Michael Parks, CST, AAS

2. Percutaneous Stone Removal In whom? How to do it? Before During After

3. Lingeman�s Law for the Management of Renal Lithiasis �If the stone problem is simple, do SWL; if the problem isn�t simple, do PNL.�

4. Simple Stone burden <2 cm Normal renal anatomy

5. Complex Stone burden >2cm Staghorn stones Abnormal renal anatomy UPJ obstruction Horseshoe kidney Calyceal diverticulum Lower pole >1cm Cystine, brushite, COM Staghorn kidney stones (staghorn calculi) are commonly associated with struvite kidney stones. What staghorn really means is that the stone that is formed occupies parts of the kidney called the "renal pelvis" and two or more "calyces" and form an "antler-like" stone formation. Seventy-five percent of staghorn stones are of the struvite variety. Ureteropelvic junction (UPJ) obstruction is a blockage in the area that connects the renal pelvis (part of the kidney) to one of the tubes (ureters) that move urine to the bladder. Calyceal diverticulum is a urine-containing cavity within the renal parenchyma, communicating with the collecting system through a narrow channel. Two types are identified: One is related to a minor calyx and usually located in the upper pole Other is connected with the pelvis or a major calyx in the central portion of the kidney. The majority of calyceal diverticulum are small and asymptomatic, and do not require any treatment. Calyceal diverticulua may rarely cause urinary tract infection, renal colic, pyuria, hematuria or hypertension. Mobile calculi and milk of calcium are characteristic findings in calyceal diverticulum. Staghorn kidney stones (staghorn calculi) are commonly associated with struvite kidney stones. What staghorn really means is that the stone that is formed occupies parts of the kidney called the "renal pelvis" and two or more "calyces" and form an "antler-like" stone formation. Seventy-five percent of staghorn stones are of the struvite variety. Ureteropelvic junction (UPJ) obstruction is a blockage in the area that connects the renal pelvis (part of the kidney) to one of the tubes (ureters) that move urine to the bladder. Calyceal diverticulum is a urine-containing cavity within the renal parenchyma, communicating with the collecting system through a narrow channel. Two types are identified: One is related to a minor calyx and usually located in the upper pole Other is connected with the pelvis or a major calyx in the central portion of the kidney. The majority of calyceal diverticulum are small and asymptomatic, and do not require any treatment. Calyceal diverticulua may rarely cause urinary tract infection, renal colic, pyuria, hematuria or hypertension. Mobile calculi and milk of calcium are characteristic findings in calyceal diverticulum.

6. Access by the urologist Glide wires for access Tract dilatation � balloons Improved intracorporeal lithotripsy (pneumatic devices, holmium laser) Flexible nephroscopy Small nephrostomy tubes Advances in PCNL Technique

7. Single stage procedure best done in OR Placement of ureteral catheter C-arm fluoroscopy Precise calyceal puncture Safety wire as far into the urinary tract as possible Amplatz sheath - always Access: General Principles

8. Operating Room Set-up

9. Selection of Renal Access Site

10. Anesthesia Requirements

11. Patient placed in dorsal lithotomy position initially Ureteral catheter placed cystoscopically on side of stone 5F open-ended catheter 7F ureteral occlusion balloon catheter Ureteral Catheter

12. Ureteral Catheter

13. Patient placed in prone position (flank inferior to center post) Arm on stone side rested on arm board (flexed 90�); opposite arm against patient Pressure points padded Patient Positioning

14. Foam wedge placed under patient for 30� elevation Brings posterior calyces into vertical orientation Patient Positioning

15. Accurate Calyceal Access

16. Accurate Calyceal Access

17. Imaging Modalities for Access in OR

18. Imaging Modalities: Triangulation Technique

19. Imaging Modalities: Triangulation Technique

20. Imaging Modalities: Triangulation Technique

21. Imaging Modalities: Triangulation Technique

22. Imaging Modalities: Triangulation Technique

23. Confirming Access

24. Guide Wires

25. Guide Wires

26. Guide Wires

27. Guide Wires

28. Tract Dilation

29. Tract Dilation

30. Tract Dilation

31. Tract Dilation

46. Rigid Power Lithotripsy

48. New instruments are longer and have improved optics Maximize use of rigid scopes and ultrasonic lithotripter Rigid Nephroscopes

50. Same instrument as flexible cystoscope Digital instruments now available Use on every percutaneous procedure best if Amplatz sheath used for access Flexible Nephroscopes

53. Amplatz sheath Pressurize irrigant to 300 mmHg Contrast plus fluoroscopy to assist in orientation, documentation Flexible Nephroscopes: Set Up

60. Improved efficiency and efficacy of PNL: Refinements in percutaneous access techniques Advances in equipment (guide wires, balloon dilation catheter, Nitinol basket) Access by the urologist Conclusions