U J - Spring 2012.pdf 522 | Urology and Nephrology Research Center, Hamedan University of Medical Sci- ences, Hamedan, Iran Seyed Habibollah Mousavi-Bahar, Ali Ahanian, Babak Borzouei Needle Manipulation for Removing Inac- cessible Stones in Parallel Calices during Percutaneous Nephrolithotomy Corresponding Author: Seyed Habibollah Mousavi-Bahar, MD Department of Urology, Shahid Beheshti Hospital, Eram Blvd, Hamedan, Iran Tel: +98 918 111 3612 Fax: +98 811 838 1035 E-mail: shmbahar@ umsha.ac.ir Received February 2011 Accepted January 2012 Point of Technique Keywords: kidney calculi, kidney calices, percutaneous nephrolithotomy, ma- nipulation INTRODUCTION Pstones in patients who are not candidate for extracorporeal shockwave - possible to access all the stones via a single-tract. In these cases, multiple ac- cess tracts may be required to increase stone-free rate, which obviously increase the risk of complications and morbidity. Other procedures have also been infundibular tilt, angular access PCNL, and SWL, as an adjuvant procedure. Here, we describe a new technique for displacing the stone from an inaccessible calyx of the kidney to an accessible area by the single pre-existing tract, called “Needle Manipulation”. CASE REPORT in two neighborhood calices or staghorn calculi that occupied calices without hy- dronephrosis and acute angle between calices were included in the study. Exclu- sion criteria were non-opaque calculi, long length of infundibulum, large size of residual stone, acute angle of infundibulum, and smooth surface of calculus. Forty-eight patients were enrolled in the study, including 33 men and 15 women, - Point of Technique 523Vol. 9 | No. 2 | Spring 2012 |U R O LO G Y J O U R N A L Needle Manipulation During PCNL | Mousavi-Bahar et al rotation. The procedure was done by one surgeon TECHNIQUE stent, like other routine procedures. By contrast material injection through the ureteral stent, the the largest stone burden. We selected the calyx with maximum access to stone burden. After tract dilatation and Amplatz sheath insertion, accessi- If stones could not be accessed in other calices, especially parallel calices, we inserted the needle into the kidney at the site of inaccessible stone un- to touch and push the stone using the needle to displace it into or near an accessible area, such as If manipulation fails to displace the stone, we can pass a guidewire through the same needle and cre- ate a new tract to remove the stone. Needle ma- nipulation may cause minimal hemorrhage, which RESULTS Among more than 1500 PCNLs, we used needle - DISCUSSION Skolarikos and Papatsoris have described that re- sidual stone fragments can occur in up to 8% of patients who undergo PCNL. When left untreated, approximately half of them will develop a stone- related complication in the future, and more than half of these patients will ultimately require anoth- er surgical intervention. Sometimes it is impossible to access all the stones by a single-tract during PCNL, which may be due to scattered stone fragments, complex stones, or a large staghorn calculus. Furthermore, an accessible stone may migrate into an inaccessible calyx dur- ing surgery. Saline irrigation of the kidney is one of the easi- est maneuvers to displace such stones, but it may not be always successful. Moreover, creating another tract can lead to increased morbidity. In some studies, multiple-tract PCNL was accom- creatinine and reduction in creatinine clearance postoperatively. Furthermore, hospitalization was prolonged, but hemorrhage was not different from single-tract PCNL. In the “Angular Percutaneous Renal Access” that was described by Liatsikos and colleagues, the skin incision was single, but it was used for multi- ple nephrostomy tracts. The cosmetic results were better than multiple-tract PCNL, but the transfu- Guidewire-assisted infundibular tilt technique has ( Displaced stone is grasped, fragmented, and removed. 524 | also been described, but its utility is limited to subjects with moderate to severe dilatation of the pyelocaliceal system, in which the parenchymal wall between the two adjacent calices is thin and permits tilting of stone bearing calyx and opening its infundibulum. This technique is not useful in patients with no or mild hydronephrosis. Adjuvant SWL can lead to complications, such as residual stone fragments, infection, and adverse effects on adjacent tissues, including urinary, gas- trointestinal, cardiovascular, genital, and reproduc- tive systems. Flexible nephroscopy during the primary operation or as a second-look procedure can increase the stone-free rate and decrease the need to multiple-tract creation, but the instru- ments are very expensive and are not available in all communities. Our technique does not need additional tract crea- tion and has no additional risk for the patient. Its limitation is seemed in patients with narrow infun- dibulum that does not permit stone or instrument passage. There is also increase in radiation time, but using a needle holder can decrease radiation exposure of the surgeon’s hand. However, needle manipulation is not useful for stones in the anterior calices. We made second tract for important resid- uals and left small residuals, and followed them by medication or SWL if needle manipulation was not helpful. CONFLICT OF INTEREST None declared. REFERENCES 1. loss during percutaneous nephrolithotomy: prospective 2. Akman T, Sari E, Binbay M, et al. Comparison of outcomes after percutaneous nephrolithotomy of staghorn calculi in those with single and multiple accesses. J Endourol. 3. Skolarikos A, Papatsoris AG. Diagnosis and management of postpercutaneous nephrolithotomy residual stone frag- 4. Ahlawat R, Dalela D. Intra-operative percutaneous caliceal irrigation--a technique for clearing caliceal residue during 5. Hegarty NJ, Desai MM. Percutaneous nephrolithotomy re- quiring multiple tracts: comparison of morbidity with sin- 6. Handa RK, Evan AP, Willis LR, et al. Renal functional ef- fects of multiple-tract percutaneous access. J Endourol. 7. Liatsikos EN, Kapoor R, Lee B, Jabbour M, Barbalias G, Smith AD. "Angular percutaneous renal access". Multiple tracts through a single incision for staghorn calculous treatment Dalela D, Sankhwar SN, Goel A, Bhandari M, Goel T. Guide- wire assisted infundibular tilt—GAIT: Solving problems of accessibility during PCNL in hydronephrotic kidneys J En- V 19/6. 9. M. 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