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LETTERS TO EDITOR
Year : 2015  |  Volume : 31  |  Issue : 4  |  Page : 374-375
 

Re: Sharma G, Sharma A. Determining the angle and depth of puncture for fluoroscopy-guided percutaneous renal access in the prone position. Indian J Urol 2015;31:38-41


Department of Urology and Renal Transplantation, Smt. Gulabben Rasiklal Doshi and Smt. Kamlaben Mafatlal Mehta Institute of Kidney Diseases and Research Centre, Dr. HL Trivedi Institute of Transplantation Sciences, Ahmedabad, Gujarat, India

Date of Web Publication1-Oct-2015

Correspondence Address:
Yusuf Saifee
Department of Urology, Institute of Kidney Diseases and Research Centre, Dr. HL Trivedi Institute of Transplantation Sciences (IKDRC-ITS), Room No. 106, Civil Hospital Campus, Asarwa, Ahmedabad - 380 016, Gujarat
India
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Source of Support: None, Conflict of Interest: None


PMID: 26604456

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How to cite this article:
Saifee Y, Nagarajan R, Pal BC, Modi P. Re: Sharma G, Sharma A. Determining the angle and depth of puncture for fluoroscopy-guided percutaneous renal access in the prone position. Indian J Urol 2015;31:38-41. Indian J Urol 2015;31:374-5

How to cite this URL:
Saifee Y, Nagarajan R, Pal BC, Modi P. Re: Sharma G, Sharma A. Determining the angle and depth of puncture for fluoroscopy-guided percutaneous renal access in the prone position. Indian J Urol 2015;31:38-41. Indian J Urol [serial online] 2015 [cited 2019 Sep 21];31:374-5. Available from: http://www.indianjurol.com/text.asp?2015/31/4/374/166479




Dear Editor,

We read with great interest the recently published article by Sharma etal.[1] The authors state that estimating the angle and depth of puncture by the technique described,helps in achieving proper access with minimal difficulty, with reduced fluoroscopy times and minimal movements of the C-arm, even using the triangulation technique. We have some comments regarding thetechnique and results reported.

The study described 42patients who underwent percutaneous nephrolithotomy. The approach was supracostal in half of these, including the supra 11thrib approach in seven patients. Use of a supracostal access in 50% of cases appears high in such a small series, considering most of the punctures were in the lower calyx(24) and only 7 were upper pole punctures. It also appears unnecessary if the triangulation technique was used, since this is known to be the preferred technique to avoid supracostal punctures.[2] Although the authors found no complications even with the supra 11thapproach, our experience andexisting literature [3],[4],[5] suggests otherwise. Besides, the need of supra11thapproach is rarely needed even for complex stones.[6]

As described by the authors, in the "Bull's-eye" technique, the needle is advanced straight in, while checking with fluoroscopy(30°) and adjusting the angle of the needle as needed to maintain the "bull's-eye" appearance. Typically a "pop" can be felt when the pelvicalyceal system is punctured, after which the C-arm is rotated back(90°)to confirmanterior-posterior position(depth). Minor adjustments of a few millimeters, if required, can be done at this stage by advancing or withdrawing the needle to get the tip of needle into the desired calyx.Aspiration of urine confirms entry.[7]

Practically speaking, therefore, in the "bull's-eye" technique,there is no need to determine angle withprotractorand then calculating depth of puncture using the Law of Sines. Additionally, in the triangulation technique, estimating depth is not required at all, asthe depth of advancement is monitored continuously with the C-arm in the anteroposterior position(90°).[7]

Although this concept seems interesting mathematically, but practically calculating the angle and depth(even with Google play app) may add to overall operative times and relying on law of sines for depth estimation may be confusing and mislead the novice surgeons considering the fact thatthere is always some movement of kidneyduring puncture-either medial displacement of kidney by needle itself or displacement of kidney with respiration.

Finally, claiming better accuracy and no complications with this technique(even with the supra 11thrib approach) might be a reflection of the authors' own extensive experience with percutanous access, rather than due to the novel technique itself.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
SharmaG, SharmaA. Determining the angle and depth of puncture for fluoroscopy-guided percutaneous renal access in the prone position. Indian J Urol 2015;31:38-41  Back to cited text no. 1
    
2.
LiatsikosEN, KapoorR, LeeB, JabbourM, BarbaliasG, SmithAD. "Angular percutaneous renal access". Multiple tracts through a single incision for staghorn calculous treatment in a single session. Eur Urol 2005;48:832-7.  Back to cited text no. 2
    
3.
MunverR, DelvecchioFC, NewmanGE, PremingerGM. Critical analysis of supracostal access for percutaneous renal surgery. JUrol 2001;166:1242-6.  Back to cited text no. 3
    
4.
LojanapiwatB, PrasopsukS. Upper-pole access for percutaneous nephrolithotomy: Comparison of supracostal and infracostal approaches. JEndourol 2006;20:491-4.  Back to cited text no. 4
    
5.
LallasCD, DelvecchioFC, EvansBR, SilversteinAD, PremingerGM, AugeBK. Management of nephropleural fistula after supracostal percutaneous nephrolithotomy. Urology 2004;64:241-5.  Back to cited text no. 5
    
6.
YadavR, AronM, GuptaNP, HemalAK, SethA, KollaSB. Safety of supracostal punctures for percutaneous renal surgery. Int J Urol 2006;13:1267-70.  Back to cited text no. 6
    
7.
MillerNL, MatlagaBR, LingemanJE. Techniques for fluoroscopic percutaneous renal access. JUrol 2007;178:15-23.  Back to cited text no. 7
    




 

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