Procedure:Â
Intraoperative left pelvic calyceal and bladder access for stone intervention
Tract Dilation
Indication: Nephrolithiasis, left lower pole stone
Referring urologist:
Date:
Operator:Â
Devices(s): NephroMax balloon for tract dilatation
Complications: None immediate.
Technique:
This procedure was performed in the operating room prior to stone intervention by the attending urologist. Consent for the procedure was obtained as part of the operative consent process.
The patient was prone and asleep at procedure initiation. Â A timeout was performed.
Ultrasonographic evaluation of the left collecting system showed the shadowing stone, however, did not provide adequate guidance for access.
The lower pole stone was targeted, and under direct fluoroscopic guidance, the stone containing calyx accessed with an 18-gauge needle. Air was injected, confirming intracalyceal location. The Glidewire could not be negotiated into the collecting system. This prompted placement of a sheath. Multiple guidewire catheter combinations were used through the sheath and ultimately, the decision made to abandon the access for a steeper more caudal approach.
Again under fluoroscopic guidance, and with steep caudal angulation, the stone was accessed with a 20 cm, 18-gauge Chiba needle. Air injection on the stone confirmed location. A Glidewire was negotiated into the LV calyceal system. The needle was exchanged for a sheath. A Cobra catheter and Glidewire were negotiated down the ureter into the bladder. The catheter was advanced over the glide and glide removed. Contrast injection confirmed location within the urinary bladder. The long sheath was advanced into the ureter. A second wire was placed. Ultimately, 2 Amplatz wires were placed from the flank into the bladder.
One wire was secured to the table as a safety measure. Over the second wire, the NephroMax balloon was advanced. Dilation was intentionally extended centrally to dilate the stenotic infundibulum. The peel-away sheath advanced to the level of the stone. The balloon was removed.
The urologist placed the scope through the peel-away and confirmed visualization of the stone. The case was then turned over to the attending urologist for stone intervention.
Findings:Â
- interpret nephrostogram. Where is the obstruction?
- other findings
Impression:Â
Difficult but successful percutaneous access to a posterior lower pole stone containing calyx with a high-grade infundibular stenosis.
The subcutaneous tract was dilated with placement of a peel-away sheath for intraoperative stone intervention as described above.
Frequently Asked Questions
What is renal calyceal access for stone intervention?
Renal calyceal access for stone intervention is a procedure used to gain entry to the kidney's calyx where stones are located. This access is crucial for performing procedures like percutaneous nephrolithotomy, which removes kidney stones. The process involves using imaging guidance to insert a needle and guidewire into the kidney through the skin.
How is the nephroMax balloon used in stone intervention?
The NephroMax balloon is used to dilate the tract from the skin to the kidney, allowing instruments to pass through for stone removal. It is inserted over a guidewire and inflated to expand the tract, which is especially useful in cases where there's a stenosis or narrowing in the kidney's infundibulum.
What complications can occur with renal calyceal access?
While complications are rare, they can include bleeding, infection, or injury to the kidney or surrounding organs. In the documented procedure, no immediate complications were noted, indicating careful planning and execution by the surgical team.
Why might a urologist need to change the approach during renal access?
A urologist might change the approach if the initial access path is not feasible, as seen in the procedure where the Glidewire couldn't be negotiated into the collecting system. Adjusting the angle or using different tools ensures successful access to the stone-containing calyx.
What is the role of fluoroscopic guidance in this procedure?
Fluoroscopic guidance provides real-time X-ray imaging, essential for accurately targeting the kidney stones and guiding instruments during the procedure. It helps verify the position of needles, guidewires, and catheters, ensuring precise access and reducing the risk of complications.
How is a guidewire used in stone intervention techniques?
A guidewire serves as a pathway for inserting other instruments into the kidney. In this procedure, the Glidewire was initially used to try and access the kidney but required adjustment for successful placement, highlighting its role in navigating the urinary tract.
What does a nephrostogram help diagnose?
A nephrostogram is an imaging test that evaluates the kidney's drainage system by injecting contrast dye. It helps identify obstructions like stones or strictures. In this procedure, it was used to interpret findings and ensure correct placement of instruments.
What is high-grade infundibular stenosis?
High-grade infundibular stenosis refers to a severe narrowing of the infundibulum, the passage connecting the calyx to the renal pelvis. This condition can complicate stone removal, requiring careful dilation to allow instrument access during procedures like percutaneous nephrolithotomy.