V11-05: RENAL CALYCEAL DIVERTICULUM WITH STONES - SINGLE-STAGE PERCUTANEOUS APPROACH
In this video, we demonstrate single-stage percutaneous approach to a calyceal diverticulum (CD) with stones.
Video of surgical technique accompanied by slides and voiceover explanation of the steps
A hemostat and then an 18G diamond-tipped needle are used to line up to the target stone. If the stone is visible on KUB, a ureteral catheter is not required. An infracostal puncture is preferred to reduce the risk of lung injury even if the CD is located in the upper pole. The needle is advanced into the CD. A 0.035-inch J-tipped movable core wire is advanced through the needle and carefully coiled, avoiding back wall perforation with the stiffer portion of the wire. Guidewire control is essential - utmost attention must be paid to keeping the guidewire secure when passing dilators to prevent loss of access. An 8/10 French coaxial dilator is passed over the J-wire and a second J wire is coiled inside the diverticulum as a safety wire. The tract is balloon dilated over the working wire. Advancing the dilator too far into the diverticulum can cause posterior wall perforation and bleeding and should be avoided. A 30F Amplatz sheath is passed over the balloon dilator. In a small diverticulum, we only place the tip of the balloon dilator into the diverticular cavity with the access sheath remaining just outside._x000D_ _x000D_ A rigid nephroscope is advanced and 11F alligator forceps are used to manually dilate the remaining tract until the diverticular cavity is visualized. Grasping forceps or a lithotripter are used to remove the stone. After removal of all stone material, the cavity is inspected for presence of a flattened renal papilla. Papilla presence would indicate an obstructed hydrocalyx rather than a calyceal diverticulum. The diverticular cavity is fulgurated with a resectoscope and a rollerball electrode using 1.5% glycine irrigant. Low energy electrocautery settings are used - 20 W coagulation and 0W cut. An 18F red rubber catheter is placed in the cavity with position confirmed on fluoroscopy. The catheter is removed on post-operative day 1 if drainage is minimal. _x000D_
This single-stage technique allows quick and effective treatment of calyceal diverticulum stones.