PCNL- TIPS & TRICKS

What is a perfect punture?

Allows easiest access to stones, lithotripsy and

complete stone clearance

Minimal risk of injury

 Avoids major vessels
 Traverses shortest distance to stones
 Minimize injury to kidneys
Ends on puncture of the
calyx
Along the axis of the
calyx and leads to
infundibulum
Decrease risk of injury to
segmental vessels,
calyceal perforation.
 Obtaining a good puncture

Planning the puncture

Opacification of collecting system
Technique of puncturing
Special situation- Non-opacified or Non-dialeted
system
Securing a good puncture and establishing a working
channel
 Planning a puncture- Imaging

IVU
CT Urogram with 3D reconstruction
Plain CT KUB- in case of renal impairment
CT Abdomen- in previous OSS
 Planning a puncture- Considerations

Posterior calyx
Straight path to calyx with highest stone burden
Dilated calyx

Lower, upper or middle pole?

Needs access to upper ureter?
Single or multiple puncture?
 Posterior Vs Anterior calyx
Identifiable on C-Arm
images
Upper and lower
polar calyces are
complex
Pure anterior and
posterior calyx in mid
pole
Anterior calyx stones
accessed via posterior
calyx
 Axis and distance of puncture
End on puncture with
straight path along the
long axis of the stone
 Dilated calyx
Choose a dilated calyx
Easier to puncture
Easier to access
 Mid pole puncture
Not suitable as a single
puncture procedure
Access to pelvis and PUJ
is compromised
May be as a part of
multiple puncture
procedure
 Single or multiple puncture
Plan earlier
Puncture, dilate,
lithotripsy then another
puncture
1st puncture along the
maximum stone burden
Lower pole to distract
upper pole to more
favorable position- below
11th rib
For stag horn stone
 Single or multiple puncture
Leave sheath in situ,
create another
No limit to number of
tract
Nephrostomy tube for
every tract
Usually stent in view of
complexity of stone
 Opacification of the collecting system
RGP- increases theater
time
But- real time
assessment, induce
HDN, dye to confirm
puncture
 Opacification of the collecting system
Open ended #7
Connected to mixture of
contrast and Methelene
blue
No need for UPJ catheter
 Positioning of patient
Prone on pillow or frame
support
Small foam support
under intended kidney
Arrangement of theater
 Puncture needle
18G two part trocar
needle
22 G Chiba needle for
multiple puncture
 Two plane puncture and dilate
Anterior posterior for
direction
Oblique for depth
End-on puncture
Dilate on oblique- depth
appreciation is essential
 Lower pole puncture in two plane
Needle at 40 degree
against patient
Posterior axillary line
Forceps over tip of
posterior calyx as a target
Mental estimation of
depth of calyx
 Lower pole puncture
Needle traverses skin,
subcutaneous tissue
stopping short of renal
capsule
Cephalo-caudal
movement to confirm
depth
Minor adjustment in
angle
 Lower pole puncture
Confirmation of position
Single decisive push to
pierce renal capsule
Advance into renal
capsule
 Lower pole puncture
Guidewire placed under
guidence
Flexi tip and stiff body
Coil in pelvis
 Upper pole puncture- Bull’s eye
Upper calyx is more
posterior pointing
Cephalic space
restriction
Vertical puncture on
upper calyx
Depth assessed on
C-Arm
 Upper pole puncture
Puncture on expiration
Return of contrast and
blue dye
 What to do after a good puncture?

PCNL is only the first step, but most important

Dilated to #8 or #10 to place 2nd guidewire
Softer 2nd guidewire to pass into ureter
Dilate tract on stiffer guidewire
Dilate under C-Arm guidence to assess depth
 Take-home message

Plan the puncture earlier

Opacify collecting system
2 plane technique for lower pole
Bull’s eye technique for upper pole
Secure puncture well