Difficult Renal Puncture Geometrical Study
Difficult Renal Puncture Geometrical Study
Volume 6, Issue 12, December – 2021 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
Difficult Renal Puncture: Geometrical Study
Jihad El Anzaoui Chatar Achraf Abdelghani Ammani
(Professor assistant of urology) (Urologist) (Professor of urology)
Urology department Urology department Urology department
Military hospital My Ismail Meknes Military hospital My Ismail Meknes Military hospital My Ismail Meknes
Meknes, Morocco Meknes, Morocco Meknes, Morocco
Akajai Ali, Amaziane Ahmed, Lakrabti Naceur, Habyebete Soufiane
(Resident of urology) Urology department,
Military hospital My Ismail Meknes
Meknes, Morocco
Abstract :- Fluoroscopyis a valuable and reliable tool formany
Background : The fluoroscopic guidance of image-guided surgical procedures (2, 3, 4).
percutaneous nephrolithotomy (PCNL) is a worldwide
known procedure. Currently, more and more In the PCNL procedure, all initial steps are dependent
practitioners perform renal puncture in monoplanar on fluoroscopy guidance.
fluoroscopic projection without need of moving the C-
The puncture of the targeted calyx can be done by
arm.
ultrasound. However, one-shot or gradual path dilation and
The depression of the tip of he calyx is the proof of the introduction of the access sheath are entirely dependent
the perfect position of the needle. on fluoroscopic guidance.
However, in the case of dificult renal puncture, the In fact, by providing a real-time localization and
surgeon or the radiologist is forced to manipulate the C- interaction of radiopaque structures (opacifiedrenalcalyx,
arm to delineate the position of the needle either it is puncture needle, guide wires, Amplatzsheath,
anterior or posterior to the calyx. ureteralstents,..) fluoroscopic imaging is essential for the
feasibility and safety of the intervention (5).
The interpretation of the fluoroscopic view is still
sometimes subject to confusion especially for nonexpert Kidney puncture on fluoroscopy guidance, in
urologists. particular, remains the most challenging procedure and the
most at risk of failure.
Results : the understanding of fluoroscopic findings is
based on geometrical considerations. the authors A failed or difficult puncture leads to repetitive
propose a well-illustrated essay trying to explain the attempts which increases the risk of bleeding and radiation
movement of the C-arm in case of failed calyceal exposure.
puncture in diferent directions.
Also, the expansion of percutaneous indications with
Conclusion : the surgeon or the radiologist needs after the advent of mini and microinstruments is leading surgeons
asessement of the first puncture, to move the C-arm in to puncture increasingly non dilated cavities, more and more
his preferred plan to delineate precisely in which difficult to puncture (6).
location is the needle in relation to the calyx and adjust Failure of the first punctures can sometimes lead the
accordingly the position of the needle. excretory cavities to collapse giving less chance of success
Keywords :- Image guided surgery, urinary stone, of subsequent punctures.
fluoroscopy, percutaneous nephrolithotomy, percutaneous Thus, the mastery of the puncture technique whatever
nephrostomy. its nature must be perfect and based on valid theoretical
I. INTRODUCTION knowledge.
Fluoroscopic guidance is the cornerstone of PCNL The triangulation technique is among the most used
which still an unmissable technique in stone surgery. techniques for puncture of the targeted calyx (7).
From a radiological point of view, Fluoroscopy It is based on geometrical concepts to correct the
provides real-time, interactive X-ray projection imaging. absence of the third dimension in the biplanar projection.
Fluoroscopic procedures consist of using an X-ray generator Currently, more urologist in the case of dilated calyx
prsoviding alow dose X-ray beam, an X-ray detector to are convinced that monoplanar vertical fluoroscopic view is
detect the X-ray pattern emergingfrom the patient body suffisent to puncture the targeted calyx (8,9).
afterremoval of scattered radiation, and an image intensifier
to create an image projection of radiopaque structures (1). In the case of non dilated calyx or complex calyceal
anatomy, the movement of C-arm is of paramount
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Volume 6, Issue 12, December – 2021 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
importance to clarify the position of the needle according to C. The user interface
the calyx. It allows through an on-board computer to control the
technical aspects of the machine (collimation, dose,
The movement of the C-arm is a helpful tool in this movement of C-arm, orientation of the image, contrast, ...),
situation as described by Gökce Mİ et al. (10). We propose a treats the image provided by the image intensifier and
geometrical model trying to explain this technique according transmits it to the screen.
to the position of the patient and the image intensifier.
D. The display
II. FLUOROSCOPY PRINCIPLE It visualizes fluoroscopy view into 2D images.
The discovery of X-rays was performed by Röntgen in a) How does the movement of the C-arm change the
1895 and the first use of X-rays in urology was attempted by fluoroscopy image ?
Wickbom in 1954 (11). The image on the screen depends mathematically on
the position of the C-arm according to the position of the
The medical use is based on the modification of the patient body. Each movement of the C-arm causes a rotation
energy of the X-ray beam after crossing the human body. or translation of the image.
As an X-ray beam passes through the body, the body Any position of the C-arm induces an intersection of
tissues and bones absorb the beam in varying amounts the X-ray beam with the patient's body in a given region and
depending on its density. The output is picked up on a with a very precise angulation, which defines the final
sensor placed on the opposite side of the beam which image on the screen.
transforms radiation into image (1).
What confuses the observer, in this case, is surely the
This image is the projection of 3D radiopaque change in orientation of the image.
structures in a flat 2D black and white spectrum.
To simplify the explanation, we present different
The principle of urography consists of the injection of positions of the C-arm with their impact on the orientation
the iodine contrast product either through an external of the image on the screen (FIG 2, FIG 3, FIG 4, FIG 5, FIG
ureteral stent, placed endoscopically in the renal cavities, or 6).
directly by needle puncture of the excretory system.
III. DIFFERENT MANEUVERS OF C-ARM
The contrast product submerges the excretory system.
The X-ray exposure delineates the pyelocalicial tree as a The manipulation of the C-armis based on the basic
biplanar projected image. principle of radiology: two views are necessary for
localization.
The typical fluoroscopy system used in urology is
composed of 4 principal components (FIG1): The first image on the position of 0oallows the
adjustment of the needle in 2 plans : craniocaudal and
A. The X-ray generator lateromedial. But itdoes notin form about the position of the
Using the emission of electrons by the heated cathode. needle in the anteroposterior plane. Although in position 0o,
The collision of electrons with anode produces X-rays. the tip of the needle appears in contact with the fornix of the
calyx, it does not mean that it is true because all parallelline
The generator is placed underneath the operating table to the direction of the X-ray beam passing by the tip of the
to limit radiation exposure. calyxis projected on one single dot on the screen. The
Collimation, which means focusing X-rays on the movement of the image intensifier by 30o or more in
targeted area, is regulated by the user interface. different plans delineates the position of the needle
anteroposteriorly by demonstrating a translation of the
B. The image detector and intensifier position of the needle on the screen. We will explain the
It collects the X-ray beam that passed through the patient direction of the displacement of the needle corresponding to
body. each movement of the C-arm. But in practice, the choice of
one direction of the movement of the C-arm is suffisent.
It performs amplification and transformation of X-rays
into light. The incident X-ray distribution is converted 1. How does the image move when the image intensifier
through 4 physical steps to the ultimate electronic signal. moves toward the surgeon by 30o ?
The X-ray generator and the image intensifier are If the needle is anterior to the calyx (red needle) in
connected by a mobile metallic C-arm. Which allowed the position 0o, it moves on the screen deeply into the calyx.
maneuver ability and the adjustment of the position of the
generator in different plans: anteroposterior, mediolateral, If the needle is posterior to the calyx (green needle), it
and craniocaudal, depending on the position of the operating goes away from the calyx.
table and the targeted area of the body. (FIG 7, FIG 8)
2. How doesthe image move when the image intensifier
move far from the surgeon by 30o ?
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Volume 6, Issue 12, December – 2021 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
If the needle is anterior to the calyx (red needle), it goes
away from the calyx
If the needle is posterior to the calyx (green needle), it
moves into the calyx.
(FIG 9, FIG 10)
3. How does the image move when the image intensifier
move toward the head of the patient by 30o ?
If the needle is anterior to the calyx (red needle), it goes
below the calyx.
If the needle is posterior to the calyx (green needle), it Fig. 3: rotation of the C-arm in the axial plane towards the
moves above the calyx. lateralside.
(FIG 11, FIG 12) Ant : anterior, post : posterior.
4. How does the image move when the image intensifier
move toward the feet of the patient by 30o ?
If the needle is anterior to the calyx (red needle), it
moves above the calyx.
If the needle is posterior to the calyx (green needle), it
moves below the calyx.
(FIG 13, FIG 14).
IV. CONCLUSION
The comprehension of the impact of C-arm movements
on the screen imageis an essential step to perform PCNL.
The interpretation of the fluoroscopic view is based on
geometrical rules easy to understand. Fig. 4: rotation the C-arm in the axial plane towards the
medial side.
V. CAPTIONS
Fig. 1: Components of the fluoroscope.
1 : X-ray generator, 2 : image intensifier, 3 : C- arm,
4 : user inetrface, 5 : screen display. Fig 5. : rotation of the C-arm in the sagittal plane towards
the head of the patient.
Fig. 2: the orientation of the fluoroscopic view in position
0 with the targeted area on the right side if supine position,
or left side if prone position. Fig 6. : rotation of the C-arm in the sagittal plane towards
the feet of the patient.
Sup : superior, inf : inferior, med ; medial, lat : lateral.
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Volume 6, Issue 12, December – 2021 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
Fig. 7 : movement of the C-arm towards the surgeon by 30o. a : the tip of the redneedlewhichisanterior to the calyx.
b : the tip of the green needlewhichisposterior. c : the tip of the targetedcalyx.
a’, b’, c’ are respectively the projections of a,b, and c on the fluoroscopicview in 0 o.
a’’, b’’, c’’ are respectively the projection of a,b, and c on the fluoroscopic view in 30o.
Fig. 8 : by changing the position of the C-arm towards the surgeon, the anterior needle moves deeply into the calyx, and the
posterior needle migrates far from the calyx.
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Volume 6, Issue 12, December – 2021 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
Fig. 9 : movement of the C-arm far from the surgeon by 30o.
Fig. 10 : by changing the position of the c arm far from the surgeon, the anterior needle moves far from the calyx, and the
posterior needle goes deeply into the calyx.
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Volume 6, Issue 12, December – 2021 International Journal of Innovative Science and Research Technology
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Fig. 11 : movement of the C-arm towards the head of the patient by 30o.
Fig. 12 : by changing the position of the c arm towards the head of the patient, the anterior needle moves below the calyx, and the
posterior needle moves above the calyx.
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Fig. 13 : movement of the C-arm towards the feet of the patient by 30o.
Fig. 14 : By changing the position of the c arm towards the head of the patient, the anterior needle moves above the calyx, and the
posterior needle moves below the calyx.
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DECLARATION OF COMPETING INTEREST [10.] Mc Clafferty CK. The X-ray'searly days. Radiol
Technol. 1995 Nov-Dec;67(2):157-8.
The authors declare that they have no known
competing financial interests or personal relationships that
could have appeared to influence.
CONTRIBUTIONS
All authors have aprticipated to the design, the writing
and the editing of the article.
AKNOWLEDGEMENTS
The authors think Mr Abdellah Ghazi for histechnical
support.
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