Review Articles

Techniques for Fluoroscopic Percutaneous Renal Access

Nicole L. Miller, Brian R. Matlaga and James E. Lingeman*,†
From the Methodist Hospital Institute for Kidney Stone Disease, Indiana University School of Medicine and International Kidney Stone
Institute, Indianapolis, Indiana

Purpose: Percutaneous nephrolithotomy has undergone considerable evolution since its introduction in the 1970s, which has
been driven by advances in access techniques, instrumentation and endoscopic technology. Recent reports suggest an increase
in the number of percutaneous stone treatments being performed. However, despite the increasing use of percutaneous
nephrolithotomy a minority of urologists obtain their own access. We reviewed the techniques for performing safe and
effective percutaneous renal access.
Materials and Methods: A literature search using Entrez PubMed® was performed. All relevant literature concerning
techniques for fluoroscopic percutaneous renal access published within the last 20 years was reviewed.
Results: The success of percutaneous nephrolithotomy is critically dependent on achieving suitable percutaneous access. The
ideal site of percutaneous puncture should be selected to maximize the use of rigid instruments, minimize the risk of
complications and attain stone-free status. Familiarity with basic renal anatomy is essential to obtain access safely.
Adherence to basic principles allows the establishment of percutaneous access in a straightforward and efficient manner.
Certain clinical situations may require special access techniques.
Conclusions: Percutaneous nephrolithotomy is the treatment of choice for complex stone disease. While the efficacy of
percutaneous nephrolithotomy relies on the establishment of effective percutaneous access, there are considerable advan-
tages for the urologist able to achieve access.

Key Words: kidney; kidney calculi; nephrostomy, percutaneous; diverticulum; fluoroscopy

n the 3 decades that have passed since PNL was first We reviewed the techniques of successful PNL access

I described it has evolved into a safe and effective treat-

ment of patients with large or otherwise complex calcu-
lous disease. Morris et al recently reported that PNL has
become an increasingly common intervention for patients
with stone disease.1,2 However, despite the increasing use of
PNL Lee et al reported that a minority of urologists, only
27% of those who were trained in percutaneous access, ac-
tually gain their own access for PNL.3 One of the more
common reasons given by respondents in this study was
inadequate skills in the techniques of access.
The placement of percutaneous access into the intrarenal
collecting system is one of the most critical aspects of PNL.
When done well, the remainder of PNL can be performed in
a straightforward, expeditious manner. However, when
done poorly, PNL can be a struggle with complications be-
coming more frequent. In a recent study Watterson et al
examined access related complications during PNL when
access was obtained by a urologist vs an interventional
radiologist.4 They concluded that, despite similar access dif-
ficulties between the groups, access related complications
were less and stone-free rates were improved during urolo-
gist acquired percutaneous access.
Submitted for publication July 7, 2006.
* Correspondence: 1801 North Senate Blvd., Suite 220, Indianap-
olis, Indiana 46202 (telephone: 317-962-2485; FAX: 317-962-2893;
e-mail: jlingeman@clarian.org).
† Financial interest and/or other relationship with Lumenis, Bos-
ton Scientific, Olympus and Karl Storz.
achieved through more commonly used fluoroscopically
guided approaches. We also examined more specialized ac-
cess methods that may be required for the success of PNL in
special clinical situations. A complete review of the potential
complications of PNL is beyond the intended scope of this
review and complications are not discussed except as they
relate to a specific access technique.
ANATOMICAL CONSIDERATIONS
AND PUNCTURE SITE SELECTION
Familiarity with basic renal anatomy is essential to obtain
access safely. In particular knowledge of the principal renal
vascular structures and their relationships to the renal col-
lecting system can decrease the risk of problematic hemor-
rhagic events. The main renal artery typically divides into
an anterior and a posterior division. The avascular field
between the anterior and posterior divisions, known as
Brodel’s bloodless line, is the ideal point of renal entry.
Because of the orientation of the kidney in the body, entry
through a posterior calix usually traverses this line. A pos-
terior calix is the preferred site of entry since it is usually
easier to negotiate a wire out of the calix and into the ureter
when the site of puncture is through a posterior rather than
an anterior calix (fig. 1). Rarely it may be preferable to
obtain access through an anterior calix. This may be accom-
plished by adhering to the same principles as for a posterior
caliceal approach.
Inadvertent puncture beyond the anterior aspect of the col-
lecting system risks vascular injury to the large anterior seg-

0022-5347/07/1781-0015/0 15 Vol. 178, 15-23, July 2007

THE JOURNAL OF UROLOGY® Printed in U.S.A.
Copyright © 2007 by AMERICAN UROLOGICAL ASSOCIATION DOI:10.1016/j.juro.2007.03.014
16 TECHNIQUES FOR FLUOROSCOPIC PERCUTANEOUS RENAL ACCESS

prone. The stone containing side is slightly elevated on a

foam pad, which is a maneuver that brings the posterior
calices into a more vertical position. The neck of the patient
is placed in a neutral position with a chest roll positioned to
facilitate ventilation. The upper extremity ipsilateral to the
affected kidney is placed at 90-degree flexion and the con-
tralateral upper extremity is tucked at the side to allow the
C-arm to be positioned as close to the patient as possible.

ACCESS TECHNIQUES

While ultrasound and computerized tomography guidance

have been described for percutaneous access,7,8 biplanar
fluoroscopy is the most commonly used imaging method.
FIG. 1. Preferred site for percutaneous access is through posterior
calix. This approach facilitates negotiation of wire out of calix and
Radiographic guidance of needle puncture into the collecting
into ureter, and may decrease risk of vascular injury since access system for antegrade percutaneous access is routinely per-
tract is created along avascular field between anterior and posterior formed using 1 of 2 techniques, including eye of the needle
divisions of renal vasculature, known as Brödel’s bloodless line. and triangulation. There are still some urologists who favor
Reprinted with permission from Lingeman JE, Lifshitz DA and
Evan AP: Surgical management of nephrolithiasis. In: Campbell’s retrograde percutaneous access, especially when the kidney
Urology, 8th ed. Edited by PC Walsh, AB Retik, ED Vaughan Jr and is mobile or malrotated. This involves retrograde placement
AJ Wein. Philadelphia: WB Saunders Co 2002; vol 4, pp 3361–3451. of a ureteral catheter, followed by passage of a sharp wire
through the catheter and out of the desired calix for access.
mental vessels, which is a problematic complication since these Two nephrostomy systems (Hunter-Hawkins and Lawson)
vessels cannot be readily tamponaded with a nephrostomy have been described to achieve retrograde percutaneous ac-
tube or occlusion balloon. Using 3-dimensional endocasts cess.9,10 Despite the feasibility of retrograde percutaneous
Sampaio et al characterized the extent of vascular injury access this technique offers no advantage over antegrade
from percutaneous puncture of the collecting system at var- percutaneous access, which enables more accurate and con-
ious locations.5 Puncture through the infundibulum of the trolled creation of the nephrostomy tract.
upper, middle and lower poles was associated with vascular
injury in 67.6%, 38.4% and 68.2% of kidneys, respectively. Eye of the Needle
Puncture through the fornix proved to be much safer and it As with most percutaneous access techniques, the eye of the
was associated with a venous injury rate of less than 8% and needle technique requires fluoroscopy to monitor and guide
no arterial lesions. Direct puncture into the renal pelvis the procedure. To this end a ureteral catheter is placed and
injured large retropelvic vessels in a third of cases. There- the patient is positioned as described. With the C-arm in the
fore, the preferred point of entry into the collecting system is 30-degree position an 18 gauge diamond tip access needle is
along the axis of the calix, through the papilla. Aligning the positioned, so that the targeted calix, needle tip and needle
access with the infundibulum also allows the most efficient hub are in line with the image intensifier, giving a bull’s-eye
use of a rigid nephroscope and decreases the need to place effect on the monitor (fig. 2). In effect the surgeon is looking
excessive torque on the rigid instruments, which may cause
renal trauma and bleeding. Infundibular puncture should be
avoided if possible, as should direct puncture of the renal
pelvis with its increased risk of vascular injury, potential
prolonged urinary leakage and easy tube dislodgment.
Puncture for renal access should be medial to the poste-
rior axillary line to avoid injury to the colon because the
position of the colon is usually anterior or anterolateral to
the most lateral part of the kidney.6 Medial puncture should
also be avoided because it may traverse the paraspinal mus-
cles increasing postoperative pain. Finally, puncture should
not be performed too close to the rib because it may injure
the intercostal nerve and vessels.

PATIENT POSITIONING

Fluoroscopically guided percutaneous access requires opaci-

fication of the renal collecting system. Most commonly ra-
diographic contrast medium is instilled via cystoscopically
placed ureteral catheters. Cystoscopy may most easily be
performed using rigid instruments and with the patient in a
dorsal lithotomy position. Although it is less convenient, FIG. 2. Eye of needle technique for percutaneous access. Diamond
flexible cystoscopy with the patient supine or prone may also tip 18 gauge access needle is positioned so that target, needle tip
and needle hub are in line with image intensifier. Note character-
be used. Following ureteral catheter placement a Foley cath- istic bull’s-eye radiographic appearance as surgeon looks down nee-
eter is also routinely placed and the patient is positioned dle into targeted calix, hence, term eye of needle.
 TECHNIQUES FOR FLUOROSCOPIC PERCUTANEOUS RENAL ACCESS
down the needle into the targeted calix and, hence, the term
eye of the needle. The needle is advanced in 1 to 2 cm
increments using a hemostat to minimize radiation expo-
sure to the surgeon. Continuous fluoroscopic monitoring is
performed to ensure that the needle maintains the proper
trajectory. Needle depth is ascertained by rotating the C-
arm to a vertical orientation. If the needle is aligned with the
calix in this view, the urologist should be able to aspirate
urine from the collecting system, confirming proper position-
ing.
Triangulation Technique
Biplanar fluoroscopy permits the determination of caliceal
orientation and selection of the optimal calix for entry. The
preferred point of entry into the collecting system is along
the axis of the calix, through the papilla. Aligning the access
with the infundibulum also allows the most efficient use of a
rigid nephroscope and decreases the need for excessive
torque on the rigid instruments, which may cause renal
trauma and bleeding.
After the targeted calix is identified with fluoroscopy
orientation of the line of puncture is performed using a
triangulation technique. The C-arm is moved back and forth
between 2 positions, that is 1 parallel and 1 oblique to the
line of puncture. With the C-arm oriented parallel to the line
of puncture adjustments are made in the mediolateral (left/
right) direction (fig. 3, A). The C-arm is rotated to the oblique
position and adjustments are made in the cephalad/caudad
(up/down) orientation of the line of puncture with care taken
not to alter the mediolateral orientation of the needle (fig. 3,
B). To decrease radiation exposure to the surgeon the C-arm
is angled away from the line of puncture with the image
intensifier angled toward the head of the patient. Mainte-
nance of needle orientation in 1 plane while making adjust-
ments in the other plane is critical for preserving proper
orientation. To facilitate precise puncture the surgeon may
rest 1 forearm on the torso of the patient, thereby stabilizing
the line of puncture and minimizing drift.
After the proper orientation of the line of puncture is
obtained ventilation is suspended in full expiration. Retro-
grade instillation of contrast dye allows collecting system
opacification and distention. An 18 gauge diamond tipped
needle is advanced toward the desired calix in the oblique
position to gauge the depth of puncture. Before the renal
FIG. 3. Triangulation technique for percutaneous access. Fluoroscopic C-arm is moved back and forth between 2 positions, including 1
parallel and 1 oblique to puncture line. A, with C-arm oriented parallel to puncture line adjustments with access needle (arrows) are made
in mediolateral (left/right) direction. Inset, corresponding fluoroscopic image. B, C-arm is rotated to oblique position and adjustments with
access needle are made in cephalad/caudad (up/down) orientation of puncture line with care taken not to alter mediolateral needle
orientation. Inset, corresponding fluoroscopic image.
17
capsule is entered final adjustments are made. Manipulat-
ing the needle after entering the renal parenchyma is dis-
couraged since this may displace the kidney and alter the
position of the targeted calix.
TRACT DILATION
AND ACCESS ESTABLISHMENT
Aspiration of urine verifies proper caliceal puncture. A
0.038-inch hydrophilic nitinol core glidewire is then
passed through the needle and into the collecting system.
While various wires can be used as long as they have an
atraumatic tip, we prefer the nitinol core glidewire for ob-
taining initial access because it is quite maneuverable and
resists kinking. Some operators elect to obtain access using
a 21 gauge puncture needle that accepts a 0.018-inch wire. If
this instrumentation is chosen, transition dilators are nec-
essary to upsize to a larger working wire. We prefer the 18
gauge access needle because it can be torqued, is easily
stabilized and does not require an additional exchange to
place a suitable working wire.
Under fluoroscopic guidance an attempt is made to ad-
vance the glidewire down the ureter. If the wire does not
pass easily into the ureter, it can be coiled in the renal
pelvis. An 8Fr fascial dilator is passed into the calix, fol-
lowed by a 5Fr Cobra tipped angiographic catheter. The
angiographic catheter helps direct the glidewire toward the
UPJ, facilitating placement of the wire down the ureter.
After the glidewire is positioned in the ureter it is exchanged
for a stiffer, polytetrafluoroethylene coated working wire,
such as an Amplatz super-stiff wire. The glidewire should
not be used as a working wire because its lubricious nature
makes it prone to displacement. An 8Fr to 10Fr coaxial
dilating system or dual lumen catheter is then used to place
a second safety wire, usually a 0.035-inch straight removal
core wire. It is imperative to have a safety wire in place
before proceeding with percutaneous tract dilation.
Several methods of tract dilation are available, including
metal telescoping dilators, semirigid Amplatz dilators and
balloon dilators.11–13 Balloon dilators have been reported to
cause significantly less bleeding than sequential dilators14
because the radial force used to spread the renal paren-
chyma is less traumatic than the shearing or cutting action
of sequential Amplatz dilators or metal telescoping dilators.
18 TECHNIQUES FOR FLUOROSCOPIC PERCUTANEOUS RENAL ACCESS
Sequential Amplatz or metal dilators may be useful in the
setting of extensive perirenal fibrosis from previous renal
surgery. However, an X-Force™ N30 nephrostomy balloon
dilation catheter (Bard Urological, Covington, Georgia) was
recently introduced, which can achieve 30 atmospheres.
This may prove advantageous in the presence of flank scar-
ring. Alternatively a 4.5 mm fascial incising needle (Cook
Urological, Spencer, Indiana) can be placed over the working
wire to facilitate balloon dilation.
An Amplatz working sheath is placed following balloon
dilation of the tract to 30Fr. Care should be taken to avoid
over advancement of the sheath because this may cause
bleeding and trauma to the renal parenchyma or collecting
system. An Amplatz sheath is always preferred because it
creates an open, low pressure (below 16 H2O) system,
thereby decreasing the absorption of irrigant into the circu-
lation.15 Further advantages of a working sheath are easy
insertion and removal of the nephroscope, a simple exchange
from rigid to flexible nephroscopy and the ability to grasp or
basket larger stone fragments.
While a percutaneous access tract is usually achieved via
the 2-step process described, the new Pathway™ balloon
expandable percutaneous access sheath (Boston Scientific,
Natick, Massachusetts) allows simultaneous balloon tract
dilation and access sheath placement.16 The potential ben-
efits of this design are decreased operative time and tissue
trauma.17 However, more data are needed to support these
conclusions.
SPECIAL SITUATIONS
Caliceal Diverticulum/Obstructed Calix
PNL is an ideal treatment for caliceal diverticulum because
it allows stone removal and ablation of the diverticular cav-
ity (fig. 4).18 –22 This is particularly true for lower pole di-
verticula and those greater than 1.5 cm.23–25 PNL offers
excellent stone-free rates (93% to 100%) and successful oblit-
eration of the diverticular cavity (76% to 100%) with a single
procedure.19,20,22
A special access technique is warranted when planning
percutaneous treatment of a caliceal diverticulum or a calix
with an obstructed infundibulum containing stone material.
Direct puncture of a caliceal diverticulum can be difficult
when the diverticulum is small and/or located in the upper
pole. Even when the diverticulum is successfully punctured,
FIG. 4. A, scout excretory urogram demonstrates multiple calculi overlying mid portion of left kidney. B, following intravenous contrast
material administration these calculi were identified in left caliceal diverticulum. Special access technique is warranted when planning
percutaneous treatment of caliceal diverticulum or calix with obstructed infundibulum containing stone material.
passing a guidewire through the communication with the
renal collecting system is usually impossible.
The surgical technique used in the percutaneous treat-
ment of caliceal diverticulum and diverticular stones has
varied. Some groups advocate dilation of the diverticular
communication or creation of a neo-infundibulum to theo-
retically improve diverticular drainage and decrease the
risk of stasis.18,19,22,26 –28 Unfortunately these techniques
require prolonged nephrostomy tube drainage across the
infundibulum. Monga et al questioned the need for estab-
lishing communication between the diverticulum and renal
collecting system.21 They performed direct percutaneous
puncture of the diverticulum and fulguration of the diver-
ticular lining without cannulation or dilation of the diver-
ticular infundibulum. Obliteration of the diverticular cavity
was documented in all patients by contrast radiography.
Our preferred technique involves a single stage percuta-
neous approach that obviates placement of a ureteral cath-
eter or entrance into the renal collecting system.29 The pa-
tient is placed prone with the side containing the caliceal
diverticulum elevated 30 degrees. A C-arm fluoroscopy unit
is used to visualize the diverticular calculi and a direct
infracostal puncture is performed in all cases using an 18
gauge diamond tipped needle and the biplanar fluoroscopic
triangulation technique, as described previously. When ac-
cess is achieved, a 0.035-inch J tipped removable core guide-
wire is coiled inside the diverticular cavity. The major ad-
vantage of the removable core J wire is that the flexible distal
end of the wire can be adapted to the size of the diverticulum,
while the wire proximal to the removed core remains rigid
enough to function as the working wire. The lubricious nature
of a hydrophilic wire, such as a glidewire, makes it prone to
dislodgement, which can result in loss of access with manip-
ulation of the wire. With the J wire in place an 8/10Fr
coaxial dilator is passed over the J wire in sequential fash-
ion. The 8Fr dilator is removed and a second 0.035-inch J
tipped removable core wire is curled inside of the diverticu-
lum to be used as a safety wire.
A balloon dilator is passed over the working wire and
dilation of the nephrostomy tract is performed (fig. 5). A
30Fr Amplatz sheath is then advanced over the balloon
dilator using fluoroscopic guidance. Special attention is
given to prevent over advancement of the balloon dilator and
sheath to avoid traumatizing the opposite wall of the diver-
 TECHNIQUES FOR FLUOROSCOPIC PERCUTANEOUS RENAL ACCESS
FIG. 5. Percutaneous access technique for treating stones in caliceal
diverticulum. With initial 0.035-inch J tipped removable core wire
(J wire) in place 8/10Fr coaxial dilator is used to curl second J wire
inside diverticulum to be used as safety wire. Balloon dilator is
passed over working wire and dilation of nephrostomy tract is
performed.
ticulum. The balloon dilator has a tapered distal end that
often precludes placement of the sheath directly into the
diverticular cavity unless the diverticulum is large. A 24.5Fr
rigid offset nephroscope (Richard Wolf, Vernon Hills, Illi-
nois) without the external sheath is placed through the
Amplatz sheath in conjunction with normal saline irriga-
tion. An 11Fr alligator forceps is used to manually dilate the
tract as needed immediately adjacent to the diverticulum.
After the tract is adequately dilated the offset nephroscope
is gently advanced into the diverticular cavity. Careful in-
spection of the urothelium with the rigid nephroscope is
performed in an effort to verify that a true diverticulum
exists rather than a flattened renal papilla associated with
an obstructed calix. Ultrasonic lithotripsy of existing diver-
ticular calculi and fulguration of the diverticulum can then
be performed via the established access.
FIG. 6. KUB shows that supracostal or upper pole percutaneous access is advantageous in certain clinical scenarios. A, large left proximal
ureteral calculus and lower pole renal calculus. Upper pole access allows excellent visualization of UPJ and proximal ureter for stone
removal. B, left upper pole partial staghorn calculus. Supracostal or upper pole access would be beneficial in this case to remove large stone
burden in upper calices.
19
Using this technique Kim et al reported an 85.7% stone-
free rate (18 of 21 renal units).29 All 16 renal units imaged
with excretory urography at 3 months revealed a reduction
in diverticular size and 87.5% showed complete resolution of
the diverticulum. The access technique described for caliceal
diverticulum is easily adapted to treat kidneys in which the
infundibulum of the desired calix of puncture is impassable,
as commonly occurs with staghorn calculi.
Supracostal or Upper Pole
Supracostal or upper pole percutaneous access is necessary
in certain clinical situations (see Appendix). The main ad-
vantage of this access technique is that the line of puncture
directly aligns with the renal axis. For this reason it is
advantageous in cases of coexisting renal calculi and UPJ
obstruction or impacted proximal ureteral calculi because it
allows excellent visualization of the UPJ and proximal ure-
ter for stone removal and/or antegrade endopyelotomy
(fig. 6, A).30 Supracostal or upper pole access may also be
necessary when a large stone burden is located in the upper
calices, such as a complete staghorn calculus, or in the
presence of multiple stone containing lower pole calices (fig.
6, B).31–34 PNL for calculi occurring in a horseshoe kidney is
often best accomplished through upper pole access due to
incomplete ascent of the kidney.
Although the percutaneous technique is similar to that
described for the lower pole, certain aspects of supracostal or
upper pole access are worthy of emphasis. The main risk of
a supracostal puncture is injury to the lung and pleura
because the upper poles of the 2 kidneys lie immediately
anterior to the posterior portion of the 11th and 12th ribs,
and can even be as high as the 10th rib.35 The risk of pleural
injury is greatest during the inspiratory phase of respira-
tion. Therefore, general anesthesia is essential to control
respiratory movements during puncture. For supracostal
access the puncture site should be placed in the upper por-
tion of the intercostal space, just lateral to the paraspinal
muscles, and puncture above the 11th rib should be avoided
when possible (fig. 7). Occasionally the upper pole can be
accessed via a laterally situated tract between the tips of the
11th and 12th ribs or even by an infracostal approach. This
type of intercostal access has been shown to decrease the
risk of pleural injury compared to a vertical supracostal
20 TECHNIQUES FOR FLUOROSCOPIC PERCUTANEOUS RENAL ACCESS

of pleural fluid while the patient is under anesthesia. If

FIG. 7. Landmarks for supracostal access. Puncture site (X) should
be placed in upper portion of intercostal space, just lateral to
paraspinal muscles. Adapted from Kim SC and Lingeman JE: Per-
cutaneous access to the urinary tract. In: Advanced Endourology:
The Complete Clinical Guide. Edited by SY Nakada and MS Pearle.
Totowa, New Jersey: Humana Press 2006; pp 43–59.
puncture but it can limit visualization of the renal pelvis,
lower pole and UPJ.36
The use of an Amplatz working sheath is mandatory in
patients with supracostal access to decrease the risk of
hydrothorax. Pulmonary complications have been reported
in approximately 16% of cases with a need for intervention
in 3% to 4%.32,33,35,37,38 Ogan et al reported the usefulness of
intraoperative fluoroscopy for detecting clinically significant
hydropneumothorax following supracostal access.39 This
technique is advantageous because it allows the aspiration
intraoperative fluoroscopy of the chest is normal, a formal
chest radiograph in the recovery room is recommended only
if the patient is symptomatic. Minor pleural effusions can be
managed conservatively but larger effusions and significant
pneumothorax, which are rare, require placement of a chest
tube.40 Small pigtail type catheters are usually sufficient
because lung injury is rare if puncture is performed in full
expiration and they are more comfortable for the patient
than larger chest tubes.
In the absence of splenomegaly or hepatomegaly injury to
the liver and spleen is extremely rare when the access punc-
ture site is below the 12th rib. However, supracostal access
can be associated with an increased risk of injury to the liver
and spleen, particularly if puncture is performed during the
inspiratory phase of respiration rather than the expiratory
phase or the puncture is above the 11th rib.41,42 To decrease
the risk of liver or spleen injury the skin puncture site
should be located as far medial as possible, adjacent to the
lateral border of the paraspinal muscles.
Supracostal puncture is also associated with increased
postoperative pain.35 This is particularly true when a ne-
phrostomy tube is left through the upper pole tract. In these
cases lower pole nephrostomy drainage via a nondilated
puncture may be advantageous since it permits the benefit
of a supracostal puncture, while minimizing patient discom-
fort from an intercostal nephrostomy tube.43 Tubeless upper
pole access should be reserved for cases in which the surgeon
is confident that all stone material of interest has been
removed.
Nondilated Puncture
The nondilated puncture technique is particularly useful as
an adjunct to standard PNL techniques in certain clinical
scenarios, such as in the presence of an eccentric calix that
is difficult to identify via the established access. In this
situation needle puncture into the desired calix without
tract dilation can be helpful (fig. 8, A). After the desired calix
is punctured an attempt is made to pass a glidewire into the
renal pelvis, where it can serve as a road map to the area of
interest. Alternatively methylene blue, carbon dioxide or
contrast material can be injected through the needle and the
colored stream or gas bubbles may be used to guide a flexible

FIG. 8. Nondilated puncture technique is particularly useful when narrow infundibulum prevents advancement of nephroscope into calix. A,
percutaneous Amplatz sheath is in place. Stone material is present in calix that could not be identified using flexible nephroscopy through
rigid access sheath. Access needle is advanced using stone as target for puncture. B, after access needle is placed into desired calix contrast
medium is instilled through needle to delineate caliceal anatomy. C, flexible nephroscope is guided into desired calix after instillation of
contrast material via access needle that functions as road map for caliceal access and stone removal. Alternatively guidewire could be
negotiated through infundibulum and back loading of flexible nephroscope or ureteroscope over guidewire into desired calix can be
accomplished via push-pull technique.
 TECHNIQUES FOR FLUOROSCOPIC PERCUTANEOUS RENAL ACCESS 21

nephroscope into the desired calix (fig. 8, B and C). Occa-

sionally a narrow infundibulum prevents advancement of
the nephroscope into the calix. In this instance a flexible
ureteroscope or balloon dilation of the infundibulum may
be necessary. Back loading of the flexible nephroscope or
ureteroscope over a guidewire into the desired calix can be
accomplished via a push-pull technique.44 The advantage of
this approach is that a nephrostomy tube is not necessary
afterward.
As mentioned, a nondilated puncture may also be useful
for inserting a small diameter nephrostomy tube into a
lower pole calix in cases of tubeless upper pole or multiple
access. The technique reported by Kim et al involves punc-
ture of the lower pole onto a flexible nephroscope inserted
through the upper pole access and directed into the desired
lower pole calix.43 FIG. 10. Y puncture percutaneous access technique. A, when calculi
are located in calices that are in parallel with or adjacent to calix of
initial puncture that cannot be accessed with flexible nephroscope,
Multiple Access Y puncture technique may be considered. B, after calix of initial
In certain cases multiple access may be required during PNL. puncture is cleared of stone working sheath is retracted outside of
In general multiple access PNL should be considered when a renal capsule and angled toward second targeted calix. Second
calix contains a stone that is larger than 2 cm and cannot be puncture is made through working sheath. Attraction of Y puncture
is that second puncture is created through same skin incision as
approached with a rigid instrument via the primary access, or first puncture, minimizing cosmetic effects of PNL. Reprinted with
if a calix contains stones of any size that cannot be reached permission from Lingeman JE, Lifshitz DA and Evan AP: Surgical
with a flexible instrument via the primary access (fig. 9). In management of nephrolithiasis. In: Campbell’s Urology, 8th ed.
Edited by PC Walsh, AB Retik, ED Vaughan Jr and AJ Wein.
most situations the additional access may be performed during Philadelphia: WB Saunders Co 2002; vol 4, pp 3361–3451.
primary PNL unless the procedure is unduly prolonged or
bleeding is deemed excessive. If calculi are located in calices
that are in parallel with or adjacent to the calix of initial minimizing the cosmetic effects of PNL. Patients with an ex-
puncture, a Y puncture technique, in which the secondary cessively large stone burden or those with complex collecting
puncture angles off of the initial nephrostomy tract, may be system anatomy may harbor a stone following PNL through
considered (fig. 10). After the calix of initial puncture is cleared the initial access track that is inaccessible by a Y puncture
of stone the working sheath is retracted outside of the renal technique. In these situations a more formal multiple access
capsule and angled toward the second targeted calix. The sec- approach is required with a separate skin incision and sepa-
ond puncture is made through the working sheath. One of the rate track, according to techniques described previously for
attractions of the Y puncture is that the second puncture is primary access.
created through the same skin incision as the first puncture,
CONCLUSIONS

PNL is the treatment of choice for complex stone disease.

However, despite the increasing use of PNL a minority of
urologists obtain their own access. Percutaneous access is
the most critical factor in determining the safety and efficacy
of PNL. For this reason and for patient comfort access is best
achieved in the operating room by the urologist or the urol-
ogist working beside a radiologist. There is no major opera-
tion performed by urologists in which the success of the
procedure depends upon another physician and PNL ideally
should be no different. Urologist acquired or directed access
ensures a 1-stage approach and allows the application of the
various access techniques reviewed. Furthermore, recent
data suggest that access related complications are less and
stone-free rates are improved during urologist acquired per-
cutaneous access.

APPENDIX
Indications For Upper Pole Access
FIG. 9. KUB reveals complete left staghorn calculus. Multiple ac-
cess was necessary to render patient stone free with PNL. Stone Staghorn calculi
analysis revealed magnesium ammonium phosphate (struvite) com- Large upper pole stone burden
position. Multiple access PNL should be considered when calix Antegrade endopyelotomy
contains stone that is larger than 2 cm and cannot be approached Large and/or impacted proximal ureteral calculi
Upper pole caliceal diverticulum
with rigid instrument via primary access or calix contains stones of
Complex lower pole calculi
any size that cannot be reached with flexible instrument via pri- Horseshoe kidneys
mary access.
22 TECHNIQUES FOR FLUOROSCOPIC PERCUTANEOUS RENAL ACCESS
Abbreviations and Acronyms
KUB ⫽ plain x-ray of the kidneys, ureters and
bladder
PNL ⫽ percutaneous nephrolithotomy
UPJ ⫽ ureteropelvic junction
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