Indian Journal of Urology
: 2015  |  Volume : 31  |  Issue : 4  |  Page : 376--377

Authors' Reply

Gyanendra R. Sharma1, Anshu Sharma2,  
1 Department of Urology, Chitale Clinic Private Limited, Solapur, Maharashtra, India
2 Department of Radiodiagnosis, Chitale Clinic Private Limited, Solapur, Maharashtra, India

Correspondence Address:
Gyanendra R. Sharma
Department of Urology, Chitale Private Limited, 165 D Railway Lines, Solapur - 413 001, Maharashtra

How to cite this article:
Sharma GR, Sharma A. Authors' Reply.Indian J Urol 2015;31:376-377

How to cite this URL:
Sharma GR, Sharma A. Authors' Reply. Indian J Urol [serial online] 2015 [cited 2021 Sep 19 ];31:376-377
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Full Text

Dear Editor,

We appreciate the keen interest taken by the authors of both the letters and are pleased that they have brought out certain questions that may intrigue the readers. We fully agree with Choudhary and Singh in the point that correspondingly opposite angles would be equal and would like to thank them for bringing out the point of vertically opposite and equal angles more lucidly. However, we would like to submit that whether the angle is measured from surgeon's side, that is, from lateral aspect or the angle is measured from the medial aspect and subtracted from 180° (as suggested by the author), it would be the same.

In response to Saifee et al., we wish to clarify the following points. The left kidney was punctured in majority of the cases. All the punctures were made in expiration, where the kidney moves up; also the left kidney is situated higher than the right kidney. Hence, majority of our lower pole punctures were supracostal (supra 12th). Subcostal access is associated with the minimal chance of pleural violation. However, if the entry above the 12th rib provides the best access to the optimal calyx, then the benefit greatly exceeds the risk.[1] Analysis of 16 reports on supracostal access has found the incidence of pleural complications to range from 0% to 18% for supra 12th and 0–100% for supra 11th access.[1] What we wish to focus here is that the risk of pleural complications can be 0%, especially if due precautions are taken.[2]

While talking about the triangulation technique, we presume that the authors are referring to the procedure described by Niles and Smith, which converts a supracostal access into a subcostal one.[3] The technique which we have described to is one where the needle is in alignment with the infundibulum [4] (and not as described by Niles and Smith) and does not decrease the incidence of Supracostal punctures. We agree with them that in the bull's eye technique, there is no need to determine the angle of puncture. We have described a technique which applies to both the bull's eye and the triangulation techniques. As regards appreciating the depth of the puncture in bull's eye technique – Ko et al. have described that the C-arm has to be tilted >10° away from the surgeon to appreciate the depth.[5] If keeping the C-arm at 0° gives an idea of the depth, there is no need to tilt the C-arm in the cephalocaudal direction in the triangulation technique, a maneuver which provides an idea of the depth while the needle is held in the mediolateral orientation.[4]

Appreciation of a "pop" when we enter the pelvicalyceal system needs experience and very often, as the authors mention, adjustment of few mm is required. We believe that this can be minimized by the technique described by us. Percutaneous renal access, for a novice, is associated with a steep learning curve of >60 cases because he has to have a three dimensional picture, mentally, of things that he is seeing two dimensionally on the C-arm.[6] The technique described by us defines three important variables – the site of puncture, the angle of puncture, and the depth of puncture. This would help a novice more than an experienced surgeon and would decrease his learning curve. The position of the kidney changes with respiration, but as mentioned in our article, all measurements were taken in end expiration (easily maintained by the anesthesiologist as all cases were done under general anesthesia) and the position of the kidney was, thus, stationary. We have clearly spelt the limitations of our study in the article.[7]

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