Mini PCNL IN LOWER INFUNDIBULAR IMPACTED CALCULUS -ESWL REFRACTORY CALCULUS

The surgical management of urinary calculus disease has evolved considerably over the past two decades. Twenty years ago, open procedures for stones were some of the most frequently performed urologic operations. Since then, however, stone management has been at the fore-front of “minimally invasive” intervention. The introduction and refinement of percutaneous and ureteroscopic access to the upper tracts, along with the nearly simultaneous development of both extracorporeal and intracorporeal lithotripsy, has relegated the role of open surgery to less than 1% of patient undergoing intervention for their stone disease(some of the superspeciality students in corporate hospitals are not even exposed to open pyelolithotomies and nephrolithotomies).

The rapid acceptance and widespread use of ESWL has made this form of stone therapy the treatment of choice for more than 50% of all patients undergoing intervention for renal and ureteral calculi. However, not all stones are amenable to ESWL and clinical studies have demonstrated that the size and composition of calculi, along with location and renal and ureteral anatomy all significantly affect successful stone fragmentation and clearance.

The percutaneous stone extraction gained acceptance as the procedure of choice for management of most patients with upper tract calculi in the late 1970’s and early 1980’s. In 1987, Leroy et al at the Mayo clinic reported a contemporary experience with percutaneous stone management in the era of ESWL. The authors concluded that despite the increased complexity of patients undergoing percutaneous management, excellent result could still be achieved with acceptably low morbidity.

Indications for PCNL
• Renal calculi greater than 2 cms in diameter.
• Stone with composition inappropriate for ESWL(lower calyceal stone more than 1.5 cm in size).
• Renal malformations like infundibular stenosis, pelvi - ureteric Junction obstruction.
• Failure of ESWL.
• ESWL not suitable because of problems in focussing For ex.Kyphoscoliosis,

The patient needs to undergo pre operative workup as required in open operation and Urine culture should be treated with antibiotics, the PCNL procedure is done with help of imaging "C" Arm under spinal anaesthesia.Intra-venous Pyelography is a must as most of the urologists decide pre-operatively the puncture and access.Often even with the development of CT urography the IVP has been a favourite with all urologists.

We had a 60 year old lady presenting with bilateral renal calculi.She had 1.5 cm calculus in the left kidney (on IVP the stone was in the lower calcyceal infundibulum) and 8 mm right renal stone.

She had undergone three sessions of ESWL outside but with no fragmentation.

She was diabetic and had grown multidrug resistant Klebsiella bacteria on Urine Culture.She was started on Ertapenam injections for 72 hours before the surgery and then taken up for left Mini PCNL and right DJ stenting. The intention behind right DJ stenting was to do secondary RIRS after a 3 weeks gap.

The posteroinferior calyceal puncture was done and dilated till 16 Fr .a 15 fr mini perc sheath was introduced and PCNL was done with Holmium LASER fibre.Complete clearance was achieved and 5 fr DJ stent was kept at the end of the procedure.As there was no pus and no bleeding with complete stone clearance both on nephroscopy and fluoroscopy the PCNL was done tubeless.