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History The first description of percutaneous renal access was by Goodwin et al in 1955 The first PCNL procedure performed by Fernstrom and Johannson 1976
Preoperative diagnostics
A detailed medical history of the patient Radiologic definition of the stone size and the anatomy of the collecting system
plain abdominal film of the kidney, ureters, and bladder (KUB) in combination with intravenous urography Ultrasound computed tomography (CT) scans
Laboratory
coagulation parameters and electrolytes urine culture - is strongly recommended
prone position - The traditional way of performing PCNL, as described by Alken et al supine position - The new way of performing PCNL by Valdivia (combined approach with simultaneous ureteroscopy is easy to perform)
Anesthesia 1. general anesthesia - mostly 2. spinal-epidural anesthesia very good report cost efficacy and safety 3. local anesthesia - seems to be a feasible in selected group of patients
Renal access
The dorsal calyx of the lower pole is the usually acces site Supracostal access to an upper calyx due to stone location in the upper pole. 10th-rib supracostal approach is prohibitive 63% risk of puncturing the lung After puncture will are passing the papilla in the long axis of the target calyx avoids contact with large vessels
Disintegration
the stones are usually disintegrated mechanically with a lithoclast device or a holmium laser. Ultrasonic disintegration Fragments can usually be flushed out through the access sheath or recovered with a stone basket or with special forceps Operation time seems to be dependent on stone size.
Standard PCNL - a nephrostomy tube is inserted after the PCNL with the intention of both draining the urine and tamponading the access tract Tubeless PCNL intern ureteral drainage Totally tubeless PCNL - without any drainage
Complications
Organ injury
Colonic injury < 1 % Lung injury Spleenic and hepatic injury
Bleeding complications
In most, it is limited selective arteriography with embolisation is feasible 1% Nephrectomy 0.2%