V6-05: Capsule to Calculus Optical Dissection for Tract Creation During Difficult Percuataneous Nephrolithotomy (PCNL)

Video

Introductions and Objectives
PCNL remains the mainstay modality for large burden kidney stone management. Access to pelvicalyaceal system is the key step for success of PCNL for complete stone clearance and minimal complication. However, many times in cases of impacted stones, staghorn calculi, nondilated pelvicalyceal systems or thin renal cortex, it becomes difficult to establish a tract into the calyx after initial puncture and the procedure may have to be abandoned. In this video we present our technique of intrarenal dissection to salvage difficult cases using standard PCNL instruments.

Methods
We performed this novel technique in 9 patients with staghorn stones or impacted calyceal stones. As per standard PCNL protocol, fluoroscopic guided puncture and guide wire placement into the collecting system is performed, then the tract is dilated with balloon or Amplatz dilators and a sheath is placed. A nephroscope is passed under direct vision and an atraumatic forceps is used to genly dissect the renal capsule and parenchyma until the calyx is entered. Standard PCNL is then performed with stone fragmentation and extraction and placement of a small bore nephrostomy tube when indicated.

Results
We used this novel technique in 9 patients where it was difficult to do standard tract dilatation and successfully established access and a stable tract into the pelvicalyceal system. There were no complications with this technique.

Conclusions
This novel technique of intrarenal dissection for tract/access to pelvicalyeal system is feasible, safe, and effective and does not increase morbidity in patients with impacted stones, staghorn calculi, or nondilated collecting systems.

Funding: None