Percutaneous Access Techniques Research Articles

Percutaneous Nephrolithotomy Success in the Transplant Kidney

Treatment for symptomatic calculi in the transplanted kidney can be problematic. Percutaneous nephrolithotomy has routinely been used but concerns exist about potential injury to adjacent organs using a percutaneous access technique. We report our experience with percutaneous nephrolithotomy in the transplant kidney. A retrospective chart review from 1988 to the present was performed of all cases of a renal transplant and subsequent renal calculi treated with percutaneous nephrolithotomy. We identified 13 patients with a renal transplant who underwent percutaneous nephrolithotomy. Presenting symptoms included renal failure in 46.1% of cases, hematuria in 23.1%, urinary tract infection/pyelonephritis in 23.1%, pain in 15.4%, fever in 7.7% and hydronephrosis in 7.7%. Average calculus size was 1.36 cm (range 0.2 to partial staghorn). A single access tract was used in 12 cases and 2 access tracts were used in 1. Ultrasonic lithotripsy was performed in 10 cases, basket extraction was performed in 3 and the 2 techniques were performed in 1. No intraoperative complications occurred. Nephrostogram 24 hours after the procedure demonstrated no residual fragments in 10 patients (76.9%). Repeat endoscopy was required in 3 patients to achieve subsequent stone-free status. Postoperative complications developed in 3 patients, including sepsis, gastrointestinal bleeding and herpes esophagitis, respectively. Mean followup was 5.3 years (range 0.6 to 9). The single stone recurrence was treated with shock wave lithotripsy. Mean creatinine was stable at 2.0 mg/dl (range 0.9 to 3.9) preoperatively to 1.7 mg/dl (range 0.9 to 2.6) at the last visit (p = 0.311). Percutaneous nephrolithotomy is safe and effective in the transplanted kidney. Minimal postoperative complications were noted and stone-free status was achieved in all cases. At long-term followup there were few stone recurrences with stable graft function after the procedure.

Percutaneous multilevel decompressive laminectomy, foraminotomy, and instrumented fusion for cervical spondylotic radiculopathy and myelopathy: assessment of feasibility and surgical technique

Extensive muscle dissection associated with conventional dorsal approaches to the cervical spine frequently results in local pain, muscle wasting, and temporarily painful and restricted neck movement. The utility of a percutaneous muscle-sparing access technique and specifically modified instrumentation for multilevel posterior cervical decompression and fusion were evaluated. Eleven patients (six men, five woman; mean age 72.8 +/- 6.3 years) presenting with refractory neck pain and progressive multilevel cervical radiculopathy and/or myelopathy due to cervical spondylosis with spinal canal and neural foraminal stenosis underwent multilevel laminectomy, foraminotomy, and subsequent instrumented posterior fusion via bilateral or unilateral percutaneous muscle dilation approaches. A novel cannulated polyaxial instrumentation system was used for unilateral transpedicular/translaminar fixation. Significant reduction of Neck Disability Index and Nurick Scale scores and partial or complete recovery of upper extremity radicular deficits was observed during follow-up (mean 14.6 months). Mean procedural blood loss was 45.5 ml, and mean length of stay in hospital was 5.7 days. Fusion was demonstrated in 10 patients between 12 and 14 months postoperatively. Operative exposure and instrumentation were significantly facilitated by specific modifications of retractor/access port systems, surgical instruments, and implants. Muscle sparing posterior decompression and instrumented fusion constitutes a safe and effective surgical option in a selected subgroup of patients with multilevel cervical spondylotic radiculomyelopathy. Specific modifications in surgical technique, instrumentation, and implants are mandatory for effective achievement of the surgical goals. The use of refined image guidance technology and intraoperative imaging can further improve surgical safety and efficacy.

Efficacy of percutaneous treatment of biliary tract calculi using the holmium:YAG laser

Few Western studies have focused on percutaneous techniques using percutaneous transhepatic choledochoscopy (PTHC) and holmium:yttrium-aluminum-garnet (YAG) laser to ablate biliary calculi in patients unable or unwilling to undergo endoscopic or surgical removal of the calculi. The authors report the efficacy of the holmium:YAG laser in clearing complex biliary calculi using percutaneous access techniques. This study retrospectively reviewed 13 non-Asian patients with complex secondary biliary calculi treated percutaneously using holmium:YAG laser. Percutaneous access was accomplished via left, right, or bilateral hepatic ducts and upsized for passage of a 7-Fr video choledochoscope. Lithotripsy was performed under choledochoscopic vision using a holmium:YAG laser with 200- or 365-microm fibers generating 0.6 to 1.0 joules at 8 to 15 Hz. Patients underwent treatment until stone clearance was confirmed by PTHC. Downsizing and subsequent removal of percutaneous catheters completed the treatment course. Seven men and six women with an average age of 69 years underwent treatment. All the patients had their biliary tract stones cleared successfully. Of the 13 patients, 3 were treated solely as outpatients. The average length of percutaneous access was 108 days. At this writing, one patient still has a catheter in place. The average number of holmium:YAG laser treatments required for stone clearance was 1.6, with no patients requiring more than 3 treatments. Of the 13 patients, 8 underwent a single holmium:YAG laser treatment to clear their calculi. Prior unsuccessful attempts at endoscopic removal of the calculi had been experienced by 7 of the 13 patients. Five patients underwent percutaneous access and subsequent stone removal as their sole therapy for biliary stones. Five patients were cleared of their calculi after percutaneous laser ablation of large stones and percutaneous basket retrieval of the remaining stone fragments. There was one complication of pain requiring admission, and no deaths. The use of PTHC with holmium:YAG laser ablation is safe and efficacious, but requires prolonged biliary access and often multiple procedures to ensure clearance of all calculi.

Vertebroplasty Utilizing Percutaneous Vertebral Body Access (PVBA) Technique for Osteoporotic Vertebral Compression Fractures in the Middle Thoracic Vertebrae

Percutaneous vertebroplasty has been reported to alleviate pain and to prevent further collapse in patients with vertebral compression fractures. Some clinicians, however, have declined to use the procedure by the transpedicular approach in patients with osteoporotic vertebral compression fracture(s) in the middle thoracic vertebrae (from T5 to T8), because the middle thoracic pedicles are smaller and more parasagittally oriented and thus do not readily facilitate needle entry through the pedicle. Percutaneous vertebral body access (PVBA) technique through the posterolateral extrapedicular approach was recently developed to facilitate needle insert to the vertebral body regardless of the size of the pedicles. The posterolateral extrapedicular approach avoids the pedicle and provides direct access to the anterior vertebral body, therefore it can easily gain access to the target area of the fractured vertebrae even in the middle thoracic vertebra while avoiding the spinal canal and pleural space. The purpose of this study is to assess the effectiveness and safety of percutaneous vertebroplasty utilizing posterolateral extrapedicular PVBA technique using polymethylmethacrylate (PMMA) for patients with painful vertebral compression fracture in the middle thoracic vertebrae. Vertebroplasty Utilizing Percutaneous Vertebral Body Access (PVBA) Technique for Osteoporotic Vertebral Compression Fractures in the Middle Thoracic Vertebrae

Acute Pulmonary Edema after Simultaneous Bilateral Percutaneous Nephrolithotomy - A case report -

Percutaneous nephrolithotomy (PCNL) is currently the procedure of choice for the removal of large and complex renal calculi. With recent developments in percutaneous access technique and in equipment for the disintegration of calculi, simultaneous bilateral PCNL has become safe. However the complications include hemorrhage, extravasation and absorption of large volumes of irrigation fluid, fever, infection, colonic perforation and pneumothorax. A 46-year-old, 59 kg, female patient in our care developed acute pulmonary edema after simultaneous bilateral PCNL under general anesthesia. The preoperative chest X-ray was normal. The patient recovered following 36 hours of intensive treatment involving fluid restriction, diuretics, sedation and continuous airway pressure ventilation. (Korean J Anesthesiol 2007; 53: 270～3)

Minimizing Endoscopic Complications in Enteral Access

Percutaneous enteral access techniques are important tools in the armamentarium of the skilled endoscopist. Endoscopic and post-procedural complications of enteral access are not uncommon, and the increasing population of patients requiring long-term feeding tubes places even more emphasis on minimizing them. Most enteral feeding tube complications are minor, but several have the potential to cause significant morbidity and even mortality if not recognized and managed correctly. When complications do arise, early recognition and aggressive management are essential to optimize outcomes. Expertise with the proper patient selection, choice of feeding tube and insertion techniques are critical to minimizing endoscopic complications of percutaneous enteral feeding tubes.

Technical strategies and anatomic considerations for parapedicular access to thoracic and lumbar vertebral bodies

To investigate and illustrate a variation on the traditional percutaneous access to the vertebral body via a parapedicular approach. An effective parapedicular access technique that could safely and reliably guide the needle tip into the center of the vertebral body was developed from cadaver dissection observations for the purpose of clinical use. A total of 102 vertebral compression fractures from T-4 to L-5 were treated via the parapedicular access at our institution between July 2005 and March 2006. There were 72 patients between the ages of 17 and 96 years (mean age: 68.2 years) who underwent treatment. The cadaver dissection revealed a relatively avascular and aneural portion of the vertebral body along the superior margin of the vertebral body-pedicle junction. A total 102 vertebral fractures were treated using the parapedicular access technique without any recognized clinical complications from the needle access or the instrumentation. The thoracic and lumbar vertebral bodies may be safely, reliably, and reproducibly accessed using a percutaneous parapedicular access technique. The technique presented represents a relatively avascular and aneural approach to vertebral body.

V929: Technique of Blind Percutaneous Access. Use of the Chiba Needle to Gain Access in Absence of Retrograde Access

You have accessJournal of UrologyVideo Session, Monday, May 22, 2006, 1:00 - 3:00 pm1 Apr 2006V929: Technique of Blind Percutaneous Access. Use of the Chiba Needle to Gain Access in Absence of Retrograde Access Benjamin R. Lee, Michael C. Ost, and Arthur D. Smith Benjamin R. LeeBenjamin R. Lee More articles by this author , Michael C. OstMichael C. Ost More articles by this author , and Arthur D. SmithArthur D. Smith More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(18)33940-5AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "V929: Technique of Blind Percutaneous Access. Use of the Chiba Needle to Gain Access in Absence of Retrograde Access." The Journal of Urology, 175(4S), p. 301 © 2016 by American Urological AssociationFiguresReferencesRelatedDetails Volume 175Issue 4SApril 2006Page: 301 Advertisement Copyright & Permissions© 2016 by American Urological AssociationMetricsAuthor Information Benjamin R. Lee More articles by this author Michael C. Ost More articles by this author Arthur D. Smith More articles by this author Expand All Advertisement PDF DownloadLoading ...

A NEW APPROACH TO UROLOGY TRAINING:: A LABORATORY MODEL FOR PERCUTANEOUS NEPHROLITHOTOMY

The efficacy of traditional operating room based training of urology residents is being reevaluated. The development of hands-on laboratory practicums to facilitate the acquisition of skills by surgical residents lessens learning curves and hastens familiarity with tissue and instrument handling. We describe an innovative model for simulated percutaneous renal access and nephrolithotomy. Porcine kidneys pre-implanted with artificial stone material were placed within intact chicken carcasses as a model for percutaneous nephrolithotomy. Urology residents were taught needle access, tract dilation and renal access sheath insertion using fluoroscopy. Training in percutaneous nephrolithotomy with the nephroscope, graspers and stone fragmentation methods followed. This simple, cost-effective model closely simulates percutaneous nephrolithotomy. Anonymous evaluations submitted by training session participants revealed a high degree of satisfaction with model effectiveness in the application of percutaneous renal access and nephrolithotomy techniques. Our percutaneous nephrolithotomy laboratory model is an effective means of skills acquisition for a complex endourological procedure. Patient care can safely be of secondary importance with respect to trainee experience in a low stress environment that provides an opportunity for supervised, repetitive performance of essential technical skills. We describe an effective percutaneous renal access and nephrolithotomy surgical training model of original design.

Use of a centrifugal vortex blood pump and heparin-bonded circuit for extracorporeal rewarming of severe hypothermia in acutely injured and coagulopathic patients.

Standard rewarming methods for posttraumatic hypothermia are ineffective or require systemic heparinization. Centrifugal vortex blood pumps (CVBPs), heparin-bonded circuits, and, potentially, percutaneous access techniques, facilitate the institution of an extracorporeal circulation by noncardiac surgeons. Seven severely hypothermic patients requiring emergent operative intervention were rewarmed intraoperatively using the CVBP with heparin-bonded circuitry. Patients were critically ill (average Injury Severity Score of 43.5 [SD, 13.6] for the traumatized patients). The mean temperature before rewarming was 31.5 degrees C (SD, 1.6 degrees C). The CVBP outflow site was the common femoral vein in all patients, with the inflow into the superficial femoral artery (n = 2), contralateral common femoral vein (n = 2), and internal jugular vein (n = 3). The mean time to rewarm to 37 degrees C was 73.3 (SD, 30.5) minutes. All patients survived the initial operation, although the ultimate survival was 43%. Noncardiac surgeons can effectively use an extracorporeal rewarming strategy incorporating a heparin-bonded CVBP to rapidly rewarm hypothermic coagulopathic patients undergoing surgery.

Percutaneous retrograde tibial access in limb salvage.

To describe a novel technique for percutaneous retrograde access of the tibial vessels after antegrade access failure in patients with chronic limb-threatening ischemia. Six patients who had failed antegrade access to infrapopliteal occlusions had attempted retrograde tibial puncture and wire passage into the proximally patent vessel. Endovascular intervention was carried out utilizing standard techniques. The patients were followed for functional class and wound healing. All six patients were successfully recanalized. Five patients experienced rapid and dramatic healing of wounds that had previously been refractory to conservative therapy. The other patient did not experience healing and ultimately died of progressive intractable congestive heart failure in the setting of a severe ischemic cardiomyopathy. Retrograde tibial access can be a valuable technique in the armamentarium of a peripheral interventionist treating patients with chronic critical limb ischemia.

Mini-access for retroperitoneal laparoscopy.

The purpose of this study was to establish the feasibility of primary mini-access to the retroperitoneal space to perform certain retroperitoneoscopic procedures in which an enlarged port is not required for extraction of the specimen. Mini-laparoscopy or needlescopic laparoscopy has been performed in the past via the transperitoneal route, but this has not yet been reported for a retroperitoneoscopic procedure. Through a 5-mm primary access and 3- or 5-mm secondary ports, retroperitoneoscopic surgery was performed in seven adults for ureterolithotomy, renal biopsy, simple nephrectomy, nephropexy, cyst decortication, or drainage of a subphrenic abscess. The access technique used was a mini-version of a previously described percutaneous access technique with some modifications. The retroperitoneoscopic procedure was successful in all seven patients, and no complications developed. The operative time, blood loss, analgesic intake, and length of hospital stay were comparable with those of a standard retroperitoneoscopic procedure. However, the cosmetic results were better. Mini-retroperitoneoscopy is feasible and is a better alternative for patients in whom the whole procedure can be performed through 5-mm or smaller ports.

Blind percutaneous renal access.

We describe a technique of blind percutaneous renal access when retrograde/intravenous imaging is not possible. We present the surgical technique, the patient population, and situations in which the technique is used. Following a review of 40 accesses, we concluded that this technique is safe, simple, and effective. It also allows the urologist to act autonomously in obtaining renal access.

Measurement of needle-tip bioimpedance to facilitate percutaneous access of the urinary and biliary systems: first assessment of an experimental system.

Percutaneous access to the renal collecting system or biliary system is most frequently performed under image guidance. However, current techniques lack a feedback mechanism to help confirm successful access. A percutaneous needle system has been developed consisting of a modified 18-gauge percutaneous access needle that measures tissue impedance at its needle tip. Initial results in utilizing this novel system to determine successful access into dilated kidney and gall bladder specimens are reported. Impedance measurements were recorded as the needle was precisely advanced through ex vivo kidney and liver/gall bladder specimens. In an anesthetized porcine model, impedance values were recorded with laparoscopic visualization as the needle was advanced percutaneously through abdominal wall, liver, and into gall bladder. A characteristic, reproducible drop in impedance was noted with successful entry into ex vivo distended kidney and gall bladder specimens. This feature was also noted during in vivo percutaneous cholecystostomy. A measurable, characteristic drop in tissue impedance signifies successful entry into the urinary and biliary systems. This impedance needle system may facilitate current percutaneous access techniques.

Potentially lethal complications of central venous catheter placement

Background: Placement of central venous catheters, although often considered to be a relatively safe and “junior”-level procedure, may be associated with life-threatening complications. Methods: A recent surgical death associated with placement of a central venous catheter at this Institution led to submission of a questionnaire to pediatric surgeons referenced through the American Pediatric Surgical Association directory regarding knowledge of similar incidents and information regarding catheter placement—related complications. Results: Results to this response, although anecdotal, provided data regarding complications of an acute nature, which fell into the categories of pneumothorax, hydrothorax, cardiac tamponade, and hemothorax. Of 10 children with cardiac tamponade, 7 were infants, and most complications were associated with needle stick for access, with symptoms developing within minutes up to 12 hours after the procedure. Drainage of the tamponade was performed by aspiration alone in 3 cases; surgical drainage in 6 children resulted in survival in 9 of the 10 patients. Hemothorax was described in 19 patients and appeared to be more common in children in the 1- to 6-year age group, usually associated with percutaneous access techniques. Thoracotomy for hemothorax was performed in 16 children with 11 survivors. Vascular injury to subclavian artery, vein, or superior vena caval were noted in most at operation. Conclusions: Although data included in this review are entirely anecdotal and not subject to scientific scrutiny or analysis, certain conclusions appear evident. Inherent risks of central venous catheters are intrinsic and should be discussed with the family in obtaining preoperative consent, including life-threatening risks that may necessitate urgent surgical intervention (by thoracotomy or other means). Certain technical aspects of the procedure should be rigidly followed with an experienced surgeon in attendance throughout the procedure. Rapid evaluation should be performed for any unexplained problems that occur in the operating theatre or during the early postoperative period. J Pediatr Surg 35:709-713. Copyright © 2000 by W.B. Saunders Company.

Percutaneous nephrolithotomy in infants and preschool age children: experience with a new technique

Objectives. To develop a less invasive method for performing percutaneous nephrolithotomy (PCNL) with the intent of decreasing the morbidity of the procedure in young children. Methods. A novel percutaneous renal access technique (“mini-perc”) was developed using an 11F peel-away vascular access sheath. Tract dilation and insertion of the sheath into the collecting system was performed with a single pass over an access wire. PCNL was performed using pediatric instruments and electrohydraulic lithotripsy. Sheath design improvements were implemented that make it specific for pediatric PCNL. Results. Eleven procedures have been performed with the 11F sheath. Patient age ranged from 2 to 6 years (mean 3.4) and weight from 5 to 24 kg (mean 12.5). The average stone burden was 1.2 cm 2. Mean procedure time, estimated blood loss, and length of hospitalization were 203 minutes, 25 mL, and 6 days, respectively. Six (85%) of 7 patients are currently stone free with an average follow-up of 12 weeks. No patient required transfusion, developed urosepsis, or had a procedure-related complication. One procedure was performed in an outpatient setting with no postoperative nephrostomy tube. Conclusions. The 11F “mini-perc” technique was successful in rendering 85% of patients stone free with minimal morbidity. Its advantages over obtaining access with standard 24 to 34F access sheaths include a smaller skin incision, single-step dilation and sheath placement, good working access for pediatric instruments, variable length, and lower cost. In addition, the hypothesized decrease in renal and body wall trauma may result in less pain, reduced severity or risk of complications, and shorter hospital stays including the possibility of performing “tubeless” outpatient PCNLs. Further study is needed to confirm these possibilities.

Percutaneous transhepatic cholelithotripsy for difficult common bile duct stones.

A study was carried out to assess the feasibility of a new rapid technique for percutaneous transhepatic access to the biliary tract with endoscopic lithotripsy (percutaneous transhepatic cholelithotripsy). 14 patients with biliary stones resistant to endoscopic retrograde cholangiography and extracorporeal shock wave lithotripsy underwent cholelithotripsy, utilizing a new dilation kit with massive teflon dilators covered by "peel-away sheets". Successful lithotripsy was performed in all patients by laser lithotripsy through a choledochoscope or ureteroscope in ten patients and by stone removal by basket in the remaining four patients. The procedure was carried out using local anesthesia in the last 11 patients. Except for two patients with transient cholangitis, no complications occurred. Difficult bile duct and intrahepatic stones can be treated successfully with a simple percutaneous transhepatic cholelithotripsy procedure including local anesthesia, dilation and stone clearance.

Video-assisted percutaneous cystoscopy of the bladder and prostatic urethra in the dog: new approach for visual laser ablation of the prostate.

A new minimally invasive approach for video laparoscopy was developed to access the bladder and prostatic urethra of the dog in order to perform laser ablation of the prostate without using either an open laparotomy or urethrostomy. During general anesthesia, a 10-mm laparoscope was introduced into the peritoneal cavity. Under direct vision, the bladder was distended, and trocars were placed percutaneously by two different methods. A 22F cystoscope was introduced through the transcystic trocar into the prostatic urethra for visual laser ablation of the prostate (VLAP). In all eight dogs, the video-assisted technique for percutaneous access to the prostatic urethra was successful. No complications were associated with placement of the Veress needle, creation of the pneumoperitoneum, or accessing of the bladder lumen and proximal urethra. The visibility in the peritoneal cavity was excellent, and hemorrhage was minimal in all cases. In two dogs, a laparotomy was performed after displacement of the cystoscope from the urinary bladder. Irrigation fluid for the cystoscope drained primarily around the trocar cuff surrounding the instrument. In one case, the irrigation fluid drained around the trocar in the bladder and filled the peritoneal cavity.

Percutaneous suprapubic cystostomy.

Suprapubic urinary diversion for the management of lesions of the bladder outlet or urethra has been facilitated by the advent of percutaneous access techniques. Prior to percutaneous endourologic techniques, an open surgical approach was necessary when the transurethral route was impassable. A variety of percutaneous suprapubic cystostomy techniques have evolved in recent years. These have been based on several different access principles and offer the urologist a number of options. Selection of an individual technique is usually a matter of preference and familiarity with a particular manufacturer's product. The list of indications for such an approach is diverse and continues to expand.

Percutaneous Nephrolithotomy for Calculi in Horseshoe Kidneys

Between 1983 and 1988, 15 patients (18 kidneys) underwent percutaneous nephrolithotomy at this unit for calculi in horseshoe kidneys. A standard 1-stage percutaneous access technique with minor modifications was used. In situ disintegration with ultrasound or electrohydraulic lithotripsy was necessary in 15 moieties (83.3%) and nephrostomy drainage was required in 12 (66.7%). Percutaneous access was not a problem and there were minimal perioperative problems. Blood transfusion was required postoperatively in 2 patients. A total of 14 kidneys (77.8%) were rendered free of stone with percutaneous nephrolithotomy alone and 2 kidneys were left with asymptomatic stone fragments of 2mm. or less. Another 2 kidneys became free of stone after extracorporeal shock wave lithotripsy, thus giving an over-all stone clearance rate of 88.8%. We conclude that percutaneous nephrolithotomy is an acceptable treatment for stones in horseshoe kidneys and it is the treatment of choice for patients in whom imaging is difficult or impossible