AB095. Five concerns need to be pay attention to in percutaneous nephrolithotomy

OBJECTIVE: To recommend our clinical experiences in five important concerns which common to be met in percutaneous nephrolithotomy (PCNL), helping the beginners easy to handle this kind of procedures. METHODS: Review PCNL in ten years in our hospital, we analyzed five important aspects which could influence the results of operations. Include selection of access site, loss of percutaneous access while dilation, different methods of stone fragmentation, controlling pressure of irrigation in PCNL, and management of complications. RESULTS: (I) Selection of access site. Because there are less blood vessels in most posterior lower or upper middle calyces, renal puncture through these two calyces would bleed less. It does not need to set up the third access, because of accessorial application of ESWL and RIRS. If necessary, puncture residual stone in calyx may be needed. (II) Loss of percutaneous access while dilation. If the guidewire was out of upper urinary tract collecting system, most of time it needs repeating puncture. If the sheath was not deep enough, the guidewire was still in collecting system, push the nephroscope into calyx along the guidewire, then advancing the sheath. (III) Different methods of stone fragmentation. The usual methods of stone fragmentation are pneumatic lithotripsy, ultrasonic lithotripsy and holmium laser lithotripsy. Pneumatic lithotripsy is efficacy and inexpensive. Almost all kinds of stones could be broken, except a few stones such as calcium oxalate monohydrate. It is too rigid that to be broken is very difficult. The speed of lithotripsy is slow, and the debris of stone should be clear off one by one. The ultrasonic lithotripsy could sucked away the debris of stone at same time of lithotripsy. The speed of lithotripsy is high. But bigger access has to be used, and it is difficult to break the stiffer stones. All kinds of stones could be broken by holmium laser, especially high power holmium laser, the debris of stone is less and speed of lithotripsy is higher than pneumatic lithotripter. But there is no stone removal function. (IV) Controlling pressure of irrigation in PCNL. It is very important to keep the sheath unobstructed, there is a relatively high pressure in mini PCNL with pneumatic or laser lithotripsy, a relatively lower pressure in collecting system in standard PCNL with ultrasonic lithotripsy. The irrigation pressure and flow rate could be changed according to the view and whether need to flush out the stone debris or not. (V) Management of severe complications. Review the experiences of damage of pleura, super selective renal arterial embolization for hemorrhage after PCNL, the use of antibiotics and management of respiratory and circulatory function for treatment of high fever and urosepsis, the management of injury of colon and stone combine with renal pelvic tumor. CONCLUSIONS: The details would determine the results of PCNL. Any mistakes would result in failure of the procedure and damage of kidney, sometimes will be lethal for the patient. Pay attention to the details is the key of successful finishing the operations.