Planning and Execution of Access for Percutaneous Renal Stone Removal in a Community Hospital Setting
18 August 2015 (online)
There have been several reports on the feasibility and safety of the superior pole approach to the kidney for percutaneous renal stone removal. To the author's knowledge, no one has published on the huge advantages this approach affords, owing to the rigid nature of the nephroscope/ultrasonic lithotripter, and due to the usually oblique position of the kidney as it lies upon the psoas. Between July 1986 and June 2014, the author has performed more than 500 percutaneous renal access procedures for stone removal at a single community hospital. Procedural technique is reviewed in detail, including the usual supremacy of the superior pole approach, the value of preprocedural sagittal computed tomographic reconstructions in forming a tentative plan of approach to the kidney, and the value of an intraprocedural partial-air nephrostogram in finalizing the plan. The importance of collaboration with the involved urologist, and knowledge of the tools available to the urologist, is emphasized.
In the first half of the 1980s, with the introduction of extracorporeal shock-wave lithotripsy and percutaneous nephrolithotomy, there was an abrupt advance in the treatment of renal calculi. Prior to that time the only option for treatment of large renal calculi, particularly staghorns, had been surgery. For these stones, a combined percutaneous–extracorporeal technique quickly evolved.
The author's first exposure to these techniques was in 1985, at the University of Virginia in Charlottesville. Here two or three “staghorn percs” were performed each week. These cases were very much team efforts; interventional radiologists created the initial access tract or tracts, and then the stone was addressed by a urologist. Decision making on subsequent maneuvers was collaborative.
Since 1986, in a single community hospital private practice setting, these methods have continued to serve well. Over the years, in a personal series of more than 500 cases, a few modifications have been made. Below are practical and technical points intended to help anyone starting out doing these procedures. 
The team approach has proven successful and efficient in the author's community hospital setting, as it makes best use of the skill and time of the radiologist, urologist, and anesthesiologist, and also of the available equipment. Procedures are staged such that the access is created in the morning, in the Department of Radiology's Special Procedure suite. Conscious sedation is used for the access procedure. The patient is then returned to the outpatient surgery nursing unit until the afternoon, when he or she is taken to the operating room (OR), where general anesthesia is induced, the tract dilated, and the stone removed. Proceeding this way we take advantage of the superb fluoroscopy available in the Department of Radiology (as opposed to the mobile C-arms used in the ORs), and the urologist and anesthesiologist need not waste time while the percutaneous access is being obtained.
No financial support has been received.
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