Name:
pro.
Description:
pro.
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/b144a10c-2ead-4480-ab55-dc3a4a45a450/videoscrubberimages/Scrubber_1.jpg?sv=2019-02-02&sr=c&sig=HL1ZXYcmYjUtWzRPzR%2Fgavcjgo7V295b%2BpmQOU0ZhRk%3D&st=2026-04-01T22%3A08%3A41Z&se=2026-04-02T02%3A13%3A41Z&sp=r
Duration:
T00H10M53S
Embed URL:
https://stream.cadmore.media/player/b144a10c-2ead-4480-ab55-dc3a4a45a450
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/b144a10c-2ead-4480-ab55-dc3a4a45a450/mini-pcnl.mp4?sv=2019-02-02&sr=c&sig=FeqR4mkq5uem0KG6UqOR5mZ8vW32IR5vasW5U5IjLO0%3D&st=2026-04-01T22%3A08%3A42Z&se=2026-04-02T00%3A13%3A42Z&sp=r
Upload Date:
2023-12-06T00:00:00.0000000
Transcript:
Language: EN.
Segment:1 Introduction and Indications.
SPEAKER 1: This is a step by step guide to perform the B-ultrasound guided mini PCNL with suction sheath. Indications. The mini PCNL can be performed for kidney stones with a diameter greater or equal to 2 centimeters, lower calyx stones over than 1.5 centimeter, symptomatic calyceal or diverticulum stones, the residual stones after failed ESWL or RIRS treatment, and the significant impacted proximal ureteral stones.
SPEAKER 1: Patient positioning.
Segment:2 Patient positioning.
SPEAKER 1: The mini PCNL can be performed in the prone split leg position. In this position, two soft padded rows are placed under the chest and upper abdomen to facilitate ventilation. The lower limbs are placed on two foam padded adaptors. The angle between these adaptors and operating table is approximately 45 degrees.
SPEAKER 1: The genitals are located at the bottom of the table, leaving room for retrograde access. This position avoids further repetition in the patient to complete the procedure. The surgical area leaves space for simultaneous antegrade and the retrograde access. A cystoscopy with a ureteroscope or flexible cystoscope is performed in the prone split leg position 5-French open-ended ureteral catheter is placed, and the 16-French foley catheter is indwelled for drainage.
SPEAKER 1:
Segment:3 Ultrasound-guided percutaneous access.
SPEAKER 1: Ultrasound-guided percutaneous access. A B-ultrasound puncture can be guided by a needle guide adapter or free hand. Free hand puncture included the inplanar or extraplanar puncture, and that each approach has its cons and the pros. Before puncture, we use fluoroscopy to identify the stone. Then an ultrasound machine with a convex transducer is used to scan the kidney and then guide to puncture.
SPEAKER 1: The kidney and other recognizable surrounding structures, such as liver, spleen, can be observed in real time on the ultrasound. The retrograde [? stylet ?] injection is used to dilate and accentuate the collecting system on ultrasound imaging when needed. Herein, we perform the implanar puncture with aid of needle-guided adapter.
SPEAKER 1: The electronically generated puncture line indicates the right puncturing length and the angle. The stone is hyperechoic with visual acoustic shadow. The needle is advanced in real time under the direct lesion into the target calyx. Then the needle stylet is removed. Aspiration or excretion of the urine through the needle confirms the correct needle position into the collecting system.
SPEAKER 1: The ultrasound probe is removed, leaving the needle in place. Next, a fluoroscopic image is obtained to confirm whether the puncture calyx is consistent with the target calyx. In case there is no excretion of the urine or saline solution from the needle, fluoroscopy can be used to adjust this position accurately.
Segment:4 Dilation of tract and Placement of sheath.
SPEAKER 1: Dilation of the tract.
SPEAKER 1: Here we used fascial dilators to dilate the tract, and the 18-French suction-metallic sheath as the working channel. After the puncture, a 0.038 Boston sensor guidewire is passed into the collecting system, confirming positioning with fluoroscopy. A 0.6 centimeter skin incision is made around the needle. The needle is slowly removed by holding the guidewire within the collecting system.
SPEAKER 1: Then the tract dilation is performed by fascial dilators. First, 14-French, and then 18-French dilator was gently rotated and gradually advanced over the guidewire to a proper location. We routinely get a fluoroscopic image to verify its direction and depth. An 18 suction-metallic sheath is advanced over that wire into the collecting system, allowing continuous flow irrigation and function during the procedure.
SPEAKER 1: A fluoroscopic image is obtained to verify the final location. Alternatively, a peel-away sheath or other sheaths can be used.
Segment:5 Nephroscopy and lithotripsy.
SPEAKER 1: Nephroscopy and lithotripsy. The nephroscope is gently advanced through the sheath into the collecting system, and the stone was identified. Then a handle is assembled to the sheath. It is a part of the sheath.
SPEAKER 1: The optic tube on the handle is connected to the specimen collection bottle, and the bottle then to the negative pressure aspirator. A lithotripter with a 1.5 millimeter ballistic probe is used to fragment the stones. The irrigation and suction sheath combination provides a high stone removal efficiency. Tiny stone fragment can be sucked out from the space between the sheath and the nephroscope.
SPEAKER 1: Larger stone pieces are removed when pulling out the nephroscope. We prefer not to have a 50 guidewire inside an access sheath in order to facilitate the stone extraction. Alternatively, a holmium laser can also be used. In this case, a 550 micrometer holmium laser fiber was used.
SPEAKER 1: The energy setting was 20 hertz, 2.0 joule, with a total power of 40 watts, obtaining a good fragmentation efficiency. An intraoperative fluoroscopic image is used to detect eventual residual stones. When it is possible, an attempt should be made to completely remove all the stone fragments.
Segment:6 Additional tracts established.
SPEAKER 1: Additional tracts established.
SPEAKER 1: In this case, some calyceal stones were inaccessible through the one percutaneous access. Therefore, we planned a second tract to treat a middle pole anterior calyx stone. The target calyx is still clearly visible and punctured quickly under ultrasound guidance.
SPEAKER 1: Saline solution injected through the retrograde ureteral catheter can be extracted from the needle. Step by step, inserting the guidewire, gradual dilation under fluoroscopy, sheathing, successful lithotripsy, and the sucking out of stone fragments. However, under fluoroscopy, some stone pieces are still left in the lower pole.
SPEAKER 1: There, we tried a third ultrasound-guided access, but failed due to a defect caused by the intra calyceal blood clots and the air. The fluoroscopic image is confirmed that the location of the puncture needle is not consistent with the target calyx. Therefore, we decided to make the puncture under fluoroscopy.
SPEAKER 1: The skin puncture side was made 2 to 3 centimeters lateral to the target calyx, and the needle was gradually advanced towards the papilla. When an accurate puncture is achieved, the tip of the needle appears to be located exactly within the target calyx with the VR at both 0 and 30 degree. Once the needle is correctly inserted into the desired calyx, force for injection of saline is attempt through the puncture needle.
SPEAKER 1: This maneuver can flush and relocate the stones into the renal pelvis. In this case, we could not achieve this result. We therefore decided to place a guidewire through the needle. This wire was then identified from the initial tract with the nephroscope. Sometimes relocated calyceal stones can be easily accessible through the original tract without additional dilatation.
SPEAKER 1: Following alongside the guidewire, the residual stones were finally found and removed, avoiding the third tract dilatation. Finally, a fluoroscopy was obtained to verify the stone clearance situation. For this second stone, we established two tracts with one auxiliary needle puncture. Combined with suction sheath, a complete stone clearance was achieved.
SPEAKER 1:
Segment:7 Exit strategy.
SPEAKER 1: Exit strategy. There were no residual stones, perforation of the calyceal system, ureteral obstruction, and severe bleeding during the whole procedure. Therefore, we performed a tubeless PCNL for this case. Skin glue or stitches are applied to seal the incision. For a shortened drainage, we leave a 5-French open-ended catheter connected to a foley ureteral catheter.
SPEAKER 1: In cases where long term renal drainage is required, a ureteral stent can be placed either via retrograde or antegrade fashion with fluoroscopic guidance. The ureteral stent can be removed 7 to 14 days post-operatively. At the end of the procedure, the stones are collected and sent for a stone composition analysis. That's all for the video.
SPEAKER 1: Thanks for watching.
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