Skill: Ability to Understand the Calyceal Anatomy

PCNL

Aim: To gain access to the desired calyx, access in the least fluroscopy time, with the lowest number of puncture attempts

Skill: Ability to understand the calyceal anatomy

Instruments: PCN needle, C arm / light pedal (depending on the module)

Error:

Repeatedly overshooting the calyx with advancement of needle 1 cm beyond calyx, prolonged fluroscopy time (> 3minutes),

Expert time : 40sec

Beginner time:

To be spoken

1. Please use the PCN needle to gain access to the desired calyx.

2. Once the renal parenchyma (the equivalent in the module) is entered avoid changing the direction of the needle.

3. Avoid multiple to and fro motion within the parenchyma (the equivalent in the module)

4. Use fluoroscopy in the intermittent mode rather than the continuous mode

5. Please make sure you understand the concept of rotating the C Arm from the 0 degree to any other angle before attempting the puncture (the equivalent in the module could be the light source if a light based module is being used

Practical considerations

·  Please review imaging of the patient especially if a CT is available before any puncture is attempted (to plan the access, the depth of the calyx, variable anatomy if present)

·  The depth of the calyx from the skin is usually between 5 to 7 cm

·  Longer PCN needles may be needed if imaging suggests a deeper kidney

·  Always orient the needle in the long axis of the calyx

·  Do not overshoot the calyx once you have considered it punctured make a reasonable number of attempts in advancing a glide wire to gain access to the PCS

·  Always note the way the guidewire enters the PCS; a guidewire which coils below/above the needle and then jumps into the pelvis is possibly in an anterior calyx