BERKELEY, CA (UroToday.com) - Introduction: The development of percutaneous renal surgery is attributed to Alken and Wickham, who popularized the procedure in prone position, which was the standard until in 1988 when the supine position for percutaneous renal access was described with good results. The supine position, described by Valdivia, was modified to facilitate simultaneous renal access anterograde and retrograde manner.
Method: The supine oblique position involves placing the patient supine at a 45 ° angle on the operating table (Figure 1); the patient holds the position supported by two runners placed under the buttocks and costal ipsilateral area so the lumbar space is free allowing the execution of the renal puncture. The ipsilateral inferior limb remains in a parallel, opened position and the contralateral inferior limb also remains open, for easier transurethral renal access (Figure 2). In addition, this position allows the application of ultrasound transducer to lance under radiological and ultrasound control.
Advantages:
- Allows the patient to be treated in supine position, very useful in obese patients with cardiovascular problems
- It allows ease of puncture of the desired calyx under ultrasound control, aided of fluoroscopy. It is a mixed approach with ultrasound and radioscopy
- It facilitates the exit of stone fragments through the Amplatz sheath
- It gives the surgeon more mobility management with the nephroscope and working tools (Figure 3)
Procedure: Ureteral catheterization and retrograde pyelography for radiological control are performed. Renal ultrasound, puncture path, and gateway location are in the lumbar area (Figure 4); the tract is checked with radiological control and needle puncture on the side wall of the abdomen identifying pelvic junction and calyx puncture (usually the inferior-posterior) and the gateway through the skin. The puncture is commenced by ultrasound guidance; the needle passing through the ultrasound probe adapter and completes the puncture by radiological control. We placed a flexible guide and performed dilatation with a high-pressure balloon (24-30 fr) to 12 At of pressure and then placed the Amplatz sheath (Figure 5).
Experience: We have performed the procedure in this position in 40 patients. In all patients the procedure was performed by a single access generally through the lower calyx, but in no case was it conducted through upper calyx access. The fragmentation of the stone is achieved through kinetic energy and the fragments are removed spontaneously by the irrigation liquid or extracted with Nitinol or NPerCircle basket. As alternative energy source is the use of Holmium-YAG laser. Upon completion of this procedure, a double-J stent can be placed and sealed with a hemostatic percutaneous tract as an alternative to percutaneous drainage tube.
Figure 1
Figure 2
Figure 3
Figure 4
Figure 5
Written by:
Miguel Angel Arrabal-Polo, PhD; Miguel Arrabal-Martin, PhD; and Armando Zuluaga-Gomez, PhD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Urology Department
San Cecilio University Hospital
Granada, Spain
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