2. What are your expectations from this workshop?

3. Introduction Inherent risks Vascular injury Small margin of error
2-6mm wide
Good afternoon and thank you for coming for this CME. Our aim behind this CME is very simple. We want to learn how to do a PCNL puncture.
The first and foremost priority in a PCNL is getting the puncture right.The biggest fear is the risk of life threatening bleed. A small error in the direction of the needle can result in disaster, and we are talking of distances as small as 2mm at the tip of the needle.Today we will see if we can ensure that our needle goes just where we want it to.

4. PCNL Masterclass Your expectations? Puncture? x Puncture!
Prone position
As the idea is for us to learn from you I would request your whole hearted participation. Please feel free to interrupt the speakers and question our beliefs and principles. We have kept time for questions and I hope you will make our lives difficult by asking all the uncomfortable questions you can think of.

5. Format Questions and answers Puncture technique PCS anatomy
Practice on the simulator
PCNL cases – Simple cases to demonstrate access
Open house
The format is arranged in the following manner. After the introductory lectures we will split into 2 groups. One will go for practicing the punctures and one group will remain in the library for discussion. In the second half we will change over.

6. Why is the PCNL puncture so difficult to learn and teach?

7. Is the PCNL puncture rocket science? The curse of binocular vision…………
Thumb exercise
The whole problem in analysing the information provided by the fluoroscopic images is the fact that we have been cursed by binocular vision. Believe me, if you put me and this one eyed weasel in a race to learn PCNL, he will win. Please do the following exercise and let me know if you agree …………….

8. Where am I looking from?
Now if you imagine yourself as the one eyed weasel sitting on the head of the c-arm you will find it very easy to understand the fluoroscopic images. Turn the c-arm in any direction you like but remember that you are sitting on the head of the c-arm and peeping with one eye closed.

9. The shadow and the space
Now that all of you have agreed to evolve into one eyed weasels please look at the image from your vantage point on the head of the c-arm. In 0 degrees both needles appear to have reached the needle. In 30 degrees the shadow of the needle which is superficial to the target is falling on the target and therefore it appears to have crossed the target. In 30 degrees the needle has not reached because the x-rays are showing you the space between the needle and the target. Please take your time and understand this concept…….

10. Problems with the puncture
2 dimensional image analysis
3 dimensional hand eye co-ordination
Learning on patients!
Therefore at the end of this CME I hope all of us will be able to convert the 2 dimensional visuo-spatial information from the c-arm into the 3 dimensional psychomotor ability to make the needle go just where we want it to.

11. Can the PCNL puncture be broken down into component steps?

12. Ideal PCNL puncture
The ideal tract is one that provides the shortest and straightest access to all calculi
Avoids major vessels, bowel and lung
Along the axis of the calyx
Minimal parenchymal damage

13. Steps of a PCNL puncture (Triangulation technique)
1. Mark the edge of the calyx on fluoroscopy with C arm at 00

14. Deciding on the puncture site
2. Mark a point about 5 cm from the edge of the calyx in the line of the calyx a b a b

15. Equilateral triangle a b c

16. 3. With the c-arm in 00 advance the needle towards the edge of the desired calyx

17. 4.Turn the c-arm towards yourself at 10/20/300 and check if you are too superficial or too deep in relation to the calyx

18. Too deep!
300 00 00
300

19. Too superficial! 00
300
Note: You do not need
An absolute end on view!

20. Finally!
300 00 00
300

21. How long should the puncture needle be?

23. USG assessment of renal depth
Depth of the kidney
USG assessment of renal depth

24. Unpublished data – NU Hospitals
Renal depth n=1028
Right
Left
Renal depth
>5cm
17 %
14 %
Mean renal depth
3.97 cm
3.87 cm
Unpublished data – NU Hospitals

26. The medial calyx is the posterior calyx. (L.A.M.P.) True or false?

27. Calyceal Anatomy Which calyx do I puncture - medial or lateral?
The end-on-calyx is the posterior calyx - true or false?
Can 3-dimensional CT scan help us improve understanding of PCNL related anatomy?

28. Posterior = Lateral (%)92 78 50 35 78 46
Brodel
Hodson
So have I stumbled on some new scientific discovery? Unfortunately, no. Kaye and Reinke looked at calyceal patterns and proved that the Brodel type of kidney with the posterior calyces pointing laterally was more common on the right and the reverse Hodson type was more common on the left. If you take a moment to look at our numbers again, you would agree with me that the numbers follow the same trend depicted in the diagrams. Therefore, there is no anatomical truth in dogmatically following the rule that posterior equals medial.
Kaye, Reinke. J Urol. July 2007; 132,

29. 78222

30. 77307

31. How do I know I am in an anterior calyx?
Acute angulation of guide wire
Depth

32. Do you always use a safety guide wire?

33. Should we do an air pyelogram?

34. Air? How much?? Air embolism – CO2?
Lipkin et al J Endourol 2011 Apr;25(4): Epub 2011 Mar 22.
Urology vol 73, issue 3, Pages 681.e1-681.e4, March 2009

35. Our attempts at instilling air

36. Is it necessary to hold the bag?

37. Where should I puncture in the intercostal space?

38. Puncturing the intercostal space

39. Why not puncture an upper calyx via an infracostal puncture?

40. Puncturing the Upper Calyx via an infracostal puncture

41. Thank You