Summary - Salute per tutti

PRESENTATIONPCNL: Tips and tricksin targeting, puncture and dilation.Antonello De Lisa, Giacomo CaddeoUnità Operativa Complessa di Urologia, Università degli Studi di Cagliari, ItalySummaryGetting an effective and safe percutaneous access is the cornerstone in performing asuccessful and uneventful PCNL. The choice of the puncture site, according to ourexperience, is one of the most important factors that may influence the outcome of theprocedurePreoperative imaging has a preliminary role in choosing the kind of approach but themost important role has to be given to intraoperative retrograde pyelography following occlusionballoon catheter placing. Ultrasound-guided renal puncture as well may show adequateanatomic details of the collecting system if a retrograde dilation is performedWe routinary perform a single subcostal lower pole access. In our opinion, when the skin incisionis located into the four-sided space between 12thrib, spine muscles, iliac crest and posterioraxillary line, the risk of most non-haemorrhagic complications may be reduced. When theneedle is proceeding towards its target, some radiological sign may confirm its correct insertionDilation and operative sheath placing are the last steps of the percutaneous tract creation.Amongst the wide offer of dilating devices, our choice usually goes to the Amplatz fascial dilatorsassociated to the “one-shot” technique and to the balloon hydraulic dilators.KEY WORDS: Percutaneous nephrolithotomy; Pyelography; Ultrasound; Dilation.Submitted 9 May 2009; 30 June 2009Getting an effective and safe percutaneous access is thecornerstone in performing a successful and uneventfulPCNL. The choice of the puncture site, according to ourexperience, is one of the most important factors that mayinfluence the outcome of the procedure and it deals withthe risk of almost major complications: haemorrhagicand non-haemorrhagic ones.When planning such a procedure, preoperative imaginghas a preliminary role in choosing the kind of approach:intravenous urography may give in most cases sufficientdetails in the choice of the percutaneous path. But themost important role has to be given to intraoperative retrogradepyelography following occlusion ballooncatheter placing: this allows to check the spatial configurationof the intrarenal collecting system with the patientlying in the working position and makes the choice ofthe right calyx easier.The “dynamic pyelography” may show in real-time thesubsequent opacification of the different calyces of thelower group, being the anterior one the first to be opacifiedwhen the patient is placed in the prone position.This helps in refining the target of the puncture, that is,in most cases, a posterior calyx. Ultrasound-guided renalpuncture as well may show adequate anatomic details ofthe collecting system if a retrograde dilation is performed.We routinary perform a single subcostal lower poleaccess. In our opinion, when the skin incision is locatedinto the four-sided space between 12thrib, spine muscles,iliac crest and posterior axillary line, the risk ofmost non-haemorrhagic complications may be reduced.On the other hand, one of the critical point that mayreduce the risks of haemorrhage is targeting the apex ofthe papilla.When the needle is proceeding towards its target, someradiological sign may confirm its correct insertion. First,the pouring of contrast dye out of the calyx when it iscompressed by the incoming tip of the needle. When thecollecting system seems to be reached, a dripping of contrastdye, metilene blue or urine out of the needle mayconfirm its right positioning.Actually, the absence of dripping may appear even when32Archivio Italiano di Urologia e Andrologia 2010; 82, 1