Urolithiasis is a common and ever-increasing problem all over the world. During the last few decades, percutaneous nephrolithotomy (PCNL) has become the preferred treatment method for moderate and large volume upper tract urinary calculi. In recent years, there have been groundbreaking advances in the field of percutaneous renal surgery in the form of minimally invasive percutaneous nephrolithotomy. Various techniques have been described over the years in the area, which have improved the results of percutaneous nephrolithotomy surgery while reducing the complication rate and morbidity.
This book provides a broad, state-of-the-art review in the field of minimally-invasive percutaneous nephrolithotomy. It serves as a valuable resource for Urologists, endourology fellows, and researchers interested in mini-percutaneous nephrolithotomy. The book reviews the latest data about percutaneous management of Urolithiasis from the world over, various classification systems for mini-percutaneous nephrolithotomy, armamentarium, different techniques, and multiple advances, plus the results including complications.
This book serves as a valuable resource for urologists dealing with and interested in learning the newer advances in percutaneous renal surgery. It delivers a comprehensive summary of the current status of minimally-invasive percutaneous nephrolithotomy in the management of Urolithiasis. All the chapters have been written by experts in minimally invasive percutaneous nephrolithotomy and present the most recent scientific data.
Author(s): Madhu S. Agrawal, Dilip K. Mishra, Bhaskar Somani
Publisher: Springer
Year: 2022
Language: English
Pages: 328
City: Singapore
Foreword
Foreword
Preface
Editors
Contents
Contributors
Part I: History, Anatomical Principles, and Imaging
1: Anatomy of the Kidney with Respect to Percutaneous Nephrolithotomy
1.1 Introduction
1.2 Renal Number
1.2.1 Clinical Implications for PCNL
1.3 Renal Position
1.3.1 Clinical Implications for PCNL
1.4 Renal Morphology and Spatial Orientation
1.4.1 Clinical Implications for PCNL
1.5 Renal Size
1.5.1 Clinical Implications for PCNL
1.6 Relationships of the Kidney with Neighboring Organs [1]
1.6.1 Posterior Relationships
1.6.2 Clinical Implications for PCNL
1.6.3 Anterior Relationships (Fig. 1.6)
1.6.4 Clinical Implications for PCNL
1.7 Gross and Microscopic Anatomy of the Kidney
1.7.1 Clinical Implications for PCNL
1.8 Renal Arteries
1.8.1 Clinical Implications for PCNL
1.9 Renal Veins
1.9.1 Clinical Implications for PCNL
1.10 Renal Lymphatic Drainage
1.10.1 Clinical Implications for PCNL
1.11 Renal Innervation
1.11.1 Clinical Implications for PCNL
1.12 Pyelocaliceal System of the Kidney
1.12.1 Clinical Implications for PCNL
1.13 Conclusions
References
2: Evolution and Classification of Minimally Invasive PCNL
2.1 History
2.2 In Summary
2.3 Evolution of Minimally Invasive Percutaneous Nephrolithotomy (PNL)
2.3.1 Miniaturization in PNL: A New but Rapidly Evolving Concept
2.4 Currently Available Miniaturized PCNL Techniques
2.4.1 Mini-PCNL
2.4.2 Minimally Invasive PCNL
2.4.3 Ultra-Mini-PCNL
2.4.4 Micro-PCNL
2.4.5 Super-Mini-PCNL and Authors’ Experience
2.5 Classification
References
3: Diagnostic Imaging for Mini Percutaneous Nephrolithotomy
3.1 Introduction
3.2 Introducing the RALARA Principle and Imaging in Nephrolithiasis
3.2.1 Paediatric Nephrolithiasis
3.3 Preoperative Diagnostic Imaging
3.3.1 Stone Characteristics and Renal Anatomy
3.3.1.1 Stone Characteristics
3.3.1.2 Renal Anatomy
3.3.2 Perirenal Organ Mapping
3.3.3 Estimation of Renal Function
3.4 Postoperative Imaging
3.4.1 Evaluation of Complications
3.4.2 Evaluation of Residual Stones
3.5 Summary
References
4: ALARA: How to Reduce Radiation Exposure
4.1 Introduction
4.1.1 Radiation Exposure Amongst Patients
4.1.2 Radiation Exposure Amongst Healthcare Professionals
4.1.3 Radiation Exposure Amongst Urologists
4.1.4 Awareness of ALARA and Radiation Exposure Amongst Urologists
4.2 Applications of Radiation in Urology and its Effective Dose
4.2.1 Diagnostic Modalities
4.2.2 Interventional Modalities
4.2.3 Newer Technology
4.3 Occupational Limits of Radiation Exposure Set by National Organization
4.4 Effects of Increased Radiation Exposure
4.4.1 Deterministic Effects
4.4.2 Stochastic Effects
4.5 Factors Affecting Increased Radiation Exposure Amongst Urologists
4.6 Measures to Reduce Radiation Exposure
4.6.1 ALARA Principles
4.6.2 Use of Protective Shields/Gear for Reducing RE
4.6.2.1 Effect of Shielding on Imaging
4.6.2.2 Protective Gear Equipment
4.6.3 Techniques to Reduce Radiation during Pre-Operative Imaging and Evaluation
4.6.4 Methods to Reduce Radiation during PCNL
4.6.5 Radiation Exposure in Pediatric Age Group and Measures to Reduce the Exposure
4.6.6 Radiation Exposure in Pregnant Women
4.6.7 Ultrasound and Virtual Reality Simulator Training Models
4.6.7.1 Ultrasound-Guided Access and Training
4.6.7.2 Virtual Reality Simulator Training
4.6.8 Clinical Governance and Radiation Safety Culture [105]
4.6.8.1 Clinical Governance [105]
4.6.8.2 Strategies to Improve Radiation Safety Culture [105]
References
Part II: Armamentarium for Mini-PCNL
5: Instrumentation for Mini-PCNL (Access Sheaths, Endoscopes, and Accessories)
5.1 Introduction
5.2 Innovative Sheaths and Mini Endoscopes
5.3 “Peel Away” Sheath
5.4 LahmeNephroscope and Sheath
5.5 Minimally Invasive PCNL
5.6 Endoscopes and Accessories
5.7 Irrigation and Suction Pumps
5.8 Sealants
5.9 Conclusion
References
6: Fragmentation Devices: Lithotripters, Lasers and Other Advances
6.1 Introduction
6.2 Lithotripters
6.2.1 Electro Hydraulic Lithotripters (EHL)
6.2.2 Mechanical or Ballistic Lithotripters
6.2.3 Ultrasonic Lithotripters
6.2.4 New Generation Dual Lithotripters
6.2.5 Cordless Lithotripters
6.3 Lasers
6.3.1 Settings of Laser and Lasing Techniques
6.3.2 Laser Fiber
6.3.3 Newer Advances in Lasers
6.3.3.1 Moses Effect and Moses Technology
6.3.3.2 Thulium Fiber Laser
6.3.4 Laser Vs. Other Modalities for miniPCNL—Head to Head Comparison
6.3.5 Complication and Safety Concerns
6.4 Other Advances
6.5 Conclusions
References
Part III: Anesthesia Considerations and Positioning
7: Anesthesia in Mini-PCNL
7.1 Introduction
7.2 Anesthetic Concerns for Mini-PCNL
7.3 Available Anesthetic Techniques for Mini-PCNL
7.4 Specific Anesthetic Problems Encountered During Mini-PCNL
7.5 Conclusion
References
8: Positioning for MIP (Prone and Supine)
8.1 Introduction
8.2 Classification of Positioning in Mini PCNL
8.2.1 Prone Position
8.2.2 Modification of Prone Positions
8.2.2.1 Reverse Lithotomy
8.2.2.2 Prone Split Leg Position
8.2.2.3 Prone Flex Position
8.2.3 Completely Supine Position
8.2.4 Modifications of Supine Position
8.2.4.1 Double S Position
8.2.4.2 Valdivia Position
8.2.4.3 Galdakao-Modified Valdivia Position
8.2.4.4 Bart’s Position for PCNL
8.2.4.5 Bart’s Flank Free Modified Supine Position
8.2.4.6 Supine Oblique Position
8.2.4.7 Semi Supine Position
8.2.5 Lateral Position
8.2.6 Sitting Position
References
Part IV: Renal Access for Mini-PCNL
9: Fluoroscopic-Guided Access
9.1 Introduction
9.2 Relevant Anatomical Considerations
9.2.1 Location
9.2.2 Vascular Anatomy
9.3 Planning for Fluoroscopic Guided Access
9.3.1 Location of Calculi within Pelvi Calyceal System?
9.3.2 Are Calculi Fixed or Changing Position within PCS?
9.3.3 Pattern of Colonic Gas Shadows
9.3.4 Which Is the Ideal Calyx to Puncture?
9.3.5 Choice of an Alternative Calyx
9.3.6 Stone Migration
9.4 Ureteric Catheterization
9.5 Use of Bolsters
9.6 Placement of Equipments in OR
9.7 How to Place C Arm and Proceed
9.7.1 For PCNL in Prone Position
9.7.2 For PCNL in Supine Position
9.8 What Does Fluoroscopy Show
9.9 Use of Contrast
9.9.1 Dilution of Contrast
9.10 Which Calyx to Puncture: Anterior or Posterior
9.11 Renal Access Techniques
9.11.1 Bull’s Eye Technique
9.11.2 Triangulation Technique
9.11.3 Gradual Descent Technique
9.12 Troubleshooting during Renal Access
9.12.1 Extravasation of Contrast (Figs. 9.82 and 9.83)
9.12.2 Inability to Pass Guide Wire
References
10: USG-guided Puncture in Mini-PCNL
10.1 Introduction
10.2 Principles of Ultrasound for Renal Access
10.3 Technique of Combined Ultrasound-fluoroscopy Guided Access
References
11: Newer Advances in Access
11.1 Integrated Optical System in the Needle
11.2 UroDyna-CT
11.3 iPAD-Assisted PCNL
11.4 Other Radiation-Based Methods
11.5 Polaris Technology
11.6 3D Ultrasonography
11.7 Ureteroscopic Doppler Ultrasonography
11.8 Real-Time Virtual Sonography (RVS)
11.9 SonixGPS
11.10 Electromagnetic Tracking (EMT)
11.11 Robots
11.12 Comparison of New Access Methods and Conclusion
References
12: Access in Supine Position
12.1 Introduction
12.2 Evolution of Percutaneous Renal Access
12.3 Access Guidance Methods
12.4 Position and Technique Description
12.4.1 Choosing the Best Calyx
12.4.2 Choosing the Instruments
12.4.3 Puncture
12.4.4 Dilation
References
13: Simulation-Based Training for Access
13.1 Introduction
13.2 Training for Percutaneous Renal Access
13.3 Available Avenues for Training
13.3.1 Animal Laboratories
13.3.2 Dry Labs
13.3.3 Hybrid Labs
13.4 Simulators Available for Dry Labs
13.4.1 Radiation Free Training Modules
13.4.1.1 Puncture Logic Bench (Fig. 13.1)
13.4.1.2 Rawandale’s Virtual Fluoroscopy Simulator (Fig. 13.2a & b)
13.4.1.3 SimPORTAL C-arm Trainer (CAT) Simulation Model (Fig. 13.3) [7]
13.4.1.4 Ultrasound Compatible PERC Simulator (Fig. 13.4)
13.4.1.5 PERC Mentor™
13.4.1.6 Virtual Reality Simulator (Marion Surgical K181) (Fig. 13.6)
13.4.2 Radiation-based Training Modules
13.4.2.1 PERC Trainer™
13.4.2.2 Vegetable Model (Fig. 13.8)
13.4.2.3 Sponge Trainer (Fig. 13.9) [13]
13.4.2.4 Rawandale’s Fluoroscopy-based Percutaneous Nephrolithotomy Simulator (Fig. 13.10) [6, 14]
13.4.2.5 3-D Printed Kidney Replica Bench (Fig. 13.11) [15–17]
13.4.3 Biological Bench Models for Hybrid Labs (Fig. 13.12)
13.5 Discussion
13.5.1 Simulation and Teaching Curriculum
13.5.2 Future of Simulation
References
Part V: Mini-PCNL Procedure
14: Intrarenal Pressure, Fluid Management, and Hydrodynamic Stone Retrieval in Mini-PCNL
14.1 Introduction
14.2 Adverse Events Due to Increased IRPs
14.2.1 Fluid Backflow and Absorption (Fig. 14.1)
14.2.2 Infections
14.2.3 Kidney Damage
14.2.4 Various Complications
14.2.5 Role of Time
14.2.6 Kidney Injury: The Role of Obstruction, Irrigation Pressure, and Irrigation Volume
14.3 IRPs during Mini-PCNL
14.3.1 IRP Measurement
14.3.2 IRP Values during Different Conditions
14.3.3 IRPs during Mini-PCNL
14.3.4 IRPs in Supine Versus Prone Mini-PCNL
14.4 Clearance of Fragments and Maintaining Low IRPs by Taking Advantage of Different Hydrodynamic Effects
14.4.1 Passive Washout
14.4.2 Active Washout
14.4.3 Ureteral Sheaths and Catheters
14.4.4 Vacuum Cleaner Effect (Fig. 14.3) [68]
14.4.5 Pressure/Suction Connected with the Nephroscope
14.4.6 Stone Clearance in Small and Extrasmall Instruments (Ultraminiperc, Superperc, Super-Mini Perc, MIP S, MIP XS)
References
15: Tract Dilatation, Nephroscopy, Stone Fragmentation, and Retrieval
15.1 Introduction
15.2 Tract Dilatation
15.2.1 Puncture Prerequisites
15.2.2 Metal Telescopic Dilatation (MTD)
15.2.3 Single-step Dilatation (SSD)
15.2.4 Balloon Dilatation (BD)
15.2.5 Fascial Amplatz Dilatation (FAD)
15.2.6 Trouble Shooting
15.3 Nephroscopy
15.4 Stone Fragmentation and Retrieval
References
16: Exit Strategy After PCNL
16.1 Introduction
16.2 Large Tube Versus Small Tube
16.3 Tubeless PCNL
16.3.1 Tubeless PCNL with Ureteric Catheter for Drainage
16.3.2 Tubeless PCNL with DJ Stent on an External String
16.4 Early Nephrostomy Tube Removal
16.5 Impact of Mini and Ultra-mini-PCNL on the Exit Strategy
16.6 Totally Tubeless PCNL
16.7 Adjuncts for Hemostasis and Sealants
16.8 Specific Situations
16.8.1 Bleeding
16.8.2 Perforation of Pelvicalyceal System
16.8.3 Complex and Staghorn Stones
16.8.4 PCNL in Children
16.8.5 PCNL in Patients with Previous Open Surgery
16.8.6 Bilateral Tubeless PCNL
16.8.7 Ambulatory Tubeless PCNL
16.8.8 PCNL in Renal Anomalies
16.8.9 PCNL in Obese Patients
16.9 Summary
References
Part VI: Newer Advances in Mini PCNL
17: Ultra-mini PCNL
17.1 Introduction
17.2 Ultra-mini PCNL
17.3 Synopsis
References
18: Micro-PCNL
18.1 Introduction
18.2 How Microperc Came into Existence
18.3 Concept of Microperc
18.4 Instruments (Fig. 18.1)
18.5 Technique
18.6 Modifications of Microperc
18.7 Outcomes and Need for Conversion [2, 4, 9–18]
18.8 Comparison with Other Techniques
18.8.1 Microperc Versus EWSL
18.8.2 Microperc Versus RIRS
18.8.3 Microperc Versus Miniperc
18.9 Microperc in Pediatric Population
18.10 Where Microperc Stands Today
References
19: Superperc
19.1 Introduction
19.2 Armamentarium
19.2.1 Multihole Ureteral Catheter
19.2.2 Shah Superperc Sheath
19.2.3 Stone Catcher Bottle
19.2.4 Low-Power Suction Machine and a Suction Bottle with a Tap
19.3 Technique
19.3.1 Preparing for Suction
19.4 Advantages [3, 4, 5]:
19.5 Disadvantages and Troubleshooting
19.6 Discussion
19.7 Future
References
20: Super-Mini-PCNL (SMP)
20.1 Introduction
20.2 Armamentarium
20.2.1 Miniaturized Nephroscope
20.2.2 Irrigation-Suction Sheath
20.3 Indications and Contraindications
20.3.1 Indications
20.3.2 Contraindications
20.4 Technique
20.5 Clinical Evidence
20.5.1 A Comparison Between SMP and RIRS in Treating 10–20 mm Lower-Pole Renal Stones
20.5.2 A Comparison Between SMP and Miniperc in Treating Renal Stones Greater than 20 mm
20.5.3 A Comparison Between SMP and SWL in Treating Pediatric Patients with Renal Stones Less than 25 mm
20.6 Summary
References
21: Flexible Mini Nephroscopy
21.1 Introduction
21.2 Flexible Mini Nephroscopy—Indication
21.3 Flexible Mini Nephroscopy—Technique
21.4 RIRS Vs. Flexible Mini Nephroscopy
21.5 Flexible Mini Nephroscopy—Outcomes
21.6 Conclusion
References
22: Endoscopic Combined Intrarenal Surgery (ECIRS)
22.1 Introduction
22.2 Evolution of Mini ECIRS
22.3 Indications
22.4 Armamentarium
22.5 Technical Considerations
22.5.1 Anaesthesia
22.5.2 Positioning
22.5.3 Retrograde Access
22.5.4 Renal Access
22.5.5 Stone Fragmentation and Retrieval
22.5.6 Exit Strategy
22.6 Follow-up
22.7 Complications
22.8 Conclusion
22.9 Future Considerations
References
Part VII: Special Situations
23: Failed Access and Secondary Puncture
23.1 Introduction
23.2 Determinants of Successful Puncture
23.2.1 Surgeon’s Expertise
23.2.2 Standardization and Preoperative Planning
23.3 Puncture Site and Secondary Puncture
23.4 Failed Access
23.4.1 Patient-related Factors
23.4.2 Surgery-related Factors
23.5 Minimizing the Failure: Recommendations from Practice
23.6 Conclusion
References
24: Simultaneous Bilateral Mini PCNL
24.1 Introduction
24.2 Causes of Bilateral Urolithiasis
24.3 Treatment Options for Bilateral Renal Stones
24.4 Evolution of Simultaneous Bilateral mini PCNL
24.5 Bilateral Simultaneous vs Staged PCNL
24.6 Advantages of Bilateral Simultaneous Mini PCNL
24.7 Disadvantages of Bilateral Simultaneous Mini PCNL
24.8 Technical Considerations
24.9 Importance of Case Selection
24.10 Prone vs Supine Position
24.11 Operation Room (OR) Set-up
24.12 Armamentarium for Bilateral Simultaneous Mini PCNL
24.13 Access and Dilatation
24.14 Nephroscopy and Stone Clearance
24.15 Exit Strategy
24.16 Follow-up
24.17 Complications
24.18 Conclusion
References
25: Special Situations Stone with PUJO, Calyceal Diverticulum
25.1 Mini-PCNL in Stone with Calyceal Diverticulum
25.1.1 Work-up
25.1.2 Considerations About Diverticulum
25.1.3 Post-operative Considerations
25.2 Mini-PCNL in Stone with PUJO
25.2.1 Special Considerations
25.2.2 Endopyelotomy Consideration
25.2.3 Intra-operative Considerations
25.2.4 Post-operative Considerations
Suggested Reading
26: PCNL in Complex Situations: Obese Patients and Spinal Deformities, Ectopic, and Pelvic Kidneys
26.1 Introduction
26.2 PCNL in Morbid Obesity
26.2.1 Introduction
26.2.2 Anesthesia Considerations
26.2.3 Positioning
26.2.4 Challenges in the PCNL Technique and their Solutions
26.2.5 Results with PCNL in Obese Patients
26.2.6 Urolithiasis Following Bariatric Surgery
26.2.7 Conclusion
26.3 PCNL in Patients with Pelvic Kidney Disease
26.3.1 Introduction
26.3.2 Issues in Patients with Pelvic Kidney Disease
26.3.3 How to Make a Percutaneous Access in These Patients
26.3.4 How to Prevent Bowel Injury?
26.3.5 Post-op Care and Complications
26.3.6 Literature Review
26.4 PCNL in Patients with Spinal Deformity
26.5 PCNL in Autosomal Dominant Polycystic Kidney Disease
26.5.1 Introduction
26.5.2 Anesthesia and Surgical Consideration
26.5.3 Issues with the Puncture and Dilatation
26.5.4 How to Make the Initial Puncture?
26.5.5 Complications and Post-Op care
26.5.6 Literature Review
26.6 Conclusion
References
27: Horseshoe Kidneys, Polycystic Kidney, and Post-transplant Kidneys
27.1 Introduction
27.2 Upper Tract Urolithiasis in Special Situations
27.2.1 Horseshoe Kidney
27.2.2 Polycystic Kidney
27.2.3 Post-transplant Kidney
27.3 Points to Remember
References
28: Paediatric Mini PCNL
28.1 Introduction
28.2 Pre-operative Considerations
28.3 Set-up and Positioning
28.4 Accessing the Collecting System and Tract Dilatation
28.4.1 Stone Fragmentation and Exit Strategy
28.5 Complications
28.6 Assessment of Stone-free Rate
28.7 Follow-up of Patients
28.8 Current Evidence of Mini PCNL (mPCNL)
28.9 Modifications and Further Considerations
References
Part VIII: Complications and Outcomes
29: Complications in Mini PCNL
29.1 Introduction
29.2 Uniform Reporting of Complications
29.3 Clinical Anatomy
29.4 Complications
29.5 Bleeding
29.6 Renal Collecting System Injury
29.7 Thoracic Complications
29.8 Colon Injury
29.9 Visceral Injuries
29.9.1 Gall Bladder Injury
29.10 Liver and Spleen Injury
29.11 Extrarenal Stone Migration
29.12 Postoperative Persistent Nephrocutaneous Leakage
29.13 Collecting System Obstruction
29.14 Infundibular Stenosis
29.15 Renal Dysfunction
29.16 Equipment Problems, Energy Sources, Tubes, and Renal Trauma
29.17 Systemic Complications
29.17.1 Fluid Overload
29.17.2 Extravasation of Fluid
29.17.3 Air Embolism
29.17.4 Venous Thromboembolism
29.17.4.1 Infection and Urosepsis
29.18 Contrast Reactions
29.19 Radiation Exposure
29.20 Neuromuscular Complications
29.21 Mortality
References
30: Outcomes of Miniaturized PCNL
30.1 Introduction
30.2 Evolution of the Concept
30.3 Does the Tract Size Correlate with Parenchymal Loss?
30.4 Initial Challenges to Miniaturization
30.5 Overcoming the Problems
30.6 Miniaturized Versus Standard PCNL: How Do the Intrarenal Pressures Compare?
30.7 Miniaturized Versus Standard PCNL: How Do the Success and Complications Compare?
30.8 Miniaturized Versus Standard PCNL: Intracorporeal Lithotripsy
30.9 Miniaturized Versus Standard PCNL: Stone Retrieval
30.10 Miniaturized Versus Standard PCNL: How Has the Drainage Post-procedure Changed?
30.11 Miniaturized PCNL Versus Retrograde Intrarenal Surgery: How Do the Success and Complications Compare?
30.12 Conclusions
References
