Setbacks/Challenges & Solutions
- The obese patient
- Dr. Canales: opt for a split prone positioning with a “Wilson Frame” positioner, allowing for continued access for anesthesia and minimal movement required to position the patient.
- Dr. Gupta: use two transverse bolsters in prone position place at the shoulder level across the chest, and one across the hips, thereby allowing the abdomen and pannus to remain free.
- Dr. Krambeck: use a single transverse bolster across the chest in prone position
- Difficult percutaneous access
- Dr. Krambeck: establish access using a floppy tip guidewire with the entire length wettened
- Remember the “Rule of 3”
- Create a new stab incision for access
- Use continuous fluoroscopy as the C-arm moves from AP to oblique view
- Try a new calyx
- Dr. Gupta: the planning differs based on the size of the cyst
- For a small cyst, obtain access directly through the cyst as if it did not exist
- For a large cyst, using ultrasound-guidance, aspirate the cyst until it is nearly nonexistent, and then attempt the access
- Dr. Gupta: Separate “wind” and “water”. Insert a stent antegrade to drain the collecting system, and pull the nephrostomy tube back into the colon, leaving it in place for about 2 weeks as a colostomy tube, and gradually remove it. Leave a ureteral stent after this for about 4 weeks.
- Tips to avoid colonic injury: look at preoperative imaging very carefully to make sure there is no retrorenal colon
- 1-2% patients have retrorenal colon, and this is increases to about 25% in patients with scoliosis
Moderator: Bodo E. Knudsen
Panelists: Benjamin K. Canales, MD; Mantu Gupta, MD; Amy Krambeck, MD
Written By: Shoaib Safiullah, MS4 for UroToday.com
at the 2017 AUA Annual Meeting - May 12 - 16, 2017 – Boston, Massachusetts, USA