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Name:
Supine PCNL
Description:
Supine PCNL
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https://cadmoremediastorage.blob.core.windows.net/4784ee5e-78c7-403a-bac9-28ff506aa820/videoscrubberimages/Scrubber_1.jpg?sv=2019-02-02&sr=c&sig=LCbubfIIEJQZYwETmuy%2FwQqFUhMkgvpwvn%2BVtyM2L9M%3D&st=2026-05-22T08%3A59%3A59Z&se=2026-05-22T13%3A04%3A59Z&sp=r
Duration:
T00H13M46S
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https://stream.cadmore.media/player/4784ee5e-78c7-403a-bac9-28ff506aa820
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/4784ee5e-78c7-403a-bac9-28ff506aa820/supine pcnl.mp4?sv=2019-02-02&sr=c&sig=EdpRzC9mOjdrfhWxC8qTdmqbi7PfkzkYITSy%2B4TZvIM%3D&st=2026-05-22T08%3A59%3A59Z&se=2026-05-22T11%3A04%3A59Z&sp=r
Upload Date:
2023-12-06T00:00:00.0000000
Transcript:
Language: EN.
Segment:1 Introduction.
SPEAKER: Presenting a step-by-step description of supine PCNL. Case 1 is a 57-year-old diabetic, hypertensive male with a history of PCNL in the past. On evaluation of the lower urinary tract symptoms, the patient was found to have a mid-polar renal calculus of 16 millimeters in maximum diameter. The patient was planned for a supine PCNL. The patient was positioned in a modified Valdivia position.
Segment:2 Patient Positioning.
SPEAKER: The other positions that can be used for this particular procedure include completely supine position, Barts flank-free position, or semi-lateral position. As compared to a prone PCNL, the anterior calyx may be more favorable calyx in the supine PCNL. Placing a 3-liter saline bag below the flank enables the exposure of the flank. In the flank-free position, you need to keep two saline bags below the hip and the ipsilateral shoulder.
SPEAKER: For supine PCNL, the C-arm and the ultrasound machine remain on the contralateral side. After a conventional ureteric catheterization, the procedure can be started, and initial surface marking to get the bearings right is done. Costal margin, 11th, 10th, 12th rib, iliac crest, and posterior axillary line are marked. A free-hand ultrasound should also be done at the stage
Segment:3 Puncture in supine position.
SPEAKER: before embarking on puncture.
SPEAKER: An ultrasound-guided puncture is achieved by scanning the kidney posterior to anterior and achieving a direct window from the calyx to the stone, which is envisioned by a clear column of fluid from the calyx to the level of the stone. In this example, the echo tip of the needle is clearly seen entering the calyx, and on withdrawal of the stylet, a clear efflux of urine is seen.
SPEAKER: This is doubly confirmed by pushing in contrast and confirming the entry to the tip of the calyx. Thereafter, a guidewire is introduced into the pelvicalyceal system. We had planned a mini PCNL for this patient. Therefore, the initial dilatation was done by a screw diameter of the size of 1 French. The plan was also to use a suction
Segment:4 Use of suction sheath.
SPEAKER: sheath, which in this case was a ClearPetra sheath.
SPEAKER: It could also be a Shah sheath, and the diameter of the sheath was about 18 French. A single step dilator of the Shah system was used and an 18-French Shah sheath was used for the supine mini PCNL. The 18-French suction sheath has an ability to suck out stone fragments as large as 2 millimeters by the side of the scope. A nephroscopy was done to visualize the stone.
SPEAKER: And for this, a 12-French Karl Storz scope was used. Primarily, a dusting setting was used with the energy of 0.5 joules and frequency of 60 hertz. A luminous 1.3-watt machine was used to deliver this energy, and the fiber was enabled with the Moses technology. A parallel fragmentation setting of 0.8 joules and 15 hertz was also kept but was used sparsely.
SPEAKER: The dust generated during painting was simultaneously sucked. During the course of stone ablation, chipping technique was also used at the corners. A continuous suction enabled good visualization throughout the procedure, and the fragments which were generated by chipping was sucked. Here is another example of a suction sheath, which is a ClearPetra sheath by the Well Lead group.
SPEAKER: Here you can see larger fragments being sucked out as the chipping goes on by stone fragmentation. Both the suction sheaths described in the presentation have the capability to suck fragments of 2-millimeter size by the side of the scope. Both the sheaths have a closed system, and the suction is finger-controlled at the [? behest ?] of the surgeon.
SPEAKER: The suction channel of the ClearPetra sheath is an offset channel whereas in the Shah sheath, it is at right angles. The Shah sheath also has a chamber where the stone can be entrapped and prevent the retrograde migration of the stone. The stone fragmentation recedes like it would in the prone PCNL, but the closed system prevents collapsing of the pelvicalyceal system and helps the surgeon to work with a slightly bigger space.
SPEAKER: Intermittent suction or suction at will helps to create a moderate pressure in the pelvicalyceal system. These suction sheaths are not classically designed to create the whirlpool effect, but this whirlpool effect or the Venturi effect is enhanced by gentle suction. If you happen to use an open system of sheath, then the pelvicalyceal system keeps on collapsing.
SPEAKER: This typically happens in system like an Amplatz sheath system. But here, by increasing the irrigation flow a little bit, the pelvicalyceal system can be kept dilated. There is a spontaneous egress of stone fragments when you use the open systems. The initial puncture, in this particular case, was a lower calyceal puncture. But in supine position, on most of the patients, it is possible to reach the upper calyx through the lower calyceal puncture.
SPEAKER: If there is a situation that you have to do a delicate upper calyceal initial puncture, it is still possible in the supine position. The suction sheaths used in this particular case prevent migration of the stone as the stone clings to the tip of the sheath, and it enables the surgeon to fragment or dust the stone very easily. Towards the end of the surgery, when only fragments are remaining, suction plays a more important role and the surgeon switches completely to a fragmentation mode from the dusting mode to achieve a complete clearance.
SPEAKER: The exit strategy is based on the intraoperative events, and in this case, we decided to do a tubeless PCNL with a ureteric catheter in situ. A customary renal compression was given at the end of the surgery and the fragments visualized in the container used for collection of stones. At post-operative day 1, complete clearance was demonstrated on CT.
SPEAKER: Case 2 is a patient, 70 years old,
Segment:5 Patient with kyphoscoliosis.
SPEAKER: with severe kyphoscoliosis and left-sided renal calculus. He had compromised renal and pulmonary function. This is a situation which is an absolute indication for a non-prone or a supine PCNL. Also, the anesthetic risk in this particular case was very, very high.
SPEAKER: So we decided to do a PCNL in local anesthesia. A flexible cystoscopy was done, and all of the bladder calculi were taken care of by basketing and use of laser. As the patient could not lie down supine, he was kept in the right lateral decubitus. A free-hand ultrasound was done from medial to lateral position to open on the best possible side of a puncture.
SPEAKER: The direct access through the pelvis was gained through an anterior calyx. Local anesthesia was infiltrated, and puncture was achieved. MIP-M system by Karl Storz was used to accomplish this procedure. Even during dilatation, ultrasound guidance was used as the patient was in lateral decubitus, which makes use of fluoroscopy very, very difficult.
SPEAKER: The stone was fragmented using the fragmentation settings of 1 joule and 10 hertz, and the corners were continuously chipped. In this particular case, a Karl Storz MIP-M system was used, which works on the principle of a whirlpool effect. The use of lateral decubitus may be essential in certain situations like severe kyphoscoliosis.
SPEAKER: The overlying spine seen in the X-ray films or uroscopy may make the procedure challenging. Our third case is a 25-year-old gentleman
Segment:6 Case of osteogenesis imperfecta.
SPEAKER: with osteogenesis imperfecta presenting with left flank pain and diagnosed to have a left staghorn calculus. All the investigations are within normal limits, and this was an absolute indication of mini and supine PCNL.
SPEAKER: A CT urography confirmed the position of the stone. A 3D reconstruction enabled us to plan the left lower polar puncture to access the staghorn calculus. The patient was positioned supine with a small bolster below the ipsilateral flank region while ureteric catheterization was done, and an ultrasound-guided approach was planned.
SPEAKER: A free-hand ultrasound scan was done from posterior to anterior to enable us to mark the perfect site of the function. The calyx directly in line with the stone was punctured. On the die study, we realized that we had punctured the inferior calyx, and the puncture was directed under fluoroscopic guidance to achieve a straighter track to the pelvis.
SPEAKER: A wire was passed into the urethra and the track was dilated using the screw dilator, and subsequently, an Amplatz sheath was passed. Here, a 28-French Amplatz sheath was placed over the serial dilators, and a 24-French scope was used to visualize the stone and subsequently disintegrate the stone. The stone was disintegrated using the pneumatic lithoclast, and the fragments were delivered using a standard forceps.
SPEAKER: A single large upper calyceal fragment was delivered using a PCNL basket. A complete clearance was thus achieved. In the examples seen in this video demonstration, we can see that PCNL in supine position can be done with all the armamentarium available to the urologist today. There are definitely some indications for which supine position is the only alternative.
SPEAKER: So our take home message is that supine PCNL can be practically
Segment:7 Take home message.
SPEAKER: done in all the cases, and in some cases, it is the only way forward. Thank you.
Segment:1 Introduction.
SPEAKER: Presenting a step-by-step description of supine PCNL. Case 1 is a 57-year-old diabetic, hypertensive male with a history of PCNL in the past. On evaluation of the lower urinary tract symptoms, the patient was found to have a mid-polar renal calculus of 16 millimeters in maximum diameter. The patient was planned for a supine PCNL. The patient was positioned in a modified Valdivia position.
Segment:2 Patient Positioning.
SPEAKER: The other positions that can be used for this particular procedure include completely supine position, Barts flank-free position, or semi-lateral position. As compared to a prone PCNL, the anterior calyx may be more favorable calyx in the supine PCNL. Placing a 3-liter saline bag below the flank enables the exposure of the flank. In the flank-free position, you need to keep two saline bags below the hip and the ipsilateral shoulder.
SPEAKER: For supine PCNL, the C-arm and the ultrasound machine remain on the contralateral side. After a conventional ureteric catheterization, the procedure can be started, and initial surface marking to get the bearings right is done. Costal margin, 11th, 10th, 12th rib, iliac crest, and posterior axillary line are marked. A free-hand ultrasound should also be done at the stage
Segment:3 Puncture in supine position.
SPEAKER: before embarking on puncture.
SPEAKER: An ultrasound-guided puncture is achieved by scanning the kidney posterior to anterior and achieving a direct window from the calyx to the stone, which is envisioned by a clear column of fluid from the calyx to the level of the stone. In this example, the echo tip of the needle is clearly seen entering the calyx, and on withdrawal of the stylet, a clear efflux of urine is seen.
SPEAKER: This is doubly confirmed by pushing in contrast and confirming the entry to the tip of the calyx. Thereafter, a guidewire is introduced into the pelvicalyceal system. We had planned a mini PCNL for this patient. Therefore, the initial dilatation was done by a screw diameter of the size of 1 French. The plan was also to use a suction
Segment:4 Use of suction sheath.
SPEAKER: sheath, which in this case was a ClearPetra sheath.
SPEAKER: It could also be a Shah sheath, and the diameter of the sheath was about 18 French. A single step dilator of the Shah system was used and an 18-French Shah sheath was used for the supine mini PCNL. The 18-French suction sheath has an ability to suck out stone fragments as large as 2 millimeters by the side of the scope. A nephroscopy was done to visualize the stone.
SPEAKER: And for this, a 12-French Karl Storz scope was used. Primarily, a dusting setting was used with the energy of 0.5 joules and frequency of 60 hertz. A luminous 1.3-watt machine was used to deliver this energy, and the fiber was enabled with the Moses technology. A parallel fragmentation setting of 0.8 joules and 15 hertz was also kept but was used sparsely.
SPEAKER: The dust generated during painting was simultaneously sucked. During the course of stone ablation, chipping technique was also used at the corners. A continuous suction enabled good visualization throughout the procedure, and the fragments which were generated by chipping was sucked. Here is another example of a suction sheath, which is a ClearPetra sheath by the Well Lead group.
SPEAKER: Here you can see larger fragments being sucked out as the chipping goes on by stone fragmentation. Both the suction sheaths described in the presentation have the capability to suck fragments of 2-millimeter size by the side of the scope. Both the sheaths have a closed system, and the suction is finger-controlled at the [? behest ?] of the surgeon.
SPEAKER: The suction channel of the ClearPetra sheath is an offset channel whereas in the Shah sheath, it is at right angles. The Shah sheath also has a chamber where the stone can be entrapped and prevent the retrograde migration of the stone. The stone fragmentation recedes like it would in the prone PCNL, but the closed system prevents collapsing of the pelvicalyceal system and helps the surgeon to work with a slightly bigger space.
SPEAKER: Intermittent suction or suction at will helps to create a moderate pressure in the pelvicalyceal system. These suction sheaths are not classically designed to create the whirlpool effect, but this whirlpool effect or the Venturi effect is enhanced by gentle suction. If you happen to use an open system of sheath, then the pelvicalyceal system keeps on collapsing.
SPEAKER: This typically happens in system like an Amplatz sheath system. But here, by increasing the irrigation flow a little bit, the pelvicalyceal system can be kept dilated. There is a spontaneous egress of stone fragments when you use the open systems. The initial puncture, in this particular case, was a lower calyceal puncture. But in supine position, on most of the patients, it is possible to reach the upper calyx through the lower calyceal puncture.
SPEAKER: If there is a situation that you have to do a delicate upper calyceal initial puncture, it is still possible in the supine position. The suction sheaths used in this particular case prevent migration of the stone as the stone clings to the tip of the sheath, and it enables the surgeon to fragment or dust the stone very easily. Towards the end of the surgery, when only fragments are remaining, suction plays a more important role and the surgeon switches completely to a fragmentation mode from the dusting mode to achieve a complete clearance.
SPEAKER: The exit strategy is based on the intraoperative events, and in this case, we decided to do a tubeless PCNL with a ureteric catheter in situ. A customary renal compression was given at the end of the surgery and the fragments visualized in the container used for collection of stones. At post-operative day 1, complete clearance was demonstrated on CT.
SPEAKER: Case 2 is a patient, 70 years old,
Segment:5 Patient with kyphoscoliosis.
SPEAKER: with severe kyphoscoliosis and left-sided renal calculus. He had compromised renal and pulmonary function. This is a situation which is an absolute indication for a non-prone or a supine PCNL. Also, the anesthetic risk in this particular case was very, very high.
SPEAKER: So we decided to do a PCNL in local anesthesia. A flexible cystoscopy was done, and all of the bladder calculi were taken care of by basketing and use of laser. As the patient could not lie down supine, he was kept in the right lateral decubitus. A free-hand ultrasound was done from medial to lateral position to open on the best possible side of a puncture.
SPEAKER: The direct access through the pelvis was gained through an anterior calyx. Local anesthesia was infiltrated, and puncture was achieved. MIP-M system by Karl Storz was used to accomplish this procedure. Even during dilatation, ultrasound guidance was used as the patient was in lateral decubitus, which makes use of fluoroscopy very, very difficult.
SPEAKER: The stone was fragmented using the fragmentation settings of 1 joule and 10 hertz, and the corners were continuously chipped. In this particular case, a Karl Storz MIP-M system was used, which works on the principle of a whirlpool effect. The use of lateral decubitus may be essential in certain situations like severe kyphoscoliosis.
SPEAKER: The overlying spine seen in the X-ray films or uroscopy may make the procedure challenging. Our third case is a 25-year-old gentleman
Segment:6 Case of osteogenesis imperfecta.
SPEAKER: with osteogenesis imperfecta presenting with left flank pain and diagnosed to have a left staghorn calculus. All the investigations are within normal limits, and this was an absolute indication of mini and supine PCNL.
SPEAKER: A CT urography confirmed the position of the stone. A 3D reconstruction enabled us to plan the left lower polar puncture to access the staghorn calculus. The patient was positioned supine with a small bolster below the ipsilateral flank region while ureteric catheterization was done, and an ultrasound-guided approach was planned.
SPEAKER: A free-hand ultrasound scan was done from posterior to anterior to enable us to mark the perfect site of the function. The calyx directly in line with the stone was punctured. On the die study, we realized that we had punctured the inferior calyx, and the puncture was directed under fluoroscopic guidance to achieve a straighter track to the pelvis.
SPEAKER: A wire was passed into the urethra and the track was dilated using the screw dilator, and subsequently, an Amplatz sheath was passed. Here, a 28-French Amplatz sheath was placed over the serial dilators, and a 24-French scope was used to visualize the stone and subsequently disintegrate the stone. The stone was disintegrated using the pneumatic lithoclast, and the fragments were delivered using a standard forceps.
SPEAKER: A single large upper calyceal fragment was delivered using a PCNL basket. A complete clearance was thus achieved. In the examples seen in this video demonstration, we can see that PCNL in supine position can be done with all the armamentarium available to the urologist today. There are definitely some indications for which supine position is the only alternative.
SPEAKER: So our take home message is that supine PCNL can be practically
Segment:7 Take home message.
SPEAKER: done in all the cases, and in some cases, it is the only way forward. Thank you.
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