CUAJ – Techniques in Urology Beiko et al

Techniques: Ultrasound-guided PCNL

Techniques ‒ Ultrasound-guided percutaneous nephrolithotomy: How we do it

Darren Beiko, MD, MBA, FRCSC1; Hassan Razvi, MD, FRCSC2; Naeem Bhojani, MD,
FRCSC3; Jennifer Bjazevic, MD, FRCSC2; David B. Bayne, MD4; David T. Tzou, MD5;
Marshall L. Stoller, MD4; Thomas Chi, MD4
1
Department of Urology, Queen’s University, Kingston, ON, Canada; 2Division of Urology, Department of
Surgery, Western University, London, ON, Canada; 3Division of Urology, Université de Montréal,
Montreal, QC, Canada; 4Department of Urology, University of California at San Francisco, San Francisco,
CA, United States; 5Division of Urology, Department of Surgery, University of Arizona College of
Medicine, Tucson, AZ, United States

Cite as: Can Urol Assoc J 2019 September 27; Epub ahead of print.
http://dx.doi.org/10.5489/cuaj.6076

Published online September 27, 2019

***

Abstract

Ultrasonography has emerged as an alternative to fluoroscopy for image-guided

percutaneous nephrolithotomy (PCNL) in many countries. Compared to fluoroscopy-
guided PCNL (F-PCNL), ultrasound-guided PCNL (US-PCNL) is easier to learn and
reduces radiation exposure to patients and providers. Despite these advantages, uptake of
ultrasound-guided PCNL (US-PCNL) in Canada has been almost nonexistent, largely
because it is not incorporated into urologists’ training. In this article, we seek to
familiarize Canadian urologists with this approach by describing our step-by-step
technique for US-PCNL. Additionally, we provide keys to successful implementation of
this technique.
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Techniques: Ultrasound-guided PCNL

Introduction
In Canada, percutaneous nephrolithotomy (PCNL) is performed almost exclusively using
fluoroscopy as the image-guiding modality of choice.1,2 While a long-established
standard for imaging guidance, this technique can be challenging to learn,3 limiting the
number of urologists who perform PCNL regularly as part of their clinical practice.4 To
the best of our knowledge, there are no publications originating from a Canadian
institution describing ultrasound-guided PCNL (US-PCNL). However, US-PCNL has
gained popularity in the United States,5 Asia,6 Europe,7 the Middle East,8 South
America,9 and Africa10 over the past several years. Some institutions use ultrasound in
combination with fluoroscopy as a strategy to reduce ionizing radiation exposure,11
whereas others use it to completely eliminate exposure to radiation during PCNL.12,13
Although several variations on access techniques exist among the many urologists
performing US-PCNL around the world,14 the main overarching goals of making renal
access easier for urologists to achieve and reduce ionizing radiation exposure for patients
and providers remain the same. When appropriate we offer our patients US-PCNL, and
herein we describe our technique and keys to successful implementation of this
procedure.

Method

Patient selection
When starting any new approach, it is important to carefully select patients to decrease
morbidity, optimize patient safety and ensure acceptable outcomes. We therefore
recommend selecting generally healthy patients when first adopting this technique.
Although obesity is not contraindicated, the extra tissue between the flank and kidney
pose a challenge during the steps requiring ultrasonography to optimize imaging.15 We
therefore recommend selecting non-obese patients initially and waiting to attempt US-
PCNL on obese patients until after mastering the technique. Usawachintachit et al
showed that successful US-PCNL was associated with the presence of hydronephrosis
and the absence of a staghorn calculus.12 In summary, the ideal initial candidate for US-
PCNL is a generally healthy, non-obese patient whose imaging demonstrates a non-
staghorn calculus and at least moderate hydronephrosis. When starting up a new US-
PCNL program, we recommend seeking out these characteristics in the first several US-
PCNL cases.

Setup and equipment

Standard prophylactic intravenous antibiotics are given according to the local
antibiogram and per the Canadian Urological Association (CUA) guideline16 and/or the
American Urological Association (AUA) Best Practices Statement.17 Standard general
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anesthesia is administered. An externalized ureteral catheter is placed via a flexible or

rigid cystoscope in the supine, cystolithotomy, frog-leg or prone position, depending on
surgeon preference and experience. We selectively hang a gravity bag of saline between
40-60 cm above the kidney to allow for passive retrograde filling of the collecting system
while draping the patient so that by the time the surgeon is ready for renal access, most
collecting systems have artificially-induced mild to moderate hydronephrosis to enable
easier renal imaging. Similarly, depending on patient factors, the patient’s anatomy and
surgeon preference, the PCNL procedure can be performed in either the supine or prone
position. Relevant surface anatomy and surgical landmarks used to plan collecting system
puncture are shown for the supine and prone positions in Figures 1a and 1b, respectively.
In addition to standard equipment required for PCNL, the short list of required additional
required capital and disposable equipment and instruments are shown in Table 1.

Procedural steps

Step 1: Renal ultrasonography

Any portable ultrasound unit can be used with a standard abdominal probe. We prefer to
use a convex ultrasound transducer (i.e. a curved-surface probe) at a frequency of 3-5
megahertz (MHz), but a linear ultrasound transducer (i.e. a flat-surfaced probe) may also
be used. Although gel is conventionally used for diagnostic ultrasound imaging, to
prevent the surgeon's hands from becoming slippery, sterile water or saline periodically
applied onto the body wall is sufficient for coupling the probe and obtaining adequate
imaging. Initially, longitudinal ultrasound scanning is performed to assess the anatomy of
the kidney and perirenal tissues. By convention, the probe is oriented so the upper pole is
on the left side of the ultrasound screen. In the longitudinal plane the kidney is often
partially obscured by acoustic shadowing from the ribs (Figure 2), so the ultrasound
probe is rotated 30-45 degrees to align parallel to the ribs, thus eliminating the acoustic
rib shadowing. Posterior calyces are identified and the appropriate entry calyx is selected.

Step 2: Renal puncture

Percutaneous renal access is achieved using a 20-centimetre, 18-gauge renal access
needle. We prefer to use an echogenic needle that facilitates easier visualization of the
needle tip, but standard non-echogenic needles may also be visualized and used. One
advantage of ultrasound is that, regardless the desired location of puncture, upper,
interpolar, and lower pole access can be achieved using a longitudinal view of the needle
entering the desired target.14 In general, the needle enters the skin approximately 1 cm
away from the caudal end of the probe for a lower pole puncture (Figure 3a) and for an
upper pole puncture, the needle typically enters the skin 1 cm from the cephalad end of
the probe, (Figure 3b). In the longitudinal view, the goal is for the needle to be visualized
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in its entirety on the ultrasound monitor as it enters into the skin, crosses through the
subcutaneous, fascial, muscular, and perinephric layers through the kidney and into the
targeted calyx (Figure 4). While it is sometimes not possible to keep the needle in the
same plane and image as it is advanced into the target calyx, gently bouncing the needle
provides visual feedback to its location so that minor adjustments can be made. By
maintaining the longitudinal view and fanning the ultrasound probe back and forth to
identify the location of the needle relative to the targeted calyx, the needle can be re-
directed into the correct plane relative to the calyx of interest. Once in the collecting
system, removal of the needle stylet facilitates visualizing efflux of urine through the
needle or aspiration of urine confirms proper positioning of needle tip in the collecting
system. Our approach is to generally control the needle freehand without a needle guide
in order to preserve maximal flexibility in terms of angle of entry into the kidney. A
needle guide can, however, be attached to the ultrasound probe. Use of a needle guide
decreases the skill needed to keep the needle in the imaging view, and can therefore
facilitate easier renal access, particularly early in the surgeon’s learning curve.

Step 3: Guidewire access

The needle stylet is withdrawn to allow passage of a J-Tip coaxial guidewire through the
access needle. We use a J-tip wire to minimize chances of collecting system perforation,
but virtually any wire can be used for this step. In order to visualize the wire under
ultrasound however, the wire must be a wrapped or lined wire (Figure 5). Hydrophilic
wires are often so smooth that they are invisible under ultrasound guidance. The
guidewire tip, and its relation to the collecting system, can be localized by gently jiggling
the guidewire forward and backward. Using this jiggling motion under ultrasound
guidance again provides visual feedback to its location. The guidewire is then secured in
place for dilation either within the intrarenal collecting system or advanced down the
ureter.

Step 4: Tract dilation

The access needle is withdrawn overtop the guidewire and an appropriate skin incision is
made. A 10Fr fascial dilator is then passed over the guidewire. Importantly, the non-
echogenic nature of common fascial dilators and safety wire introducers (made of
polypropylene or similar synthetic polymer) causes them to obscure visualization of the
guidewire as it passes over top the wire (Figure 6). Hence, under ultrasound guidance, it
is by ultrasonographically detecting the obscuring of the guidewire that the position of
the fascial dilator tip is established. With ultrasound guidance, balloon dilation is much
easier to visualize compared to serial dilation, and we recommend utilizing a balloon
device for tract dilation and sheath placement. To achieve this, the balloon-dilating
catheter is then advanced over the guidewire and its tip is positioned into the collecting
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system. Most balloon tips are slightly echogenic compared to the wire and the goal is to
visualize the tip as it advances into the collecting system to verify accurate placement.
Jiggling of the guidewire can aid in ensuring proper positioning of the balloon tip, which
is ideally within the entry calyx in most cases. Dilation of the balloon is then performed
to create the working tract (Figure 7).

Step 5: Sheath placement

Over the balloon dilator, a percutaneous access sheath is carefully advanced under
ultrasound-guidance. As this step is difficult to track ultrasonographically, it is
recommended the sheath be advanced only until the back end of the balloon is seen
through the external aspect of the sheath (Figure 8). This can be measured before
placement of the balloon to estimate correct sheath placement. The balloon catheter is
then withdrawn, leaving the sheath and guidewire in place.

Step 6: Nephroscopy and stone removal

Nephroscopy for stone removal proceeds from this point per usual care. This
endoscopically driven step is performed using the same technique as standard
fluoroscopy-guided PCNL (F-PCNL). With an ultrasound console available in the
operating room, ultrasonographic imaging can be used to verify location of the flexible
nephroscope and residual stones to ensure visualization and stone clearance of all
relevant calyces similarly to how retrograde/antegrade pyelography is used currently.

Step 7: Renal drainage

We achieve ultrasound-guided renal drainage by placing a 10Fr cope loop pigtail
nephrostomy tube and/or 6Fr ureteral stent. These drainage tubes can be visualized as
parallel echogenic lines in the collecting system. In cases when tube or stent positioning
cannot be confirmed ultrasonographically, cystoscopy and/or nephroscopy may be used
as necessary to confirm coiling of ureteral stent in the bladder and coiling of stent/pigtail
nephrostomy in renal pelvis, respectively.

Step 8: Nephrostogram
Contrast-enhanced ultrasound nephrostogram18 is performed using a low dose ultrasound
contrast agent solution. We inject 1.5 mL of Optison™ (GE Healthcare) through the
nephrostomy tube, immediately followed by a 5 mL injection of 0.9% NaCl flush, to
assess of patency of ureteropelvic junction and ureter.

Discussion
Since the inception of PCNL in the 1970’s,19 fluoroscopy has been the most commonly
used imaging modality used to guide the surgical steps, as reflected by 86.3% of PCNL
cases being performed with fluoroscopy guidance in the CROES Global PCNL study.20
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Mounting concerns regarding cumulative doses of ionizing radiation imposed on patients

with urolithiasis have emerged in recent years.21 In an effort to adhere to radiation safety
principles such as ALARA (as low as reasonably achievable), intraoperative radiation-
reducing maneuvers during endourologic cases have been implemented.22-24 It follows
that perhaps the most obvious advantage of US-PCNL over F-PCNL is the reduction—or
in some cases, complete elimination—of ionizing radiation exposure to the patient and
members of the operating room (OR) team. Obese patients appear to experience the
greatest reduction in ionizing radiation exposure and therefore may benefit most from
US-PCNL.25 As outlined in Box 1, there are many other potential advantages to using
ultrasound to guide PCNL. First, ultrasound can be conveniently performed in any
position, ranging from the prone position (the PCNL position most familiar to Canadian
urologists) to the supine position. Second, easier identification of a posterior calyx
compared to fluoroscopy facilitates a geometrically favorable access to most of the
collecting system. In fact, ultrasound often identifies additional posterior calyces that are
not readily seen fluoroscopically. Third, ultrasonography provides real-time visualization
of renal pathology (i.e. cysts, calyceal diverticula, tumours) and surrounding visceral
organs and structures (i.e. liver, spleen, bowels, pleura/lung, great vessels), thereby
preventing or decreasing the risk of organ injury. Furthermore, Doppler flow imaging
permits identification of intrarenal blood vessels, which in turn can help avoid blood
vessel injury and excessive bleeding. Fourth, intraoperative setup is improved because
the ultrasound machine requires much less square footage than fluoroscopy machines in
the tight-spaced OR working environment. Fifth, when completely fluoroscopy-free US-
PCNL is performed, physicians and OR personnel may experience less fatigue and back
and neck pain/discomfort because there is no need to wear protective lead aprons.
Elkoushy et al found that 64.2% of endourologists have orthopedic complaints, and these
complaints correlated with combined annual caseload of ureteroscopy and PCNL
procedures.26 Sixth, ultrasound facilitates contrast-enhanced ultrasound nephrostogram, a
modality that allows assessment of patency of the ureteropelvic junction and ureter post-
PCNL.18 Seventh, of great importance to hospital administrators, US-PCNL has been
shown to be associated with lower institutional costs than F-PCNL.27 Eighth, residency
program directors and fellowship program directors will be reassured by the relatively
short learning curve of US-PCNL5,28,29. Finally, US-PCNL can be particularly
advantageous in certain circumstances such as pediatric cases where radiation exposure is
of greater concern, or urinary diversions when retrograde catheterization is not possible.
Despite these numerous advantages, there are some disadvantages to US-PCNL
compared to F-PCNL. The most obvious disadvantage is the lack of both familiarity and
expertise in the interpretation of ultrasonographic static and dynamic images compared to
standard fluoroscopic images for most urologists. At the present time, Canadian
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urologists are much more familiar with performing and interpreting retrograde
pyelography and antegrade nephrostography compared to renal ultrasound. Additionally,
in 2019 ultrasound still lacks anatomic detail of the collecting system that is provided by
standard pyelography, particularly concerning the infundibulo-pelviceal anatomy and
angles. This can render certain steps of US-PCNL to be more challenging compared to F-
PCNL, including guidewire placement, tract dilation, sheath placement and placement of
a nephrostomy tube or ureteral stent. However, these disadvantages can be overcome as
experience is gained.
Potential disadvantages notwithstanding, ultrasound-guided PCNL has emerged,
however, as a reliable, effective and safe option. A systematic review on US-PCNL
versus F-PCNL was recently published, and it demonstrated that US-PCNL is as effective
as F-PCNL and is associated with lower complication rates.30 Certainly the known risks
of ionizing radiation have contributed to the trend toward US-PCNL, but as outlined in
Box 1 there are several added benefits of using ultrasonography to guide PCNL.

How can I pursue US-PCNL training?

For urologists performing PCNL who are interested in learning this technique, there are
several training options to consider. First, one may pursue a formal or informal
observership or preceptorship with a skilled specialist, and although this may sometimes
be available locally (for example, with an interested local interventional radiologist),
often a visit to an expert at his/her own institution can be beneficial. Alternatively, one
may attend a diagnostic and/or therapeutic ultrasonography course to learn the basic skills
needed to perform renal ultrasonography in various positions. There has been an increase
in the number of PCNL courses that teach ultrasound-guided techniques, created by
urologists for urologists and designed to impart this skill set. One practical and
inexpensive way of familiarizing oneself with renal ultrasound imaging is to take
advantage of any opportunities to perform renal ultrasonography on patients in multiple
settings, with their consent (i.e. in clinic, in the emergency room, during shock wave
lithotripsy or in the operating room immediately prior to PCNL or other procedures).
With this approach, one can overcome the first learning curve in adopting US-PCNL –
namely mastering the ability to obtain a good image of the kidney and collecting system.
Another inexpensive way of training is to use one of the low fidelity simulation models
that are available.28 Breaking up the mastery of US-PCNL into two skills—diagnostic
renal imaging and needle control—is a good framework by which the learner can focus
on the two skills separately and thereby move toward learning US-PCNL in a systematic
fashion.
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How do I start performing US-PCNL?

After training, the next step is to implement the technique in one’s operating room. In
doing so, there are several recommended keys to success. Acquisition of all required
capital and disposable equipment and instruments, listed in Table 1, is crucial. Ideally,
one can acquire equipment that one is familiar with and/or trained with. Many hospitals
and operating room suites have one or more portable ultrasound units, so in general the
cost to start up an US-PCNL program should not be prohibitive.27 Obtaining support from
one’s nursing and anesthesiology colleagues should be easy since US-PCNL will
decrease everyone’s exposure to ionizing radiation and may eventually result in
fluoroscopy-less PCNL and elimination of the need to wear lead intraoperatively. One
final recommendation applicable when starting up any new clinical program in general is
to avoid making any other substantive changes in preoperative or postoperative patient
management as the program is being built. By maintaining one’s usual care and PCNL
clinical pathway, the true effects of US-PCNL on OR team performance and patient
outcomes will be discernable.
We recommend a stepwise progression in converting the above 8 steps from
fluoroscopy guidance to ultrasound guidance. We recommend progressing by initially
using ultrasound to guide step 1 and maintaining fluoroscopy for steps 2 through 8. Once
step 1 has been mastered, then one can progress to step 2, performing steps 1 and 2 using
ultrasound guidance and steps 3-8 using fluoroscopy, and so on. Until all 8 steps have
been mastered, one will have to employ radiation safety measures and wear radiation
protection equipment. This stepwise introduction of ultrasound techniques is expected to
result in mastery that will facilitate a safe progression from F-PCNL to completely
fluoroscopy-less US-PCNL. Only once one has reliably achieved zero-fluoroscopy PCNL
will one become comfortable scrubbing in for PCNLs without wearing radiation safety
equipment.
As stated above, proper patient selection is paramount to successful adoption of
US-PCNL and implementation of a surgical program. We recommend initial cases
involve non-staghorn calculi in healthy, non-obese patients with hydronephrotic kidneys.
Hydronephrosis provides a larger volume “target” for needle puncture. Retrograde saline
injection can be performed to artificially induce hydronephrosis. Alternatively, contrast-
enhanced ultrasound nephrostogram can be performed via retrograde ureteral contrast
injection to guide puncture when there is no hydronephrosis.31
As for any new program, periodic evaluation and re-evaluation is recommended.
If technology permits, part of the evaluation may involve video recording, but certainly a
review of patient outcomes, particularly compared to one’s F-PCNL experience, is
recommended.
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Conclusions
Ultrasound-guided PCNL has been widely shown to be safe and effective. This technique
is a “win-win” opportunity; patients as well as OR personnel will be exposed to less
ionizing radiation. Although learning US-PCNL may seem like a daunting task initially,
the literature has shown that this technique is relatively easy to learn and achievable by
any practicing urologist. We recommend it for urologists already performing PCNL who
want to increase the safety of PCNL and also for urologists not performing PCNL who
are interesting in learning PCNL.
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References

1. Duvdevani M, Razvi H, Sofer M, et al. Third prize: contemporary percutaneous

nephrolithotripsy: 1585 procedures in 1338 consecutive patients. J Endourol
2007;21:824-9.
2. Noureldin YA, Elkoushy MA, Andonian S. Predictors of fluoroscopy time during
percutaneous nephrolithotomy: impact of postgraduate urology trainees and
S.T.O.N.E. nephrolithometry score. J Endourol 2015;29:542-7.
3. Tanriverdi O, Boylu U, Kendirci M, et al. The learning curve in the training of
percutaneous nephrolithotomy. Eur Urol 2007;52:206-11. Epub 2007 Jan 10.
4. Sivalingam S, Cannon ST, Nakada SY. Current practices in percutaneous
nephrolithotomy among endourologists. J Endourol 2014;28:524-7. doi:
10.1089/end.2013.0447. Epub 2014 Jan 31.
5. Usawachintachit M, Masic S, Allen IE, et al. Adopting Ultrasound Guidance for
Prone Percutaneous Nephrolithotomy: Evaluating the Learning Curve for the
Experienced Surgeon. J Endourol 2016;30:856-63.
6. Li J, Xiao B, Hu W, et al. Complication and safety of ultrasound guided
percutaneous nephrolithotomy in 8,025 cases in China. Chin Med J (Engl)
2014;127:4184-9.
7. Ramón de Fata F, Pérez D, Resel-Folkersma L, et al. Analysis of the factors
affecting blood loss in percutaneous nephrolithotomy: a registry of the Spanish
Association of Urology in the supine position. Actas Urol Esp 2013;37:527-32.
8. Inanloo SH, Yahyazadeh SR, Rashidi S, et al. Feasibility and Safety of
Ultrasonography Guidance and Flank Position during Percutaneous
Nephrolithotomy. J Urol 2018;200:195-201.
9. Batagello CA, Vicentini FC, Marchini GS, et al. Current trends of percutaneous
nephrolithotomy in a developing country. Int Braz J Urol 2018;44:304-313.
10. Gamal WM, Hussein M, Aldahshoury M, et al. Solo ultrasonography-guided
percutanous nephrolithotomy for single stone pelvis. J Endourol 2011;25:593-6.
11. Zhu W, Li J, Yuan J, et al. A prospective and randomised trial comparing
fluoroscopic, total ultrasonographic, and combined guidance for renal access in
mini-percutaneous nephrolithotomy. BJU Int 2017;119:612-618. doi:
10.1111/bju.13703. Epub 2016 Nov 28.
12. Usawachintachit M, Tzou DT, Hu W, et al. X-ray-free Ultrasound-guided
Percutaneous Nephrolithotomy: How to Select the Right Patient? Urology
2017;100:38-44.
13. Nouralizadeh A, Sharifiaghdas F, Pakmanesh H, et al. Fluoroscopy-free
ultrasonography-guided percutaneous nephrolithotomy in pediatric patients: a
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single-center experience. World J Urol 2018;36:667-671.

14. Chu C, Masic S, Usawachintachit M, et al. Ultrasound-Guided Renal Access for
Percutaneous Nephrolithotomy: A Description of Three Novel Ultrasound-Guided
Needle Techniques. J Endourol 2016;30:153-8.
15. Usawachintachit M, Tzou DT, Washington III SL, Hu W, Li J, Chi T. Ultrasound-
guided renal access and tract dilation. Videourology 2016;31:Published online 19
September 2016. https://doi.org/10.1089/vid.2016.0046
16. Mrkobrada M, Ying I, Mokrycke S, et al. CUA Guidelines on antibiotic
prophylaxis for urologic procedures. Can Urol Assoc J 2015;9:13-22. doi:
10.5489/cuaj.2382.
17. Wolf JS Jr, Bennett CJ, Dmochowski RR, et al. Best practice policy statement on
urologic surgery antimicrobial prophylaxis. Urologic Surgery Antimicrobial
Prophylaxis Best Practice Policy Panel. J Urol 2008;179:1379-90. doi:
10.1016/j.juro.2008.01.068. Epub 2008 Feb 20.
18. Chi T, Usawachintachit M, Mongan J, et al. Feasibility of Antegrade Contrast-
enhanced US Nephrostograms to Evaluate Ureteral Patency. Radiology
2017;283:273-9.
19. Fernström I, Johansson B. Percutaneous pyelolithotomy. A new extraction
technique. Scand J Urol Nephrol 1976;10:257-9.
20. Andonian S, Scoffone CM, Louie MK, et al; CROES PCNL Study Group. Does
imaging modality used for percutaneous renal access make a difference? A
matched case analysis. J Endourol 2013;27:24-8.
21. Elkoushy MA, Andonian S. Lifetime Radiation Exposure in Patients with
Recurrent Nephrolithiasis. Curr Urol Rep 2017;18:85.
22. Arenas JL, Baldwin DD. Techniques for Minimizing Radiation Exposure During
Evaluation, Surgical Treatment, and Follow-up of Urinary Lithiasis. Curr Urol
Rep 2015;16:45.
23. Elkoushy MA, Shahrour W, Andonian S. Pulsed fluoroscopy in ureteroscopy and
percutaneous nephrolithotomy. Urology 2012;79:1230-5.
24. Smith DL, Heldt JP, Richards GD, et al. Radiation exposure during continuous
and pulsed fluoroscopy. J Endourol 2013;27:384-8.
25. Usawachintachit M, Masic S, Chang HC, Allen IE, Chi T. Ultrasound Guidance
to Assist Percutaneous Nephrolithotomy Reduces Radiation Exposure in Obese
Patients. Urology 2016;98:32-38. doi: 10.1016/j.urology.2016.04.012. Epub 2016
Apr 22.
26. Elkoushy MA, Andonian S. Prevalence of orthopaedic complaints among
endourologists and their compliance with radiation safety measures. J Endourol
2011;10:1609-13.
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27. Hudnall M, Usawachintachit M, Metzler I, et al. Ultrasound Guidance Reduces

Percutaneous Nephrolithotomy Cost Compared to Fluoroscopy. Urology
2017;103:52-8.
28. Filippou P, Odisho A, Ramaswamy K, et al. Using an abdominal phantom to
teach urology residentes ultrasound-guided percutaneous needle placement. Int
Braz J Urol 2016;42:717-26.
29. Song Y, Ma Y, Song Y, et al. Evaluating the Learning Curve for Percutaneous
Nephrolithotomy under Total Ultrasound Guidance. PLoS One
2015;13:10:e0132986. doi: 10.1371/journal.pone.0132986. eCollection 2015.
30. Yang YH, Wen YC, Chen KC, et al. Ultrasound-guided versus fluoroscopy-
guided percutaneous nephrolithotomy: a systematic review and meta-analysis.
World J Urol 2018 Sep 22. doi: 10.1007/s00345-018-2443-z. [Epub ahead of
print]
31. Usawachintachit M, Tzou DT, Mongan J, et al. Feasibility of Retrograde Ureteral
Contrast Injection to Guide Ultrasonographic Percutaneous Renal Access in the
Nondilated Collecting System. J Endourol 2017;31:129-134.
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Figures and Tables

Fig. 1. Surface anatomy and surgical landmarks for ultrasound-guided percutaneous

nephrolithotomy. (A) Supine; (B) prone.

B
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Fig. 2. Acoustic shadows from stones (small arrows) and rib (large arrow) in longitudinal
plane.
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Fig. 3. Needle enters skin 1 cm from caudal or cephalad end of ultrasound probe for (A)
lower and (B) upper pole puncture, respectively.

B
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Fig. 4. Visualization of needle (arrow) in its entirely as it traverses all layers into kidney.

Fig. 5. Non-hydrophilic guidewire readily visualized as it secures lower pole access

(same case as Fig. 4).
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Fig. 6. Position of tip of 10 Fr fascial dilator over guidewire determined by obscuring of

guidewire by non-echogenic dilator (same case as Fig. 5, illustrates effect of fascial
dilator).

Fig. 7. Balloon dilation of lower pole tract (same case as Fig. 6).
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Fig. 8. Percutaneous access sheath advanced until back end of balloon is seen through
external aspect of sheath.

Box 1. Advantages of ultrasound-guided percutaneous

nephrolithotomy (US-PCNL)
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Table 1. Capital and disposable equipment needs for ultrasound-guided

percutaneous nephrolithotomy
Portable ultrasound unit
Reusable Convex ultrasound transducer
Needle guide
Sterile ultrasound console cover
Sterile ultrasound probe cover
Disposable Echogenic tip access needle
J-Tip coaxial guidewire
10Fr fascial dilator
Ultrasound contrast agent solution