V9-04 DIRECT VISUALIZATION PERCUTANEOUS NEPHROLITHOTOMY WITHOUT FLUOROSCOPY

Abstract

INTRODUCTION AND OBJECTIVES: Percutaneous nephrolithotomy (PCNL) remains a challenging procedure associated with significant potential for patient morbidity. In an attempt to decrease the morbidity of PCNL, we have developed a novel technique employing direct visualization with ureteroscopy to decrease ambiguity associated with fluoroscopy guidance, while eliminating ionizing radiation exposure. In this video, we demonstrate PCNL techniques that obviate the need for fluoroscopy. METHODS: This video demonstrates fluoroless PCNL in a 56 year-old female with large left renal stone burden (>4 cm). The patient was positioned prone and split-leg. Utilizing visual and tactile cues, a super-stiff and standard guidewire were placed from below using a flexible cystoscope. Using flexible ureteroscopy, the ideal calyx for access was selected. Under ultrasound guidance, an access needle was placed into the selected calyx, which was directly visualized on ureteroscopy. With the aid of a stone basket, an access wire was pulled into the ureter to allow for subsequent exchange to a super-stiff guidewire. Under direct visualization with the ureteroscope, the balloon and access sheath were positioned. The ureteroscope was left with the tip occluding the ureteropelvic junction to prevent distal migration of fragments. Stone comminution was accomplished with an ultrasonic lithotripter. Stone-free status was assured intraoperatively using a combination of flexible nephroscopy and ureteroscopy. A nephrostomy tube and multipurpose angled ureteral catheter were placed under direct vision ureteroscopically to conclude the procedure. RESULTS: Operative time was 4 hours 36 minutes. Estimated blood loss was <50 mL. On post-operative day one, a 15 mAs low-dose CT (<1 mSv) demonstrated stone-free status. CONCLUSIONS: This technique combines the methods of many pioneering endourologic surgeons in a unique way to perform PCNL under direct visualization. We believe this technique offers significant promise both by eliminating uncertainties encountered when operating under fluoroscopic guidance and reducing the risk of radiation exposure to patients and operating room staff.