Tract Dilatation Using Biprong Forceps Under Direct Endoscopic Vision: A Salvage Technique for “Short” Dilatation in Percutaneous Nephrolithotomy

Abstract

Introduction: In some cases, during obtaining access for percutaneous nephrolithotomy (PCNL), working sheath fails to enter the caliceal system. In this video, we present a salvage technique for “short” dilatation of the tract. Materials and Methods: After obtaining access and dilating the tract, at the beginning of nephroscopy, sometimes it is observed that the working sheath did not enter the calix and is placed in the renal parenchyma or even out of the renal capsule (“short” dilatation). In this situation, we use a biprong forceps to dissect and dilate the tract under direct endoscopic vision using nephroscope as described previously by Lezrek et al.1 When the nephroscope reaches the caliceal system, the working sheath is advanced to the calix by twisting over the nephroscope. Results: As long as the guidewire is properly located in the caliceal system, we are able to enter the collecting system using this technique without significant hemorrhage or other complications. Between May 2016 to December 2016, we had 31 patients (17 men and 14 women) with mean age of 46 ± 15 years on whom we used this salvage technique. Mean body mass index was 25 ± 5 kg/m2, 19 (61%) stones were in right side, there was no hydronephrosis in 48%, and 16% were nonopaque stones. In 16%, there was a single caliceal stone, 16% had multiple calixes stones, 29% had a single pelvic stone, and 38% had staghorn stones. Nineteen percent had history of open stone surgery and 9% had history of PCNL. The lower pole calix was accessed in 21 patients (67%) followed by upper pole calix access in 6 patients (19%). Dilatation lasted 6 ± 6 minutes and nephroscopy time was 44 ± 29 minutes. In all cases, we were able to obtain access using this technique. Complication occurred in 10 (32%) patients. Based on Clavien–Dindo classification, grade I occurred in three patients (10%), grade II in six patients (19%), and grade IIIa in one patient (3%). Mean hemoglobin drop was −1.9 ± 1.4 g/dL. Conclusions: This safe, quick, and effective technique could be used in cases with “short” dilatation as a salvage procedure. For example, in case we fail to get the sheath in the calix in the first try, the contrast material may leak out of the collecting system, causing difficulty in confirming the entrance of the sheath in the collecting system using fluoroscopy, especially when managing nonopaque or pelvic stones. Likewise, in diverticular stones sometimes it is not possible to enter the diverticula but we can use a biprong forceps to dilate the parenchyma overlying the stone and place the sheath on the impacted calculi. Moreover, in case the guidewire becomes kinked during the passage of the Amplatz dilator, this technique is also useful. Furthermore, this method helps reduce radiation exposure and avoids significant complications that may be associated with too far dilatation. This is a salvage technique for cases in which standard techniques fail, and may not become a substitution for the standard principles. Putting forward this technique may trigger debates to determine its merits and demerits. Patient Consent: The author has received and archived patient consent for video recording/publication in advance of video recording of the procedure. No competing financial interests exist. Runtime of video: 5 mins