Supine - PCNL for a renal stone in the left renal pelvis using dual action lithotripsy

Introduction

This tutorial provides a comprehensive guide to performing a supine percutaneous nephrolithotomy (PCNL) for treating a renal stone in the left renal pelvis using dual action lithotripsy. The procedure is relevant for urologists and medical professionals involved in endourology and stone management. Understanding the techniques and steps involved can enhance surgical skills and improve patient outcomes.

Step 1: Patient Preparation

• Ensure the patient is in a supine position on the operating table.
• Conduct a thorough preoperative assessment including:
  • Medical history
  • Imaging studies (CT scan or ultrasound) to determine stone size and location
  • Renal function tests
• Obtain informed consent after explaining the procedure, risks, and benefits.

Step 2: Anesthesia Administration

• Administer general anesthesia to ensure the patient is completely sedated and comfortable.
• Monitor vital signs and ensure proper positioning to avoid any complications.

Step 3: Surgical Access

• Use ultrasound to identify the renal pelvis and the stone's location.
• Insert a guide needle percutaneously into the renal pelvis under imaging guidance.
• Confirm correct placement with contrast injection if necessary.

Step 4: Dilation of the Access Tract

• Use a series of dilators to gradually expand the tract created by the guide needle.
• Ensure dilation is adequate to allow for the insertion of the nephroscope.

Step 5: Nephroscopy and Stone Fragmentation

• Insert the nephroscope into the renal pelvis through the dilated tract.
• Visualize the stone using the nephroscope.
• Use dual action lithotripsy for fragmentation:
  • Activate both ultrasonic and pneumatic energy sources for effective stone breakup.
  • Carefully remove stone fragments using a grasping tool.

Step 6: Irrigation and Clearance

• Continuously irrigate the area to wash out stone fragments.
• Check for any residual fragments using imaging.
• Ensure complete clearance of stones to prevent recurrence.

Step 7: Placement of Nephrostomy Tube

• If necessary, place a nephrostomy tube for postoperative drainage.
• Secure the tube and ensure proper positioning to facilitate drainage.

Step 8: Postoperative Care

• Monitor the patient in the recovery area for any complications.
• Provide pain management and instructions for care of the nephrostomy tube if placed.
• Schedule follow-up appointments to assess healing and renal function.

Conclusion

This tutorial outlines the essential steps for performing a supine PCNL using dual action lithotripsy. Mastering these techniques not only enhances surgical proficiency but also contributes to better patient care. Always stay updated on the latest practices and technologies in urology to improve outcomes and reduce complications.