Advances in Percutaneous Nephrolithotomy

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Key points

  • Percutaneous nephrolithotomy (PCNL) is increasingly applied to moderate stone burdens, particularly for stones in the lower pole calyces.

  • CT can be used to obtain percutaneous access when intraoperative fluoroscopic access is considered unsafe.

  • Supine PCNL is associated with reduced operative times but has not demonstrated an advantage over traditional prone PCNL.

  • Liberal use of flexible nephroscopy and prone retrograde ureteroscopy can reduce the need for multiple percutaneous accesses.

  • New

Indications

One of the most important factors in selecting the optimal surgical modality for the patient with nephrolithiasis is stone size because size has been shown to strongly influence stone-free rate, need for secondary procedures, and complication rate for some treatment modalities. Historically, PCNL has been the treatment of choice for the management of large and/or complex stones. Indeed, the American Urologic Association (AUA) Guidelines for the Management of Staghorn Calculi states that

Positioning

PCNL has historically been performed with the patient in a prone position. Retrograde placement of a ureteral catheter before PCNL has traditionally been performed with the patient in the dorsal lithotomy position before repositioning the patient prone. The prone split-leg approach was introduced as a modification to prone positioning to increase efficiency and decrease the number of operative interventions required for patients with both upper and lower tract pathology.25 This approach has

Access

The key to a successful percutaneous procedure is well-placed access into the kidney. The percutaneous puncture can be performed under fluoroscopic, ultrasound, MRI, or CT guidance, and it can be obtained from an antegrade or retrograde approach. In 2003, three-quarters of the practicing urologists in the North Central Section of the AUA who responded to a survey reported feeling comfortable performing PCNL, but only 11% of that group routinely obtained percutaneous access without the

Tract dilation

Historically, a variety of methods have been used to dilate the nephrostomy tract, including metal telescoping Alken dilators, sequential Amplatz dilators, and balloon dilation.84 In general, balloon dilation is thought to be quicker than fascial dilation, which requires numerous passes of metal or plastic dilators. Additionally, the numerous passes that are required during dilation with sequential dilators increase the likelihood of wire dislodgement or perforation of the collecting system,

Lithotripsy devices

Successful and efficient PCNL relies heavily on the effectiveness of the lithotripsy device. Ultrasonic lithotripsy has historically constituted the mainstay of stone fragmentation because it effectively fragments most stones and incorporates an efficient suction device for aspiration of fragments. A disadvantage of ultrasonic lithotripsy is its relative inability to effectively fragment and, therefore clear, hard stones, including those with a significant proportion of cystine, calcium oxalate

Postoperative drainage options

The final surgical decision of PCNL is the need for and type of drainage tube. Historically, a large-bore catheter, such as a 24 F Councill catheter, a reentry Malecot catheter, or a nephroureteral stent, was placed at the end of the procedure and left indwelling for several days to provide drainage and tamponade the nephrostomy tract. The advantages of a large-bore catheter include reliable and efficient drainage, maintenance of the tract for a secondary percutaneous procedure, and prevention

Management of residual fragments

The goal of any surgical stone procedure is complete stone removal. Although the single procedure stone-free rate for PCNL is higher than for SWL or URS for comparable sized stones,4, 9 the likelihood of residual fragments after PCNL for large renal calculi is as high as 67%, using strict CT criteria.110 As such, secondary percutaneous procedures to retrieve residual stones and achieve a stone-free state have been encouraged. Likewise, there has been interest in ways to enhance the

Postprocedure imaging

Postoperative imaging after PCNL is aimed at identifying renal and extrarenal complications, such as pleural violation, colonic, splenic or hepatic injury, or urinary extravasation or hemorrhage, and at assessing stone-free status. One of the more common extrarenal complications is the occurrence of hydrothorax associated with pleural transgression during percutaneous access. Historically, many urologists have routinely obtained a chest radiograph in the postanesthesia care unit after PCNL,

Summary

PCNL was developed in an effort to reduce the morbidity and mortality associated with open renal surgery but still represents the most morbid of the minimally invasive surgical modalities for stone removal. However, in recent years, efforts to reduce the morbidity and increase the effectiveness and efficiency of the procedure have brought PCNL closer to SWL and URS as the optimal first-line treatment of a variety of renal and ureteral calculi.

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