Difficulties with access in percutaneous renal surgery

Abstract

Percutaneous renal surgery provides a minimally invasive approach to the kidney for stone extraction in a number of different clinical scenarios. Certain clinical cases present inherent challenges to percutaneous access to the kidney. Herein, we present scenarios in which obtaining and/or maintaining percutaneous access is difficult along with techniques to overcome the challenges commonly encountered. Also, complications associated with these challenging percutaneous renal surgeries are discussed.

Keywords: PCNL; angiomyolipoma; calyceal diverticulum; horseshoe kidney; nephrolithotomy; obesity.

Figure 1.

(a) Preoperative CT imaging of nephrolithiasis in the setting of renal AML. (b) CT guided percutaneous access to the renal collecting system in the setting of renal AML.

Figure 2.

Percutaneous management of stones within calyceal diverticula including fulgration of the diverticular lining and dilation of the infundibulum following stone extraction.

Figure 3.

(a) Retrograde pyelogram of a horseshoe kidney with intrarenal calculi. (b) Fluoroscopically guided percutaneous access to a horseshoe kidney via upper pole access.

Figure 4.

(a) Setup for laparoscopically-guided means for percutaneous access to a pelvic kidney. (b) Coaxial retrograde guidance of a wire and ureteral catheter into a desired calyx. (c) Retrograde puncture through the renal parenchyma with a needle-end wire. (d) Percutaneous access to a pelvic kidney obtained by image guidance through the greater sciatic foramen.

Figure 5.

(a) Retrograde pyelogram in a hypermobile kidney to identify the calyx away from the ideal working tract which provides the shortest excursion from the skin. (b) Establishing percutaneous access obtained to the calyx of interest after a council-tipped catheter is passed into the renal collecting system through the shortest excursion tract and outward tension on the catheter provides stabilization of the hypermobile kidney.

Figure 6.

(a) Using the grasping forceps as a tool to withdraw the working sheath in cases of obese patients where the sheath is advanced under the level of the skin or subcutaneous tissues. (b) Technique of using a catheter with a balloon inflated in the renal collecting system to control and withdraw a working sheath advanced under the level of the skin or subcutaneous tissues.

Figure 7.

(a) Challenge with advancement of an access wire in cases of full staghorn calculi because the needle sheath remains outside the collecting system. (b) Advancing the needle sheath to the level of the stone while extracting the needle stylet allows for obtaining successful wire access adjacent to the stone in the collecting system.