| Objective:Different factors can determine the outcomes of ultrasound-guided calyceal puncture in percutaneous nephrolithotomy(PCNL).In an attempt to reduce the complications of PCNL and to improve the accuracy of ultrasound-guided percutaneous renal puncture.Picture archiving and communication system(PACS)on computed tomography(CT)imaging was used to delineate renal and peri-renal anatomy as well as stone characteristics.We analyzed the effect of predictors on ultrasound-guided calyceal puncture outcomes in PCNL,and discussed the operating methods to improve the accuracy of ultrasound-guided percutaneous renal puncture.In order to improve the precision of the puncture target by ultrasonic guided,we designed a laser-guided puncture device for ultrasound-guided puncture in the longitudinal imaging planes,and assessed the feasibility of in-plane planned laser-guided punctures in PCNL performed with the ultrasound.In order to apply ultrasound guidance to precisely achieving renal access for PCNL,coordinating the needle hand with the imaging hand to advance the needle within the imaging plane into the chosen target is required.The aim of this study was to evaluate the safety and effectiveness of ureteroscopy-assisted one-shot dilation(UAOSD)technique for percutaneous renal access in mini-percutaneous nephrolithotomy(mini-PNL).Method:After obtaining ethics approval,a retrospective review of mini-PNLs performed at a tertiary stone center(The Affiliated Hospital of Jining Medical University)between November 2011 and May 2016 was performed.(1)Between November 2011 and November 2014,a total of 255 patients were included.The patients were assigned into two groups depending on the dilation technique during surgery.Intraoperative urologist-directed percutaneous renal access by OSD technique with a 9.8 Fr rigid ureteroscope assisted was performed under ultrasound.Patient demographics,stone size,procedural parameters,stone-free rate,hospitalization,and perioperative complications were recorded and compared.(2)Seventy-three patients with complex kidney stones and renal calyx diverticulum calculi underwent mini-percutaneous nephrolithotomy.All percutaneous renal access were carried out 20 Fr.As finding the renal calyx diverticulum calculi,the 16 Fr peel-away sheath was inserted into the 20 Fr outside sheath as the inner sheath on the concrete circumstances as needed.The stones were fragmented and removed through the telescopic renal sheath.(3)According to the direct endoscopic visualization,whether the puncture channel was passed through the renal nipple,the patients were divided into the precise puncture group and the non-precise puncture group.The distance between the skin to the calyx of puncture(DSC)was measured on preoperative CT.The width of the target calyx and the ratio of DSC with the width of the target calyx were recorded.Measurements were independently performed by two urologists and the average was used for analysis.Patient demographics,stone size,body mass index(BMI),procedural parameters,stone-free rate,hospitalization,and perioperative complications were recorded and compared.Mann-Whitney U and Pearson chi-square tests were used for comparisons with P <0.05 considered significant,and the results were analyzed with univariate analysis and multivariate analysis by non-conditional Logistic regression analysis.(4)We designed a laser-guided puncture device for ultrasound-guided puncture in the longitudinal imaging planes,and an ex vivo organ model for percutaneous renal surgery was performed.According to the application of the laser puncture guide,they were divided into laser-guided puncture group(group A)and conventional freehand ultrasound guided puncture group(group B)with 10 ex vivo organ models.10 punctures were performed with the laser guidance system or by freehand method.Puncture success was depicted with the water flowing out of the end of the needle after puncture.After finished by one experienced senior urologist,all operations performed by one inexperienced resident.Planning time,puncture time,tract length,and attempts were documented.Results:(1)Ureteroscopy-assisted one-shot dilation(UAOSD)technique by ultrasound-guided was performed in 171/255 patients(Group A),while OSD technique under fluoroscopy was utilized in the other 84 patients(Group B).The two groups were similar with regard to demographic and stone characteristics.No statistically significant differences in terms of operation time and hospitalization were observed.There was less decline of tract development time,hemoglobin drop after surgery and proportion of postoperative fever(>38.5?)in Group A compared to Group B(2.1 vs.6.5 min,P= 0.038;1.7 vs.3.2 g/dl,P=0.002;3.5% vs.10.7%,P=0.048).The one-attempt dilation success rate was significantly higher in Group A(P=0.008).(2)The median operating time with telescopic renal sheath(n=46)was significantly shorter than with single sheath(n=27)at 66.7 vs91.5 minutes,respectively(P<0.001).In the telescopic renal sheath group,there was significantly less bleeding(0.39±0.22 g/d L vs.0.59±0.32 g/d L,respectively;P=0.002)and higher stone free rates(95.7% vs 85.2%,respectively;P=0.045)compared with the single sheath group.All patients in the telescopic renal sheath group had mild hematuria,which resolved within two days.A small proportion in the single sheath group(1/27)received perioperative anti-infection therapy and fever rates were similar in the single sheath and telescopic sheath group.No serious complications such as pneumothorax and intestinal injury.During 22.4 months of follow-up,hydronephrosis did not occur among61 patients.(3)The successful ultrasound-guided calyceal puncture was performed in137/219 patients(Group A),while unsuccessful ultrasound-guided calyceal puncture was performed in the other 82 patients(Group B).The two groups were similar with regard to demographic and stone characteristics.No statistically significant differences in terms of median stone burden and the extent of hydronephrosis were observed.The median DSC was highly correlated with BMI.A total of 137 ultrasound-guided calyceal punctures(62.56%)were performed successfully.Multivariable analysis revealed that independent risk factors for successful ultrasound-guided calyceal puncture were the actual level of the surgeon,DSC and the width of the target calyx.(4)All punctures were successful.The two groups were similar with regard to planning time and median tract length in 5.62 cm.In laser-guided puncture group,median puncture time and attempts of the senior urologist compared with a resident decreased significantly(P<0.05).Moreover,in both groups,the senior urologist had better performance than the residents with less attempts(1.3 vs.2.8times,P = 0.009;1.6 vs.4.0 times,P =0.001).Conclusions:(1)Ureteroscopy-assisted one-shot dilation(UAOSD)technique by ultrasound-guided introduced in present study is compensable to OSD technique under fluoroscopy for tract development in the management of patients undergoing mini-PNL for renal stone treatment.(2)Ureteroscopy-assisted one-shot dilation(UAOSD)techniques make totally ultrasound guidance for mini-PNL safe,efficacious and well-tolerated.(3)Telescopic renal sheath in the applications of mini-percutaneous nephrolithotomy is an effective method to treat complex kidney stones and renal calyx diverticulum calculi.Our technique is cost-effective and readily adapted without the need for additional instruments.(4)Ultrasound-guided puncture in the longitudinal imaging planes,keeping the entire needle fully visualized from skin to kidney direct the tip of the needle into the end of the chosen calyx is the most important step in PCNL.Independent risk factors for successful ultrasound-guided calyceal puncture were the actual level of the surgeon,DSC and the width of the target calyx.We conclude that both DSC and the width of the target calyx can be used as tools for predicting ultrasound-guided percutaneous success.(5)The tested laser guidance system was feasible to perform successful percutaneous punctures of the kidney in this ex vivo study.We believe the in-plane laser-guided puncture technique in PCNL with the ultrasound is an excellent additional instrument that allows the urologist to handle complex punctures.The application of laser guided puncture outfit is conducive to bridge the gap between novice and experienced surgeon,enhance the confidence of the performer,reduce the incidence of the complications of percutaneous nephrolithotomy,is worth popularizing in clinical. |
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