Name:
The Surgical Technique of Mini Percutaneous Nephrolithotomy
Description:
The Surgical Technique of Mini Percutaneous Nephrolithotomy
Thumbnail URL:
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Duration:
T00H12M14S
Embed URL:
https://stream.cadmore.media/player/8b0d5be5-e4f7-4959-9329-b511d1f89fae
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/8b0d5be5-e4f7-4959-9329-b511d1f89fae/The Surgical Technique of Mini Percutaneous Nephrolithotomy.mp4?sv=2019-02-02&sr=c&sig=kaPF5tlmZyO4VHiG23GGf8jMPMHpmuvoapU4O9%2FAnA0%3D&st=2026-04-01T09%3A47%3A34Z&se=2026-04-01T11%3A52%3A34Z&sp=r
Upload Date:
2023-10-19T00:00:00.0000000
Transcript:
Language: EN.
Segment:1 INTRODUCTION AND INDICATIONS.
SPEAKER: This is a step-by-step guide to performing the mini percutaneous nephrolithotomy. Indications. The mini PCNL can be performed for renal stones greater than 2 centimeters, lower pole renal stones greater than 1 centimeter, renal stones previously unresponsive to ESWL, renal stones and calyceal diverticulum, as well as large impacted proximal ureter stones.
SPEAKER:
Segment:2 PATIENT POSITIONING.
SPEAKER: Patient positioning. The mini PCNL can be performed in the prone split leg position with the patient's arms outstretched above his or her head. Gel bolsters are used in a horizontal fashion across the patient's xiphoid and pubic bone. There is easy access to the urethra during the case. All pressure points, including knees and ankles, are padded extensively with foam.
SPEAKER: After the patient is prepped and draped, a prone cystoscopy can be performed to place a open-ended catheter or an occlusion balloon into the collecting system prior to the start of the case. Alternatively, patients can be placed in the supine position, a modified version of the Bart's plank-free position with contralateral leg slightly flexed and ipsilateral arm draped across the body.
SPEAKER:
Segment:3 ULTRASOUND GUIDED ACCESS.
SPEAKER: Ultrasound-guided percutaneous access. The renal calculus is identified, seen here, with the posterior shadow. On doppler, a twinkle artifact is also noted. An ultrasound needle guide placed on the ultrasound probe allows for easy placement of the percutaneous needle used.
SPEAKER: The needle is slowly advanced into the posterior calyx.
SPEAKER: Of note, it is timed with respirations in order to increase accuracy of insertion. Once the tip of the needle is confirmed to be within the targeted calyx, the ultrasound probe and ultrasound guide are removed from the needle.
SPEAKER: The inner cannula is removed and confirmation into the collecting system is visualized with good urine drip. In the event there is no urine visualized, fluoroscopy is available to assist in placing your needle accurately.
SPEAKER: An angled tipped sensor wire is guided into the collecting system. Fluoroscopy demonstrates through and through access with the sensor wire, however, the PCNL can be performed without through and through access. Of note, the previously placed 5 French open-ended ureteral catheter is also present for retrograde access.
Segment:4 DILATION OF TRACT.
SPEAKER: Dilation of tract. A small half centimeter skin incision is made. The percutaneous needle is removed, maintaining access into the collecting system with the sensor wire. A 10 French fascial dilator is used to dilate the fascia. Note the twisting motion used to advance this dilator.
SPEAKER: Fluoroscopy confirms positioning of the dilator. The dilator is then removed. The 16.5 French metallic dilator is advanced into the collecting system over the sensor wire.
SPEAKER: This can be done with either fluoroscopy or ultrasound guidance. The tip of the dilator remains distal to the stone.
Segment:5 ACCESS SHEATH.
SPEAKER: Placement of sheath. The metallic sheath is then placed over the metallic dilator into the collecting system.
SPEAKER: One can use fluoroscopic guidance to assess the depth needed to advance into the collecting system. The metallic dilator is then removed.
SPEAKER: Final positioning is confirmed on fluoroscopy. Alternatively, various access sheets can be used, including this one, that when connected to suction and irrigation, provide continuous fluid dynamics for easy stone removal.
Segment:6 NEPHROSCOPY LITHOTRIPSY.
SPEAKER: Nephroscopy and lithotripsy.
SPEAKER: The nephroscope is advanced through the access sheet and into the collecting system. The renal calculus is noted. The access sheet is gently advanced into the collecting system.
SPEAKER: A lithotripter with a combination of ultrasonic and ballistic energy with a 1.5 millimeter probe is used to fragment the stone. Alternatively, a holkium or thulium-based laser can also be used.
SPEAKER: A vortex effect created within the sheath allows for fragments to be removed systematically.
SPEAKER: The safety wire can be removed to increase the vortexing effect. As seen here, a relatively hard stone of 1,100 hounsfield units can be easily broken up using 100% ballistic, 100% ultrasonic energy, and a frequency of 8 hertz.
SPEAKER:
SPEAKER: After all fragments are removed, final nephroscopy is performed to ensure all residual pieces have been evacuated.
Segment:7 URETERAL STENT.
SPEAKER: Ureteral stent placement. A ureteral stent can be placed either via retrograde or antegrade fashion. Here, an antegrade approach is used with fluoroscopic guidance.
SPEAKER: During the entire case, a Foley catheter has been used to maintain maximal drainage of the collecting system.
Segment:8 TRACT CLOSURE.
SPEAKER: Tract closure. Surgiflo hemostatic matrix with thrombin is inserted into the tract and the access sheath is removed. Gentle pressure is held at the access site.
SPEAKER: The access site is simply dressed with a 4 by 4 dressing and Tegaderm. Patients can be discharged same day from the recovery room. Stent removal can take place in the office three to 10 days postop.
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