Search

Background and purpose: Choosing the optimal approach of the collecting system is crucial for the success of percutaneous nephrolithotomy (PCNL). We present the experience of 3017 cases performed using radiological approach, ultrasound approach or a combination of these two methods. Patients and methods: PCNL was introduced in our department in 1993, and a number of 3017 procedures were performed until the end of 2007. The ultrasound guided puncture of the kidney is used since 1997 having a growing trend (45% of the cases in 2007 used ultrasound or combined ultrasound and fluoroscopic approach). Without exception, all cases had an ultrasound examination before surgery. Out of the 3017 cases, 2023 (67%) had fluoroscopic approach only (group A), 331 (10.9%) used the ultrasound approach (group B), while other 663 (22.1%) used the combined approach (group C). It it worth mention that in 6 cases the whole procedure was performed exclusively under ultrasound control. In all cases the puncture was performed by the urologist. In 91% of the cases we punctured a postero-inferior calix by a subcostal approach, but middle and upper calix were also used. 97.5% of the cases needed a single nephrostomy, the other needed two and exceptionally three approaches. In some situations a stone was moved from its position in a middle calix into the renal pelvis by pushing it with the punction needle under ultrasound control. Results: Introducing the ultrasound approach reduced the number of failures of PCNL (12.75% in group A, 7.5% in group B and 4.9% in group C). The stone free rate had the same variations (74.17% in group A, 77.59 in group B, 79.1% in group C). The number of serious complications (except those of infectious ethiology) was also smaller in the two groups which used ultrasonography (for example the blood transfusion was needed in 0.8% in group A, 0.3% in group C and in no case in group B). The mean duration of the use of X-rays during the whole procedure was 6.5 minutes in group A and only 3.1 minutes in group C. Conclusions: Ultrasound guidance of the punction offers a better accuracy of this crucial phase of PCNL and gives the possibility to choose the best approach to the stone burden. This reflects in the better stone free rate and the smaller number of complications. An association of ultrasound and fluoroscopic control of the punction seems to have the best results. The use of ultrasound reduces the exposure to X-rays of both the patient and the surgeon