Procedure: 

Intraoperative left pelvic calyceal and bladder access for stone intervention

Tract Dilation

Indication: Nephrolithiasis, left lower pole stone

Referring urologist:

Date:

Operator: 

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.   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: 

  1. interpret nephrostogram.  Where is the obstruction?
  2. other findings

Impression: 

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.