Willard Goodwin & associates reported their experience with percutaneous nephrostomies in 16 patients 1955Willard Goodwin & associates reported their experience with percutaneous nephrostomies in 16 patients 1976Fernstrom & Johansson described a procedure through which a renal pelvic calculus could be extracted through a percutaneous tract 1976Fernstrom & Johansson described a procedure through which a renal pelvic calculus could be extracted through a percutaneous tract Early 80sPercutaneous nephrolithotomy gained widespread popularity Early 80sPercutaneous nephrolithotomy gained widespread popularity

4 PCNL & ESWL With the advent of ESWL in the mid 80s, the indications for percutaneous stone extraction were narrowed With the advent of ESWL in the mid 80s, the indications for percutaneous stone extraction were narrowed As the limitations of ESWL were recognised, percutaneous surgery once again rose in popularity with a redefined role in stone management As the limitations of ESWL were recognised, percutaneous surgery once again rose in popularity with a redefined role in stone management

5 PCNL: what is it? Percutaneous nephrolithotripsy Percutaneous nephrolithotripsy Retrograde pyelogram Retrograde pyelogram Tract formation for renal access Tract formation for renal access

6 PCNL: what is it? Stone fragmentation & retrieval Stone fragmentation & retrieval

7 Indications PCNL is the preferred treatment for PCNL is the preferred treatment for 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) Obesity EAU Guidelines on Urolithiasis 2001

8 Imaging modalities for percutaneous access Image guided Image guided Fluoroscopy Fluoroscopy USG USG

9 Imaging modalities for percutaneous access Fluoroscopy Fluoroscopy Most commonly employed Most commonly employed Use of 2-plane fluoroscopy to achieve accurate needle entry Use of 2-plane fluoroscopy to achieve accurate needle entry Radiation safety: patient, surgeons, staff Radiation safety: patient, surgeons, staff

10 Imaging modalities for percutaneous access Ultrasonography: Ultrasonography: The simplest & most direct The simplest & most direct Minimises radiation exposure Minimises radiation exposure Allows imaging of intervening structures between skin and kidney Allows imaging of intervening structures between skin and kidney Sonographic identification of the puncture needle may be technically demanding Sonographic identification of the puncture needle may be technically demanding Inability to clearly visualise and manipulate a guidewire once it is placed through the percutaneous access tract Inability to clearly visualise and manipulate a guidewire once it is placed through the percutaneous access tract

11 Dilatation of the nephrostomy tract Progressive fascial dilators Progressive fascial dilators Metal coaxial dilators Metal coaxial dilators Balloon dilation catheters Balloon dilation catheters

12 Dilation of the nephrostomy tract Fascial dilators Fascial dilators Progressively larger Teflon tubes designed to slide over a inch GW Progressively larger Teflon tubes designed to slide over a inch GW Size ranging from 8 to 36 Fr Size ranging from 8 to 36 Fr Inserted in a rotating, screw-type fashion Inserted in a rotating, screw-type fashion Advantages: Advantages: Safe Safe Ideal for dilation of fibrous tracts Ideal for dilation of fibrous tracts Disadvantages: Disadvantages: Dependence on the integrity of the GW Dependence on the integrity of the GW

13 Dilation of the nephrostomy tract Metal coaxial dilators Metal coaxial dilators Stainless steel, mounted together in a telescopic fashion Stainless steel, mounted together in a telescopic fashion 8 Fr hollow guide rod that slides over a GW 8 Fr hollow guide rod that slides over a GW A set of six metal tubes ranging in diameter from 9 to 24 Fr, each adapting exactly to the lumen of the next dilators A set of six metal tubes ranging in diameter from 9 to 24 Fr, each adapting exactly to the lumen of the next dilators

14 Dilation of the nephrostomy tract Balloon dilation catheters Balloon dilation catheters To achieve tract dilation in a single step To achieve tract dilation in a single step Avoid the need for serial dilation Avoid the need for serial dilation Generate lateral compressive forces, theoretically less traumatic Generate lateral compressive forces, theoretically less traumatic Drawback: relative inability to dilate dense fascial tissue or scar tissue Drawback: relative inability to dilate dense fascial tissue or scar tissue

15 Mini-perc technique Use of 13 to 20 Fr tract Use of 13 to 20 Fr tract Smaller volume of renal parenchyma dilated, leading to decrease in blood loss and post-op pain Smaller volume of renal parenchyma dilated, leading to decrease in blood loss and post-op pain Lahme et al Eur Urol. 40(6):619-24

16 Stone fragmentation Electrohydraulic Lithotripsy Electrohydraulic Lithotripsy Fragments stones with shock waves generated by an underwater electrical discharge Fragments stones with shock waves generated by an underwater electrical discharge Narrow margin of safety owing to the risk of damage to ureteral mucosa and ureteral perforation Narrow margin of safety owing to the risk of damage to ureteral mucosa and ureteral perforation

17 Stone fragmentation Holmium:YAG laser lithotripsy Holmium:YAG laser lithotripsy Occurs primarily through a photothermal mechanism that causes stone vaporisation Occurs primarily through a photothermal mechanism that causes stone vaporisation Highly absorbed by water Highly absorbed by water Zone of thermal injury associated with laser ablation ranges from 0.5 to 1.0 mm Zone of thermal injury associated with laser ablation ranges from 0.5 to 1.0 mm Able to fragment all stones Able to fragment all stones regardless of composition

18 Stone fragmentation Ballistic Lithotripsy Ballistic Lithotripsy A jackhammer effect A jackhammer effect Swiss LithoClast Swiss LithoClast Effective means for stone fragmentation in the entire urinary tract with wide margin of safety Effective means for stone fragmentation in the entire urinary tract with wide margin of safety Relatively high rate of stone propulsion Relatively high rate of stone propulsion

19 Stone fragmentation Ultrasonic lithotripsy Ultrasonic lithotripsy Probe tip causes the stone to resonate at high frequency and break Probe tip causes the stone to resonate at high frequency and break When placing it on compliant tissues such as the urothelium, damage is minimal because the tissue does not resonate with the vibrational energy When placing it on compliant tissues such as the urothelium, damage is minimal because the tissue does not resonate with the vibrational energy

20 Minimally Invasive PCNL (MPCNL) according to the Chinese Method: A Comparison with Traditional PCNL CW Wong, TC Fung, CW Fan, SM Hou, SK Li Division of Urology, Department of Surgery Pamela Youde Nethersole Eastern Hospital Hong Kong

21 Chinese MPCNL Minimally invasive PCNL, according to the Chinese method Minimally invasive PCNL, according to the Chinese method MPCNL MPCNL First described by Lahme, Germany in 2001 First described by Lahme, Germany in 2001 Eur Urol. 40(6): The term Chinese MPCNL The term Chinese MPCNL Coined by Dr SK Li, PYNEH at ELSA 2005 Coined by Dr SK Li, PYNEH at ELSA 2005 Based on the approach described by Professor Li Xun, Guangzhou, China Based on the approach described by Professor Li Xun, Guangzhou, China

22 Essential features Puncture: Puncture: Kidney puncture based on pre-op imaging and tactile feedback Kidney puncture based on pre-op imaging and tactile feedback Minimal use of fluoroscopy Minimal use of fluoroscopy Size Fr 18 tract Size Fr 18 tract Stone fragmentation: Stone fragmentation: LithoClast ® (using 1 mm probe) LithoClast ® (using 1 mm probe) Stone removal: Stone removal: Mainly by retrograde saline flushing Mainly by retrograde saline flushing

23 Puncture & tract dilatation Puncture & tract dilatation Patient in prone position puncture site in 11th intercostal space 12 th rib 11 th rib

24 Miniaturized endoscope Olympus ® slim compact cystoscope

25 Pressurized irrigation 350mmHg

26 Access to all calyces & ureter

27 MPCNL: the technique

28 Method Patients Patients 16 consecutive cases of staghorn stones 16 consecutive cases of staghorn stones Underwent Chinese MPCNL by one single Surgeon Underwent Chinese MPCNL by one single Surgeon Statistical analysis Statistical analysis Results were retrospectively compared to that of the last 20 cases of traditional PCNL using Fr sheath Results were retrospectively compared to that of the last 20 cases of traditional PCNL using Fr sheath

29 Results – stone characteristics Chinese MPCNL PCNL Stone diameter (cm) Stone area (mm ² ) Type n (%) Borderline 5 (31) 13 (65) Partial 9 (56) 5 (25) Complete 2 (13) 2 (10)

30 Results – operative parameters & outcome Chinese MPCNL PCNL OR time (minutes) Length of stay (day) Stone clearance n (%) Complete 8 (50) 12 (60) Residual 4 mm 2 (12.5) 2 (10) Residual > 4 mm 6 (37.5) 6 (30) Auxiliary treatment 56

31 Results - complications Chinese MPCNL PCNL Complications n (%) Transfusion 1 (6.3) 5 (25) UTI 1 (6.3) 2 (10) Pleural effusion 1 (6.3) 0 TOTAL 3 (18.9) 7 (35)

32 Advantages of Chinese MPCNL Miniaturised endoscope allows good calyceal and ureteric access even with middle calyceal puncture Miniaturised endoscope allows good calyceal and ureteric access even with middle calyceal puncture Middle calyceal puncture at 11th intercostal space avoids risk associated with supra-11th upper pole calyceal puncture Middle calyceal puncture at 11th intercostal space avoids risk associated with supra-11th upper pole calyceal puncture A Fr 18 percutaneous tract minimises trauma with less blood loss A Fr 18 percutaneous tract minimises trauma with less blood loss

33 Conclusion PCNL is a good and valuable method for removal of renal calculi PCNL is a good and valuable method for removal of renal calculi Different techniques of percutaneous renal access, tract dilation and stone fragmentation have been developed Different techniques of percutaneous renal access, tract dilation and stone fragmentation have been developed Mini-perc is an evolving PCNL technique Mini-perc is an evolving PCNL technique An effective treatment option even for staghorn stone An effective treatment option even for staghorn stone Good stone clearance Good stone clearance Good calyceal and ureteric access Good calyceal and ureteric access A safe option A safe option Reducing trauma Reducing trauma Less transfusion requirement Less transfusion requirement

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36 The needle is being advanced with the C-arm at 30 degrees. A, Use of a clamp to reduce radiation exposure to the hands of the urologist. B, The C-arm is rotated back to the vertical position, and the depth of the needle is ascertained.


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