Percutaneous Stone Removal: entry and exit techniques
Fichel L, Clayman R.V.
Department of Urology, University of California Irvine, Irvine, CA
Table of Contents
Patient begins in a prone position
0:00:14
Legs abducted on spreader bars to access the urethra
0:00:17
Male patients are moved down the table so that the phallus hangs free, pointing towards the floor
0:00:28
Adequate padding over the extremities and torso, preferably with gel pads, is paramount
0:00:34
Nephrostomy drapes can then be placed over the flanks and perineum
0:00:36
Procedure begins with flexible cystoscopy
0:00:43
A previously placed stent is encrusted and not easily removed
0:00:50
To circumvent this problem, a hydrophilic guidewire is placed alongside the stent, fluoroscopically
0:00:58
In this instance, the patient is a female and the tip of the stent is delivered periuretherally
0:01:08
A 10 French coaxial sheath can then be passed over the stent and into the ureter
0:01:12
Once the ureter is protected by the 10 French sheath, the stent can safely be removed by traction
0:01:30
With only the safety wire in place, a coaxial dilator sheath is passed into the upper ureter and pelvis
0:01:43
Leaving wire in place, the catheter is removed
0:01:49
Super-stiff guide wire passed into upper collecting system
0:01:55
Safety wire coiled and snapped to the drape
0:02:02
An appropriate length ureteral access sheath can be passed over the super-stiff wire into the collecting system of the kidney
0:02:11
Tip of access sheath is optimally placed exactly at the uretero-pelvic junction (UPJ)
0:02:18
A Foley Catheter is then placed alongside the access sheath to drain the bladder during the procedure
0:02:27
Examine collecting system using a flexible ureteroscope
0:02:41
Air nephrogram created by injecting air through the ureteroscope
0:02:55
As the patient is in a prone position, the air bubbles float to the top, towards the posterior calyces identifying the calyceal architecture
0:03:12
A lower pole posterior calyx is chosen for access
0:03:13
Local anesthetic used to numb the skin prior to puncture
0:03:21
Small knick made in the skin with a 11 blade
0:03:26
Repeat air nephrogram is created and nephrostomy tip is used to relocate the calyx
0:03:35
When properly aligned in the AP position, the needle appears as a radio-opaque dot on the fluoroscope screen as the tip, shaft and hub are all superimposed on one other
0:03:41
Needle advanced 4-6 cm into the flank
0:03:45
C arm rotated obliquely
0:04:00
thereby laying out the path of the needle
0:04:02
Surgeon can see the tip of the needle as it enters the calyx into the air bubble
0:04:10
Removal of inner cannula should result in a small expulsion of air through the needle hub, followed by urine
0:04:14
A curved guidewire is passed down the needle and into the renal collecting system
0:04:18
Wire manipulated down the ureteral access sheath under ureteroscopic guidance
0:04:48
Coaxial sheath passed over this wire
0:05:19
Super-stiff working wire passed through and through
0:05:45
Wire clipped to the drape
0:05:54
18 gauge fascial incising needle used to make a cruciate incision
0:06:00
A 30 French high pressure dilating balloon catheter is passed into the collecting system, so that the tip of balloon rests within the calyx, proximal to the infundibulum
0:06:11
Balloon inflated and 30 French nephrostomy sheath passed over the balloon until it too rests in the calyx, proximal to the infundibulum
0:06:18
If the nephrostomy sheath is too long, it can be bifurcated by heavy scissors, but it should never be cut in half
0:06:36
Deflate balloon and remove, nephroscopy and lithotripsy can commence
0:07:19
Following successful lithotripsy the entire collecting system should be inspected with flexible and rigid nephroscopy
0:07:31
Once a stone-free state is confirmed, a ureteral occlusion balloon catheter is passed retrograde up the ureter over the exchange wire to the level of entry to the collecting system
0:07:42
The balloon inflated up the tip of nephrostomy sheath, which in turn has been pulled back to the entry point of the collecting system
0:07:56
Balloon is inflated under direct vision, thereby occluding the entry to the nephrostomy sheath at the level of the collecting system
0:08:07
Once in position, this balloon acts to prevent large quantities of FloSeal from being injected into the collecting system
0:08:18
With the balloon fixed in place the laparoscopic FloSeal applicator with syringe firmly attached, is placed at the base of the nephrostomy sheath
0:08:25
FloSeal slowly injected, while the applicator tip and the nephrostomy sheath are pulled back in tandem
0:08:41
Residual FloSeal within the applicator can then be discharged; blowing FLoSeal into percutaneous tract
0:08:55
Through-and-through wire slowly withdrawn until tip lies in the renal pelvis
0:09:08
All other guidewires should be removed
0:09:18
A 36 cm 7 French tail spin can now be passed retrograde, and its coil placed in the renal pelvis
0:09:22
Tail end of the catheter is then placed in the bladder using a Kelly clamp for cystoscopic manipulation
0:09:33
Residual FloSeal wiped away from the skin and incision closed with thermobond
0:09:43
Urine is a light pink color
0:09:57
Typically urine clears overnight and catheter is removed
0:10:01
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This video describes the entry and exit techniques for percutaneous stone removal.
 
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Dec 26, 2009 4988 VA:02:17:413:2009
 
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