Urology trainees may lack experience in gaining renal access during percutaneous nephrolithomy (PCNL). Establishing the correct depth of initial percutaneous needle insertion is one of the major obstacles. As such, we have identified an easy technique, which can be performed, to establish correct depth adjustment allowing easier access.An initial attempt is made to insert the percutaneous needle into the desired posterior calyx in the antero-posterior (AP) plane. If the needle does not traverse into the desired calyx immediately, it is concluded that the needle track must be too shallow or too deep. The C-arm is then rotated 20 to 30 degrees from the vertical, in the axial plane, towards the operating surgeon and, using the image intensifier, very careful note is made of the end of the needle in this plane, compared with the end of the needle initially in the AP plane, to see if it has moved "medially" or "laterally." The 3-finger technique is then performed by the surgeon, to establish if the needle path is too deep or too shallow. This technique is currently being performed by trainees under direct consultant supervision with 13 successful cases so far.The 3-finger technique has been successfully used to demonstrate and teach PCNL access to urology trainees. In all 13 cases, percutaneous renal access was achieved successfully by trainees without immediate or late complications. Also, positive and encouraging feedbacks were received from those trainees, and all expressed willingness to continue using the same new technique in the future.Our new technique is cheap, safe, easy to learn and use, and of particular benefit to junior trainees who are beginning to perform PCNL access.

This chapter contains sections titled: Introduction Pathology Clinical features Evaluation of patients with suspected urinary stones Treatment Imaging References

AIM:To evaluate whether the overall safety and efficacy profile of percutaneous surgery for urinary stone disease in older (>70 years) patients might influence the decision for the procedure in the elderly.MATERIALS AND METHODS:A large database was created from our patients (n = 1058) who underwent percutaneous surgery for stone disease between 1991 and 2003 in the Scottish Lithotriptor Centre, including clinical and operation details for each case. Only percutaneous nephrolithotomy cases with full details were studied (n = 779) and were grouped into two age groups: (1) between 17 and 69 years and (2) over 70 years. Statistical analysis evaluated differences in terms of operation-related adverse events, stone-free success rates, and clinical success rates (including stone-free cases and cases with residual fragments <4 mm). Further analysis was performed for the same endpoints after stratification of the patients by (1) previous stone procedures and (2) special clinical features.RESULTS:In the overall database, no statistically important differences were found between the two groups in terms of stone burden before surgery, adverse events rates, complete stone-free rates, and clinical success rates. However, a statistical trend toward higher clinical success rates in favor of the younger group was seen (P = 0.051). Stratification of our database according to previous stone disease procedures or special clinical or anatomic characteristics has only shown a statistically important difference for clinical success rates in favor of the older group without special features (P = 0.01).CONCLUSION:In experienced hands, age-related morbidity or age itself should not be a discouraging consideration when deciding on performing percutaneous nephrolithotomy, as the procedure is as equally feasible and safe in the elderly as in the younger patient population.

OBJECTIVE:To review the safety and efficacy of supracostal puncture during percutaneous nephrolithotomy (PCNL) for renal calculi.PATIENTS AND METHODS:Over a 12-year period, 66 patients had either an upper-pole puncture alone or combined with middle- or lower-pole puncture during PCNL for renal calculi. All punctures were made by an experienced uroradiologist and were either supra- or subcostal. We retrospectively reviewed all case notes and radiographs to determine stone-clearance rates and complications associated with the site and number of punctures.RESULTS:There was an overall stone-free rate of 78% with upper-pole puncture alone or combined with middle- or lower-pole puncture. There was a 3% thoracic complication rate with upper pole punctures, and an overall complication rate of 30% for both thoracic and non-thoracic complications.CONCLUSION:Upper-pole puncture in PCNL is associated with minimum morbidity if done by an experienced urologist or radiologist. The stone-free rate appears to be more dependent on stone size and complexity than the site of puncture.

OBJECTIVETo review patients with an extended follow-up after extracorporeal shock wave lithotripsy (ESWL) or percutaneous nephrolithotomy (PCNL) for calyceal diverticular stones (CDS), over a 15-year period, assessing the long-term outcome.PATIENTS AND METHODSIn all, 56 patients were treated for symptomatic CDS disease by ESWL (38) or PCNL (18). The stone-bearing diverticula were in the upper calyces in 26, middle calyces in 24 and lower calyces in six patients, and in the right kidney in 22 and in the left in 34. The most frequent symptom was ipsilateral flank pain (84%) and 32% of patients presented with associated chronic urinary tract infections. In a retrospective analysis, we assessed stone size, diverticulum location, stone-free rate, symptom-free rate, complications and extended follow-up.RESULTSIn the short-term in the ESWL group, 21% of patients were stone-free and 61% were asymptomatic; 8% developed symptoms and 8% developed recurrence or stone-growth the long term. There were six minor complications. In the PCNL group, 15 patients (83%) were stone-free in the short term; two had a recurrence (11%) and two had stone growth (11) in the long term. There were three complications after PCNL.CONCLUSIONSThis series shows that PCNL is an effective and durable means of treating CDS, regardless of stone size or location of the diverticulum. Despite low stone-free rates with ESWL, most patients were rendered symptom-free with minimal complications. The long-term recurrence rates, 8% for ESWL and 11% for PCNL, were comparable.

Introduction: Horseshoe kidney is the commonest congenital renal fusion anomaly, and is often complicated by urolithiasis. We focus on our 16 years of experience with stone management in horseshoe kidneys. Materials and Methods: We reviewed the progress of 44 patients treated between 1987 and 2002. Shock wave lithotripsy (SWL) was used in 25 patients; the average stone surface area was 91 (range 10–1,600) mm2 and average follow-up was 36.5 (range 1–91) months. 19 patients underwent percutaneous nephrolithotomy (PCNL); the average stone surface area was 197 (range 6–2,400) mm2. Follow-up data are available for 8 patients and the average follow-up was 42.3 (range 3–144) months. Results: In the SWL group the 3-month stone-free rate (SFR) was only 31%. In the PCNL group the SFR was 75% on the postoperative day-1 KUB. Complications occurred in 9 patients. Conclusions: Stone management in horseshoe kidneys is challenging: PCNL produces a higher SFR with minimal major complications and failed access. PCNL thus appears to be the preferred management option in patients with urolithiasis in horseshoe kidneys.

Urosepsis after percutaneous nephrolithotomy (PCNL) is a severe complication, and its avoidance can sometimes be difficult despite antibiotic prophylaxis. Authors from the UK with a considerable experience in this procedure describe a prospective controlled study using ciprofloxacin for 1 week before PCNL, and found that it significantly reduces the risk of urosepsis. OBJECTIVE To evaluate whether 1 week of ciprofloxacin before percutaneous nephrolithotomy (PCNL) in patients with stones of ≥ 20 mm or pelvicalyceal dilatation, reduces urosepsis, as we previously reported that such patients have four times the risk of urosepsis after PCNL. PATIENTS AND METHODS Patients undergoing PCNL, and who fulfilled strict selection criteria, were recruited prospectively into a study which was conducted in two phases. The study methods were similar to those previously described; patients with dilated pelvicalyceal systems and/or stones of ≥ 20 mm from phase 1 (previously published) acted as controls. In the subsequent phase, the same selection criteria applied and only those with stones of ≥ 20 mm and/or dilated pelvicalyceal systems were given ciprofloxacin 250 mg twice daily for 1 week before PCNL and comprised the treatment arm. Midstream urine samples, renal pelvic urine and fragmented stones were collected to assess culture and sensitivity. Systemic inflammatory response syndrome (SIRS) was used to define urosepsis after PCNL. The urologists monitoring the patients after PCNL and conducting the analysis were all unaware of the characteristics of the stones or intravenous urography findings before PCNL. In all, 115 patients (54 in phase 1 and 61 in phase 2) were recruited, of whom 46 in phase 1 and 52 in phase 2 had stones of ≥ 20 mm and/or a dilated pelvicalyceal system, and became the control and treatment arms, respectively. RESULTS The patient demographics were similar in both arms. There was three times less risk of upper tract infection (relative risk 3.4, 95% confidence interval 1.0–11.8, P = 0.04) and SIRS (2.9, 1.3–6.3, P = 0.004) in the patients receiving ciprofloxacin (treatment arm). CONCLUSIONS The administration of oral ciprofloxacin for 1 week before PCNL in patients with stones of ≥ 20 mm or dilated pelvicalyceal systems significantly reduced the risk of urosepsis.

Purpose: We sought to identify whether changes in technology and local practice have improved outcomes in the minimally invasive management of pediatric stone disease.Materials and Methods: We reviewed retrospectively case notes and imaging from 1988 to 2003, noting treatment modality, stone-free rates, ancillary therapy and complications.Results: A total of 122 children (140 renal units) with a mean age of 7.7 years underwent 209 extracorporeal shock wave lithotripsy (SWL) sessions. Stone size ranged from 6 to 110 mm. Stone-free rates were 84% for cases involving stones smaller than 20 mm, and 54% for those involving stones 20 mm or greater. For complex calculi 40% of patients were stone-free and 45% required ancillary procedures, with an overall complication rate of 26%. A total of 37 children (43 renal units) with a mean age of 6.4 years underwent 46 percutaneous nephrolithotomies (PCNLs). Stone size ranged from 8 to 155 mm. The overall stone-free rate was 79%. Of these patients 34% required ancillary procedures, with a major complication rate of 6%. A total of 35 children (35 renal units) with a mean age of 5.9 years underwent 53 ureteroscopies. Holmium laser was the most effective treatment modality in this group, with a 100% stone-free rate and no complications.Conclusions: For most renal stones smaller than 20 mm SWL was the most effective primary treatment modality. There was no statistical difference between the 2 lithotriptors for stone-free or ancillary procedure rate. The stone-free rate was dependent on stone size rather than type of lithotriptor. For renal stones 20 mm or greater and staghorn calculi we switched from SWL to PCNL as primary treatment, as stone-free rates were higher and the ancillary procedure and re-treatment rates were lower with PCNL. Electrohydraulic lithotripsy and pulse dye laser were initially used to treat ureteral stones. However, with the introduction of holmium laser technology we achieved higher stone-free rates and lower complication rates. Holmium laser lithotripsy is now used as a primary treatment modality for ureteral stones.

Purpose: Urosepsis due to manipulation during percutaneous nephrolithotomy (PCNL) can be catastrophic despite prophylactic antibiotic coverage, and negative midstream urine culture and sensitivity testing (C&S). It has been postulated that bacteria in the stone may be responsible for systemic infection. In this prospective study we determined the correlation between different sites of urine sampling, including stones, and also ascertained which is more predictive of urosepsis. Material and Methods: All patients undergoing PCNL who fulfilled our selection criteria were recruited. The samples collected were 1) midstream urine and bladder urine at cystoscopy, 2) renal pelvic urine collected at percutaneous puncture of the pelvicaliceal system and 3) extracted and later fragmented stones. They were sent immediately for C&S. Patients were monitored for systemic inflammatory response syndrome (SIRS). Results: A total of 54 procedures were suitable for analysis. Midstream urine C&S was positive in 11.1% of cases, stone C&S was positive in 35.2% and pelvic C&S was positive in 20.4% (p 0.009). Pelvic urine C&S predicted infected stones better than bladder urine C&S. Of the patients 37% had SIRS and 3 experienced septic shock. Patients with infected stones or pelvic urine were found to be at a relative risk for urosepsis that was at least 4 times greater (p 0.0009). Bladder urine did not predict SIRS. Stone C&S had the highest positive predictive value of 0.7. Preoperative hydronephrosis correlated with infected pelvic urine. No patients with urosepsis had positive blood C&S. Conclusions: The results of this study suggest that positive stone C&S and pelvic urine C&S are better predictors of potential urosepsis than bladder urine. Therefore, routine collection of these specimens is recommended.

Purpose: To report our experience with ureteroscopy in the treatment of pediatric urinary tract calculi and present a review of the literature.Patients and Methods: Between 1988 and 2003, 52 ureteroscopic procedures were performed in 25 male and 10 female children aged 11 months to 15 years (mean 5.9 years). Using a semirigid 6.8F 43-cm ureteroscope and routine antibiotic prophylaxis, stones were fragmented with a pulsed-dye laser (N = 14; stone size 6-15 mm with a mean of 9.6 mm), electrohydraulic lithotripsy (EHL) (N = 26; stone size 3-20 mm with a mean of 8.4 mm), or a holmium laser (N = 7; stone size 5-15 mm with a mean of 10 mm); removed by basket extraction (N = 5; stone size 5-8 mm with a mean of 7 mm); or both. Stenting or ureteral dilatation was not performed routinely.Results: With the pulsed-dye laser, there was an overall stone-free rate of 72%. Complications consisted of one ureteral perforation and one stenosis of the intramural portion of a megaureter (14% complication rate). With EHL, the overall stone-free rate was 92%. Complications consisted of one case each of ureteral perforation and incipient urinary retention and five of mild fever (27%). With the holmium laser, the overall stone-free rate was 100%, and there were no complications. Basketing likewise produced a 100% stone-free rate, and there was one complication, a mucosal tear in a patient who also underwent pulsed-dye laser lithotripsy.Conclusion: Ureteroscopy is a safe and effective means of treating the majority of pediatric ureteral calculi, although retreatment rates are higher with multiple stones and in younger children. Dilatation of the vesicoureteral junction is usually not necessary with ureteroscopes < 8F, nor is ureteral drainage required after uncomplicated ureteroscopy. The holmium laser is the most effective and safest method of fragmentation regardless of stone composition. Ureteroscopy for this indication should be performed only by an experienced endoscopist.