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Year : 2012  |  Volume : 28  |  Issue : 3  |  Page : 367-368
 

Virtual access in percutaneous nephrolithotomy - The "all-seeing needle"


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Date of Web Publication19-Oct-2012

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How to cite this article:
Gupta DK. Virtual access in percutaneous nephrolithotomy - The "all-seeing needle". Indian J Urol 2012;28:367-8

How to cite this URL:
Gupta DK. Virtual access in percutaneous nephrolithotomy - The "all-seeing needle". Indian J Urol [serial online] 2012 [cited 2019 Dec 8];28:367-8. Available from: http://www.indianjurol.com/text.asp?2012/28/3/367/102733

Bader MJ, Gratzke C, Seitz M, Sharma R, Stief CG, Desai M. The ′′All-Seeing Needle′′: Initial Results of an Optical Puncture System Confirming Access in Percutaneous Nephrolithotomy. EurUrol 2011;59:1054-9.



   Summary Top


In percutaneous nephrolithotomy (PCNL) the collecting system is accessed using either fluoroscopic or ultrasonographic control. Although very safe there is still a risk of injury to the colon or pleura because of the blind method of inserting the initial puncture needle. The authors developed a novel instrument-an optical needle puncture system to ensure precise and safe percutaneous access to the collecting system prior to tract dilation. The system consists of a modified three-part needle: A sheath having 1.6 mm outer diameter (4.85-Fr/16-gauge) that is a little larger than the standard (1.3-mm/18-gauge) needle; a hollow inner stylet having a 1.3-mm (3.9-Fr) outer diameter; and a Y piece with an outlet for irrigation system. For irrigation, a manually operated 20-ml syringe or an irrigation pump can be used. The micro-optic with an integrated light lead is inserted either in the outer sheath of the puncture needle or in the hollow inner stylet. The optic length can be adjusted inside the needle sheath with the help of a slide adapter. The optical fiber cord is connected to a light source and camera. The camera and light cables are mounted on a four-joint arm and kept away from the sterile field. The optical assessment was done in terms of image distortion, resolution, angle, and field of view.

The needle was used in 15 patients for percutaneous access. The pelvi-caliceal system was evaluated by ultrasound and then the optical needle system was inserted in the puncture-guide attachment of the ultrasound probe. Once the target calyx was identified, the skin was punctured at the posterior axillary line and the pelvi-caliceal system was entered .During percutaneous access, entry through the subcutaneous tissue, muscle layer, surrounding fatty tissue and into the collecting system was visualized via the video monitor in real time, without the need of fluoroscopy monitor. Once percutaneous access was achieved and the desired calyx and stone identified, the needle stylet was removed and a floppy, J-tipped guide-wire (0.018-inch) was inserted into the needle shaft and appropriately positioned. Thereafter, the needle was removed and the position of the working wire was checked via fluoroscopy. Now the tract was dilated to 30 Fr, using coaxial telescopic dilators, prior to PCNL.

In all 15 cases, visualization of the punctured kidney calyces and confirmation of target calculi was done prior to tract dilation. In four patients, due to suboptimal placement of the needle chances of creating a poor tract were realized; therefore, optical re-puncture was performed. In another three patients, it was not possible to secure the guide-wire in either another calyx or down the ureter due to an unfavorable needle angle while in one patient, the initial puncture failed to hit the target calyx (missed puncture).


   Comments Top


The key requisite to any successful percutaneous procedure is good access by traversing the shortest straight distance from the skin through a papilla of the target calyx into the collecting system. Obtaining optimal renal access is a fundamental step in the learning curve of PCNL and remains a challenging task for many urologists.

Complications may develop immediately from the initial puncture; therefore, establishing an optimal and atraumatic access to the pelvi-caliceal system is the most important initial step in a successful PCNL procedure. [1] PCNL-related complication depends on various factors, including percutaneous access technique, patient status, and stone complexity. Intraoperative and postoperative blood loss is common and of variable severity during PCNL. Intraoperative bleeding frequently results from faulty needle, secondary to parenchyma lacerations during tract dilation, over-advancement of the sheath into the parenchyma, or from stone disintegration. [2],[3] Faulty placement of the needle can also injure the kidney and adjacent organs, compromising the planned percutaneous procedure as well as the outcome. The initial puncture, therefore, should be trans-parenchymal, postero-lateral and along the direction of the infundibulum.

Combined use of ultrasound and optical guidance allows safe identification of the location of the needle and its percutaneous path immediately upon entry. Good control of visually guided puncture and placement of a working wire in a secure position avoids puncture-related complications. As the optical puncture system provides visual confirmation of the three-dimensional caliceal anatomy, it may avoid complications related to poor access.

In conclusion, it seems that the optical puncture system may guides initial access and helps avoid access-related surrounding organ injuries before tract dilatation for percutaneous nephrolithotomy, although it is seen during laparoscopy that an optical trocar does not always result in lesser injuries. Furthermore, a larger number of cases are required to clearly define the role of an optical puncture needle system in the present technique of percutaneous access.

 
   References Top

1.Michel MS, Trojan L, Rassweiler JJ. Complications in percutaneous nephrolithotomy. EurUrol 2007;51:899-906.   Back to cited text no. 1
[PUBMED]    
2.Skolarikos A, de la Rosette J. Prevention and treatment of complications following percutaneous nephrolithotomy. CurrOpinUrol 2008;18:229-34.  Back to cited text no. 2
[PUBMED]    
3.Srivastava A, Singh KJ, Suri A,Dubey D, Kumar A, Kapoor R,et al. Vascular complications after percutaneous nephrolithotomy: Are there any predictive factors? Urology 2005;66:38-40.  Back to cited text no. 3
    




 

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