pcnl a global perspective dr cw wong division of urology department of surgery pamela youde...
Post on 29-Mar-2015
227 Views
Preview:
TRANSCRIPT
PCNLPCNLA Global PerspectiveA Global Perspective
Dr CW WongDr CW WongDivision of UrologyDivision of Urology
Department of SurgeryDepartment of SurgeryPamela Youde Nethersole Eastern HospitalPamela Youde Nethersole Eastern Hospital
Introduction and historyIntroduction and history PCNL: what is it?PCNL: what is it? IndicationsIndications Imaging modalities for percutaneous accessImaging modalities for percutaneous access Dilatation of the nephrostomy tractDilatation of the nephrostomy tract Mini-perc techniqueMini-perc technique Mode of stone fragmentationMode of stone fragmentation Chinese MPCNL: PYNEH experience Conclusion
Introduction and historyIntroduction and history 18651865 Thomas Hillier described first Thomas Hillier described first
percutaneous nephrostomypercutaneous nephrostomy
19551955 Willard Goodwin & associates reported Willard Goodwin & associates reported their experience with percutaneous their experience with percutaneous nephrostomies in 16 patientsnephrostomies in 16 patients
19761976 Fernstrom & Johansson described a Fernstrom & Johansson described a procedure through which a renal pelvic procedure through which a renal pelvic calculus could be extracted through a calculus could be extracted through a percutaneous tractpercutaneous tract
Early 80sEarly 80s Percutaneous nephrolithotomy Percutaneous nephrolithotomy gained gained widespread popularitywidespread popularity
PCNL & ESWLPCNL & ESWL
With the advent of With the advent of ESWLESWL in the mid 80s, in the mid 80s, the indications for percutaneous stone the indications for percutaneous stone extraction were narrowedextraction were narrowedAs the As the limitations of ESWLlimitations of ESWL were recognised, were recognised,
percutaneous surgery once again rose in percutaneous surgery once again rose in popularity with a redefined role in stone popularity with a redefined role in stone managementmanagement
PCNL: what is it?PCNL: what is it?
Percutaneous nephrolithotripsyPercutaneous nephrolithotripsyRetrograde pyelogramRetrograde pyelogramTract formation for renal accessTract formation for renal access
PCNL: what is it?PCNL: what is it?
Stone fragmentation & retrievalStone fragmentation & retrieval
IndicationsIndications PCNL is the preferred treatment for PCNL is the preferred treatment for
Large stone burden 2 cm or 1.5 cm for lower calyceal stones Staghorn stones Stones that are difficult to disintegrate by ESWL
(calcium-oxalate monohydrate, brushite, cystine) Stones refractory to ESWL or ureteroscopy Urinary tract obstructions that need simultaneous
correction (e.g. PUJ obstruction) Malformations with reduced probability of fragment
passage after ESWL (e.g. horseshoe or dystopic kidneys, calyceal diverticula)
Obesity
EAU Guidelines on Urolithiasis 2001
Imaging modalities for Imaging modalities for percutaneous accesspercutaneous access
Image guidedImage guidedFluoroscopyFluoroscopyUSGUSG
Imaging modalities for Imaging modalities for percutaneous accesspercutaneous access
FluoroscopyFluoroscopyMost commonly employedMost commonly employedUse of 2-plane fluoroscopy to achieve Use of 2-plane fluoroscopy to achieve
accurate needle entryaccurate needle entryRadiation safety: patient, surgeons, staffRadiation safety: patient, surgeons, staff
Imaging modalities for Imaging modalities for percutaneous accesspercutaneous access
UltrasonographyUltrasonography::The simplest & most directThe simplest & most directMinimises radiation exposureMinimises radiation exposureAllows imaging of intervening structures Allows imaging of intervening structures
between skin and kidneybetween skin and kidneySonographic identification of the puncture Sonographic identification of the puncture
needle may be technically demandingneedle may be technically demanding Inability to clearly visualise and manipulate a Inability to clearly visualise and manipulate a
guidewire once it is placed through the guidewire once it is placed through the percutaneous access tractpercutaneous access tract
Dilatation of the nephrostomy tractDilatation of the nephrostomy tract
Progressive fascial dilatorsProgressive fascial dilatorsMetal coaxial dilatorsMetal coaxial dilatorsBalloon dilation cathetersBalloon dilation catheters
Dilation of the nephrostomy tractDilation of the nephrostomy tract
Fascial dilatorsFascial dilatorsProgressively larger Teflon tubes designed to Progressively larger Teflon tubes designed to
slide over a 0.038 inch GWslide over a 0.038 inch GWSize ranging from 8 to 36 FrSize ranging from 8 to 36 Fr Inserted in a rotating, screw-type fashionInserted in a rotating, screw-type fashionAdvantages:Advantages:
SafeSafeIdeal for dilation of fibrous tractsIdeal for dilation of fibrous tracts
Disadvantages:Disadvantages:Dependence on the integrity of the GWDependence on the integrity of the GW
Dilation of the nephrostomy tractDilation of the nephrostomy tract
Metal coaxial dilatorsMetal coaxial dilators Stainless steel, mounted together in a telescopic Stainless steel, mounted together in a telescopic
fashionfashion 8 Fr hollow guide rod that slides over a GW8 Fr hollow guide rod that slides over a GW A set of six metal tubes ranging in diameter from 9 to A set of six metal tubes ranging in diameter from 9 to
24 Fr, each adapting exactly to the lumen of the next 24 Fr, each adapting exactly to the lumen of the next dilatorsdilators
Dilation of the nephrostomy tractDilation of the nephrostomy tract
Balloon dilation cathetersBalloon dilation cathetersTo achieve tract dilation in a single stepTo achieve tract dilation in a single stepAvoid the need for serial dilationAvoid the need for serial dilationGenerate lateral compressive forces, Generate lateral compressive forces,
theoretically less traumatictheoretically less traumaticDrawback: relative inability to dilate dense Drawback: relative inability to dilate dense
fascial tissue or scar tissuefascial tissue or scar tissue
Mini-perc techniqueMini-perc technique
Use of 13 to 20 Fr tractUse of 13 to 20 Fr tractSmaller volume of renal parenchyma Smaller volume of renal parenchyma
dilated, leading to decrease in blood loss dilated, leading to decrease in blood loss and post-op painand post-op pain
Lahme et al Eur Urol. 40(6):619-24Lahme et al Eur Urol. 40(6):619-24
Stone fragmentationStone fragmentation
Electrohydraulic LithotripsyElectrohydraulic LithotripsyFragments stones with shock waves Fragments stones with shock waves
generated by an underwater electrical generated by an underwater electrical dischargedischarge
Narrow margin of safety owing to the risk of Narrow margin of safety owing to the risk of damage to ureteral mucosa and ureteral damage to ureteral mucosa and ureteral perforationperforation
Stone fragmentationStone fragmentation
Holmium:YAG laserHolmium:YAG laser lithotripsy lithotripsyOccurs primarily through a photothermal Occurs primarily through a photothermal
mechanism that causes stone vaporisationmechanism that causes stone vaporisationHighly absorbed by waterHighly absorbed by waterZone of thermal injury associated with laser Zone of thermal injury associated with laser
ablation ranges from 0.5 to 1.0 mmablation ranges from 0.5 to 1.0 mmAble to fragment all stonesAble to fragment all stones
regardless of compositionregardless of composition
Stone fragmentationStone fragmentation
Ballistic LithotripsyBallistic Lithotripsy A “jackhammer” effectA “jackhammer” effect Swiss LithoClastSwiss LithoClast Effective means for stone fragmentation in the entire Effective means for stone fragmentation in the entire
urinary tract with wide margin of safetyurinary tract with wide margin of safety Relatively high rate of stone propulsionRelatively high rate of stone propulsion
Stone fragmentationStone fragmentation
Ultrasonic lithotripsyUltrasonic lithotripsyProbe tip causes the stone to resonate at high Probe tip causes the stone to resonate at high
frequency and breakfrequency and breakWhen placing it on compliant tissues such as When placing it on compliant tissues such as
the urothelium, damage is minimal because the urothelium, damage is minimal because the tissue does not resonate with the the tissue does not resonate with the vibrational energy vibrational energy
Minimally Invasive PCNL (MPCNL) according to the Chinese Method:
A Comparison with Traditional PCNL
CW Wong, TC Fung, CW Fan, SM Hou, SK Li
Division of Urology, Department of SurgeryPamela Youde Nethersole Eastern Hospital
Hong Kong
Chinese MPCNLChinese MPCNL Minimally invasive PCNL, according to the Minimally invasive PCNL, according to the
Chinese methodChinese method
MPCNLMPCNL First described by First described by LahmeLahme, Germany in 2001 , Germany in 2001
Eur Urol. 40(6):619-24Eur Urol. 40(6):619-24
The termThe term Chinese MPCNLChinese MPCNL Coined by Coined by Dr SK LiDr SK Li, PYNEH at ELSA 2005, PYNEH at ELSA 2005 Based on the approach described by Based on the approach described by Professor Li Professor Li
XunXun, Guangzhou, China, Guangzhou, China
Essential featuresEssential features
PuncturePuncture::Kidney puncture based on pre-op imaging Kidney puncture based on pre-op imaging
and tactile feedbackand tactile feedbackMinimal use of fluoroscopyMinimal use of fluoroscopySize Fr 18 tractSize Fr 18 tract
Stone fragmentation:Stone fragmentation:LithoClastLithoClast®® (using 1 mm probe) (using 1 mm probe)
Stone removal:Stone removal:Mainly by retrograde saline flushingMainly by retrograde saline flushing
Puncture & tract dilatationPuncture & tract dilatation
Patient in prone position
puncture site in 11th intercostal space
12th rib
11th rib
Miniaturized endoscopeMiniaturized endoscope
Olympus® slim compact cystoscope
Pressurized irrigationPressurized irrigation
350mmHg
Access to all calyces & ureterAccess to all calyces & ureter
MPCNL: the techniqueMPCNL: the technique
MethodMethod
PatientsPatients16 consecutive cases of staghorn stones16 consecutive cases of staghorn stonesUnderwent Chinese MPCNL by one single Underwent Chinese MPCNL by one single
SurgeonSurgeon
Statistical analysisStatistical analysisResults were retrospectively compared to that Results were retrospectively compared to that
of the last 20 cases of traditional PCNL using of the last 20 cases of traditional PCNL using Fr 24-28 sheathFr 24-28 sheath
Results – stone characteristicsResults – stone characteristics
Chinese Chinese MPCNLMPCNL PCNLPCNL
Stone diameter (cm) Stone diameter (cm) 3.79 3.79 1.3 1.3 3.36 3.36 0.94 0.94
Stone area (mmStone area (mm²²) ) 784.8784.8 926.3926.3
Type n (%) Type n (%)
BorderlineBorderline 5 (5 (3131)) 13 (13 (6565))
PartialPartial 9 (9 (5656)) 5 (5 (2525))
Complete Complete 2 (2 (1313)) 2 (2 (1010))
Results – Results – operative parameters & outcomeoperative parameters & outcome
Chinese Chinese MPCNLMPCNL PCNLPCNL
OR time (minutes) OR time (minutes) 94.794.7 122122
Length of stay (day) Length of stay (day) 6.76.7 7.67.6
Stone clearance n (%) Stone clearance n (%)
CompleteComplete 8 (8 (5050)) 12 (12 (6060))
Residual Residual ≤ ≤ 4 mm 4 mm 2 (2 (12.512.5)) 2 (2 (1010))
Residual > 4 mmResidual > 4 mm 6 (6 (37.537.5)) 6 (6 (3030))
Auxiliary treatmentAuxiliary treatment 55 66
Results - complicationsResults - complications
Chinese Chinese MPCNLMPCNL PCNLPCNL
Complications n (%)Complications n (%)
TransfusionTransfusion 1 (1 (6.36.3)) 5 (5 (2525))
UTIUTI 1 (1 (6.36.3)) 2 (2 (1010))
Pleural effusionPleural effusion 1 (1 (6.36.3)) 00
TOTALTOTAL 3 (18.9)3 (18.9) 7 (35)7 (35)
Advantages of Chinese MPCNLAdvantages of Chinese MPCNL
Miniaturised endoscope allows Miniaturised endoscope allows good calyceal good calyceal and ureteric accessand ureteric access even with middle calyceal even with middle calyceal puncturepuncture
Middle calyceal puncture at 11th intercostal Middle calyceal puncture at 11th intercostal space space avoids riskavoids risk associated with supra-11th associated with supra-11th upper pole calyceal punctureupper pole calyceal puncture
A Fr 18 percutaneous tract A Fr 18 percutaneous tract minimises trauma minimises trauma withwith less blood lossless blood loss
ConclusionConclusion PCNL is a good and valuable method for PCNL is a good and valuable method for
removal of renal calculiremoval of renal calculi Different techniques of percutaneous renal Different techniques of percutaneous renal
access, tract dilation and stone fragmentation access, tract dilation and stone fragmentation have been developedhave been developed
Mini-perc is an evolving PCNL techniqueMini-perc is an evolving PCNL technique An effectiveAn effective treatment option even for staghorn stone treatment option even for staghorn stone Good stone clearanceGood stone clearance Good calyceal and ureteric accessGood calyceal and ureteric access A A safesafe option option Reducing traumaReducing trauma Less transfusion requirementLess transfusion requirement
The needle is being advanced with the C-arm at 30 degrees. A, Use of a clamp to reduce radiation exposure to the hands of the urologist. B, The C-arm is rotated back to the vertical position, and the depth of the needle is ascertained.
top related