(1)
Surgery, University of Melbourne, Parkville, Victoria, Australia
This chapter lists the equipment that I prefer for PCNL, i.e. what works for me. All manufacturers produce excellent instruments. All personnel, nurses, theatre technicians, surgeons and assistants, must have previous PCNL experience and training.
Medical Personnel
Anaesthetist:
The anaesthetist must be familiar with PCNL. Specific experience is required for positioning the head and airway (prone, face support and protection, renal bolster, airway management).
Patient position: prone, “swimming position” of arms, I.V. line in the forward arm on the side of the stone.
Bairhugger and temperature control.
“TUR syndrome”.
Cessation of respiration in inspiration for needle puncture.
Awareness of potential problems and appreciation of the need to alert the surgeon early, i.e. blood loss, hypotension, hypothermia and “TUR syndrome”.
Awareness of possible pneumothorax with supra costal approaches.
Potential for air embolism with retrograde air injection during the renal puncture.
Nursing:
Experienced PCNL nurses:
PCNL is technical and complex. Endoscopes, lithotrites, guide wires, graspers and nephrostomies are all procedure specific. The theatre nurse must have the ability to anticipate surgical requirements, and have all the equipment tested and functional before the skin puncture is made. The surgeon cannot interrupt a difficult procedure to wait for faulty or unchecked equipment, e.g. sonotrode malfunction.
Theatre technician/orderly:
PCNL requires uninterrupted function of the light source, monitors, suction, sonotrode, pneumatic lithotripter and fluid irrigation. Any breakdown can be critical. Patient positioning and transfer are also critical.
Radiographer:
The radiographer must be familiar with PCNL, placement of the C-arm, collimation or coning, parallax, and have a good rapport and communication with the surgeon. It is important that the surgeon gives precise requests to the radiographer, which they both understand, e.g. “snapshot”, “continuous screen”, “rotate the C-arm on its axis” and so on.
Assistant:
Must understand the principals of radiation, the nature of percutaneous surgery and the critical responsibility of maintaining the guide wire in the kidney. Junior residents should not be allowed to assist at PCNL without previous observation and instruction. Having a guide wire displaced as a result of assistant inexperience is stressful and potentially disastrous.
Surgeon:
The surgeon is entirely dependent on the theatre team. The surgeon cannot control the imaging, set up or maintain the technical equipment. Rapport between the surgeon and the entire theatre team is paramount.
Equipment Requirements
Operation Table
Requirements
Lithotomy and screening.
Eccentric operating table columns to enable the C-arm to be positioned below the patient to screen from the bladder to the kidney.
Arm boards in the “swimming” position.
Patient Positioning
Requirements
Multiple pillows.
Covered sponge triangular renal bolsters and flat pads for the kidney, hips and chest.
“Trauma beanbag” (for spinal cord injury patients and patients with skeletal deformities, e.g. spina bifida).
Patient trolley (to roll the patient on and off the operating table during the transfer from lithotomy).
Imaging
X-ray display box or digital monitor. All preoperative x-ray images must be available and on display before the procedure commences.
The images should be clearly visible to the surgeon for reference during the procedure.
C-ARM
Access requirements
Fig. 2.1
Area to be imaged during radiological screening in lithotomy
Lithotomy
For retrograde catheter, ureteric stone manipulation and insertion of stent if required.
PCNL
Must have free access from the lower chest to the bladder and be able to rotate the C-arm from side to side for parallax II screening during the renal puncture.
Fig. 2.2
Area to be screened for PCNL in the prone position
Access
The surgeon must control the imaging of the upper urinary tract. This requires a 5–6 Fr retrograde ureteric catheter (RGC) inserted cystoscopically to lie within the renal pelvis. If the catheter tip is below the PUJ, it can be very difficult or impossible to image and dilate all the calyces for puncture. The RGC must be fixed to a urethral catheter by adhesive tape to prevent displacement.
Retrograde contrast should be a “50–50” solution of saline and contrast medium with a few drops only of methylene blue. The surgeon requires direct access to the external tip of the RGC to inject contrast, saline with methylene blue, insert guide wires and to establish a “universal guide wire” (UGW).
Hydrophilic or “Slippery” Guide Wires
These are my preference. They do not kink. They can be held atraumatically with artery forceps. They flex, coil and pass easily into the pelvis without trauma and are particularly useful when negotiating ureteric stones. They are essential if using the single-stage dilator because they do not kink. The cystoscopic guide wire can be reused for the renal puncture following the insertion of the retrograde catheter.
“Slippery” wires are more expensive than standard metal guide wires. Due to their springiness and lack of friction, “slippery wires” can “flip out” of the collecting system, especially if put in the hands of an inexperienced assistant!
Artery Forceps
Artery forceps are used to hold guide wires, dilate the lumbodorsal fascia and act as skin markers for the needle puncture. I prefer straight artery forceps because they need to pass parallel to the guide wire when dilating the lumbodorsal fascia.
Retrograde Catheter
I use a 6 Fr gauge open-ended RGC with a Leur lock proximally.
Open-ended catheters are necessary
To pass over a guide wire
For flushing calculi in the ureter
To establish a universal guide wire
Urethral Catheter
16 Fr Foley
Functions
Drain bladder.
Attach and fix retrograde catheter tape. I prefer one-inch waterproof tape, known commercially as “Sleek”. The tape should be “suitably fashioned”, i.e. the ends folded over so that the assistant can detach the tape under the drapes if required, with a “mesentery” to properly fix the ureteric catheter to the urethral catheter.
Fixation of the Ureteric Catheter Prior to Placing the Patient Prone
Fig. 2.3
Urinary catheters and drainage for PCNL
Fig. 2.4
Method of attaching the ureteric catheter to the Foley Catheter so that it can be easily accessed and will not slip during PCNL
Contrast
We use Urograffin 70 % 50 ml mixed with 50 ml 0.9 % saline and 0.5 ml of methylene blue, just enough to give the injected contrast mixture a faint blue tinge. The methylene blue concentration should be just light enough to distinguish aspirated contrast from urine, but not so dark as to confuse the aspirate with blood.
Contrast should not be infused at the time of retrograde catheter insertion when the patient is in lithotomy, except in particular circumstances such as identifying the pelviureteric junction when performing an endoscopic pyeloplasty, when dealing with a radiolucent calculus or to delineate ureteric anatomy, such as with bifid ureter. Retrograde contrast infusion is also indicated where there is a suggestion that there has been a ureteric injury, or the guide wire cannot be manipulated into the kidney. In a routine PCNL for stone, infusion of contrast prior to screening for the renal puncture will mask the location of the stone. Minimum volume extension tubing (140 cm, Pkt 25) is attached to the 6 Fr RGC proximal Leur lock after positioning the patient for the PCNL to enable the surgeon to infuse contrast for the renal puncture. With this arrangement, the surgeon can inject the contrast.
Patient Drape
Once prone, the drape must attach to the patient, be waterproof and have an access window for the puncture and nephrostomy access. We find that craniofacial neurosurgical drapes are ideal, and use the barrier Craniotomy Drape (Ref. 888442) by Molnlycke Health Care.
Bairhugger: Blankets and Drapes
Patients can rapidly develop hypothermia due to convection from the spread of fluid over the body surface, so drapes must be waterproof. Heat reflective “Space Blankets”, plastic sheeting or a second Bairhugger (depending on availability) should be used below the level of the urethral catheter to maintain temperature and dryness over the lower extremities. A warming Bairhugger is preferable for the upper chest, shoulders and arms.
These precautions are particularly critical during paediatric PCNL, where the effects of blood loss and cooling are magnified.
Antibiotics
All patients are given antibiotics with the induction of anaesthesia whether their urine cultures are positive or sterile. Patients with obstructive calculi, particularly those with neurogenic bladders or urinary diversions may be admitted 48 h prior to surgery for nephrostomy and parenteral antibiotics. Our routine prophylaxis is a cephalosporin and aminoglycoside.
DVT: Prophylaxis
Although DVT is uncommon following PCNL, we fit all our patients with below-knee thromboembolism-deterrent stockings prior to PCNL. In high-risk patients, we use Clexane and pneumatic calf compressors.
Scalpel
A sharp-pointed no. 11 or no. 15 scalpel blade is required to make a small stab through the dermis before inserting the PCNL needle.
Guide Wires
We routinely use the Terumo 0.035 inch × 100 cm “slippery” hydrophilic guide wire with a straight floppy tip. These are atraumatic, coil easily in the kidney, readily “find their way” along the ureter and bypass calculi.
However, they are springy and can easily “flip out” of the kidney and can slip through the surgeon’s fingers. We always hold these slippery wires with artery forceps.
Also, as these wires are straight tipped, they may pass through and out of the collecting system during a “through and through” puncture, and may also be difficult to advance between the stone and collecting system where the stone is tightly impacted. In these situations, we use a “J-wire” (where the tip is a half circle). We routinely keep an unopened “J-wire” on the urology trolley. The ‘J-wire’ comes with an introducer (“golf tee”) which straightens the tip so the wire can be introduced into the PCN cannula.
Guide Wires-Types
“Slippery” guide wire
Metal
Straight wire with floppy “J” tip
Super stiff guide wire with floppy tip
Fig. 2.5
Guide wires and the “Golf Tee” introducer
Nephrostomy Track Dilators
Five Varieties
Amplatz serial exchange dilators
Metal telescoping dilators (“car aerial”)
Balloon dilators
Webb single-stage dilator
“Mini Perc” single-stage dilators
Characteristics of Various Dilators
Amplatz Serial Exchange Dilators
Positives
Familiar
Smooth
Flexible
Tapered tip
Often the best dilator in the presence of dense scar tissue
Negatives
Long and cumbersome internal 8 Fr “guide” or “long grey” inner dilator.
Single use.
The entire set has to be opened (expensive) even if only using one dilator.
Bleeding occurs between dilator exchanges.Related posts:
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