PCNL TARGETING

1. CONTRAST INJECTED AT THE RENAL PELVIS OVER A STONE IN THE RENAL PELVIS OR HYDRONEPHROTIC RENAL PELVIS ANTERIOR CALYCES FILL FIRST FOLLOWED BY POSTERIOR CALYCES.

2. MOVING THE IMAGE INTENSIFIER (II) TOWARD THE OPERATOR WILL SHORTEN THE PROFILE OF POSTERIOR CALYCES AND LENGTHEN THE PROFILE OF ANTERIOR CALYCES.

3. MOVING THE IMAGE INTENSIFIER (II) AWAY FROM THE OPERATOR WILL ELONGATE THE POSTERIOR CALYCES AND SHORTEN THE PROFILE OF ANTERIOR CALYCES.

4. MOVING THE IMAGE INTENSIFIER TO 90 DEGREES OR ALMOST TO 90 DEGREES WILL SHOW THE POSTERIOR CALYCES CLOSER TO THE SPINE AND POSTERIOR RIBS.

5. BASED ON THE INTENDED POLE OF ACCESS, CONCENTRATE ONLY ON THAT SEGMENT OF THE CALYCEAL SYSTEM WHEN ASSESSING THE ORIENTATION OF THE CALYCES.

6. WHEN INJECTING CONTRAST INTO THE COLLECTING SYSTEM, INJECT IN SMALL ALIQUOTS OF 1-2 CC AND OBSERVE WHICH CALYCES ARE FILLING FIRST.

7. AFTER ADEQUATELY DISTENDING THE RENAL COLLECTING SYSTEM, IF AVAILABLE, OPTIONALLY YOU CAN USE ULTRASOUND TO IDENTIFY A POSTERIOR CALYX. MARK IT ON THE SKIN AND CHECK IF IT CORRESPONDS TO THE CALYX DETERMINED AS THE POSTERIOR CALYX ON FLUOROSCOPY.

8. AFTER HITTING THE STONE IN THE RENAL PELVIS OR HYDRONEPHROTIC RENAL PELVIS, ALWAYS ASPIRATE FIRST TO CHECK FOR URINE RETURN. THIS SERVES TO CONFIRM THE POSITION OF THE TIP OF THE NEEDLE AND ALSO ELIMINATES PREMATURE INJECTION OF AIR INTO THE COLLECTING SYSTEM WHICH WOULD LIMIT USING ULTRASOUND AS THE GUIDANCE ACCESS IF ULTRASOUND-GUIDED CALYCEAL PUNCTURE IS BEING PLANNED OR NEEDED.

9. INJECTING AIR INTO THE COLLECTING SYSTEM, MAKES THE POSTERIOR NON-DEPENDENT CALYCES LUCENT AND LESS DENSE AND CONFIRMS THEIR POSTERIOR LOCATION.

10. ROTATE THE IMAGE INTENSIFIER TOWARDS YOU UNTIL THE TARGET POSTERIOR CALYX HAS THE SMALLEST AND MOST ROUND PROFILE. MARK THE SKIN, ADVANCE ACCESS NEEDLE TO THE TARGET, PERIODICALLY CHECKING DEPTH BY ROTATING IMAGE INTENSIFIER TO AP PROJECTION.