Prone Percutaneous Access: Case Discussion—Caliceal Diverticular Calculi

  • John D. DenstedtEmail author
  • Andrew Fuller


Since its initial description by Fernstrom and Johansson in 1976, percutaneous nephrolithotomy (PCNL) has evolved with improvements in technique and equipment to become the gold standard form of management for large stones in the upper urinary tract. It has now largely replaced open surgery in this context. Although alternatives such as supine patient positioning have emerged in the last decade, the vast majority of PCNL cases worldwide continue to be performed prone, with high stone-free rates (SFR) and a low incidence of major complications (Duvdevani et al., J Endourol, 21:824–9, 2007; de la Rosette et al., J Endourol, 25:11–7, 2011).

The ability to safely and efficiently achieve percutaneous renal access depends on a number of factors including appropriate training, careful preoperative planning, recognition of anatomical variation, interpretation of radiological investigations, reproducible technique, and the availability of specialized instrumentation to effectively delineate and negotiate the urinary tract. Tract placement by the treating urologist without the involvement of an interventional radiologist in routine cases has been shown to be associated with excellent outcomes (Tomaszewski et al., J Endourol, 24:1733–7, 2010; El-Assmy et al., J Urol, 178:916–20, 2007; Watterson et al., J Urol, 176:142–5, 2006). Additionally, such an approach allows PCNL to be performed as a one-stage procedure with the opportunity to place additional tracts as dictated by intraoperative findings.

This chapter summarizes what we believe to be a series of safe and effective strategies when performing percutaneous renal access. In presenting the chapter, we acknowledge that there are many effective alternate approaches to PCNL, some of which may not have been incorporated into this work. Many cases require the endourologist to safely apply a range of techniques in combination to achieve the desired outcome.


Renal Pelvis Shock Wave Lithotripsy Extracorporeal Shock Wave Lithotripsy Stone Removal Ureteral Catheter 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Caliceal diverticulum


Computed tomography


Percutaneous nephrolithotomy


Stone-free rate


Shock wave lithotripsy


Transdiverticular puncture and neoinfundibulotomy


Ureteropelvic junction






Urinary tract infection


  1. 1.
    Duvdevani M, Razvi H, Sofer M, Beiko DT, Nott L, Chew BH, Denstedt JD. Contemporary percutaneous nephrolithotripsy: 1585 procedures in 1338 consecutive patients. J Endourol. 2007;21(8):824–9.PubMedCrossRefGoogle Scholar
  2. 2.
    de la Rosette J, Assimos D, Desai M, Gutierrez J, Lingeman J, Scarpa R, Tefekli A. The clinical research office of the endourological society ­percutaneous nephrolithotomy global study: indications, complications, and outcomes in 5803 patients. J Endourol. 2011;25(1):11–7.PubMedCrossRefGoogle Scholar
  3. 3.
    Tomaszewski JJ, Ortiz TD, Gayed BA, Smaldone MC, Jackman SV, Averch TD. Renal access by urologist or radiologist during percutaneous nephrolithotomy. J Endourol. 2010;24(11):1733–7.PubMedCrossRefGoogle Scholar
  4. 4.
    El-Assmy AM, Shokeir AA, Mohsen T, El-Tabey N, El-Nahas AR, Shoma AM, et al. Renal access by urologist or radiologist for percutaneous nephrolithotomy—is it still an issue? J Urol. 2007;178(3 Pt 1):916–20. discussion 920.PubMedCrossRefGoogle Scholar
  5. 5.
    Watterson JD, Soon S, Jana K. Access related complications during percutaneous nephrolithotomy: urology versus radiology at a single academic institution. J Urol. 2006;176(1):142–5.PubMedCrossRefGoogle Scholar
  6. 6.
    Management of ureteral calculi: EAU/AUA nephrolithiasis panel. 2007 [cited 2012 Feb 10]. Available from:
  7. 7.
    Mariappan P, Smith G, Moussa SA, Tolley DA. One week of ciprofloxacin before percutaneous nephrolithotomy significantly reduces upper tract infection and urosepsis: a prospective controlled study. BJU Int. 2006;98(5):1075–9.PubMedCrossRefGoogle Scholar
  8. 8.
    Hopper KD, Sherman JL, Luethke JM, Ghaed N. The retrorenal colon in the supine and prone patient. Radiology. 1987;162(2):443–6.PubMedGoogle Scholar
  9. 9.
    Patel U, Walkden RM, Ghani KR, Anson K. ­Three-dimensional CT pyelography for planning of percutaneous nephrostolithotomy: accuracy of stone measurement, stone depiction and pelvicalyceal reconstruction. Eur Radiol. 2009;19(5):1280–8.PubMedCrossRefGoogle Scholar
  10. 10.
    Sampaio FJ. Renal anatomy: endourologic considerations. Urol Clin North Am. 2000;27(4):585–607.PubMedCrossRefGoogle Scholar
  11. 11.
    Sukumar S, Nair B, Ginil KP, Sanjeevan KV, Sanjay BH. Supracostal access for percutaneous nephrolithotomy: less morbid, more effective. Int Urol Nephrol. 2008;40(2):263–7.PubMedCrossRefGoogle Scholar
  12. 12.
    Lang E, Thomas R, Davis R, Colon I, Allaf M, Hanano A, et al. Risks, advantages and complications of intercostal vs subcostal approach for percutaneous nephrolithotripsy. Urology. 2009;74(4):751–6.PubMedCrossRefGoogle Scholar
  13. 13.
    Raza A, Moussa S, Smith G, Tolley DA. Upper-pole puncture in percutaneous nephrolithotomy: a retrospective review of treatment safety and efficacy. BJU Int. 2008;101(5):599–602.PubMedCrossRefGoogle Scholar
  14. 14.
    Sinnatamby CS. Last’s anatomy. Regional and applied. 10th ed. Edinburgh: Churchill Livingstone; 1999.Google Scholar
  15. 15.
    Munver R, Delvecchio FC, Newman GE, Preminger GM. Critical analysis of supracostal access for percutaneous renal surgery. J Urol. 2001;166(4):1242–6.PubMedCrossRefGoogle Scholar
  16. 16.
    Hopper KD, Yakes WF. The posterior intercostal approach for percutaneous renal procedures: risk of puncturing the lung, spleen and liver as determined by CT. AJR Am J Roentgenol. 1990;154(1):115–7.PubMedCrossRefGoogle Scholar
  17. 17.
    Yadav R, Gupta NP, Gamanagatti S, Yadav P, Kumar R, Seith A. Supra-twelfth supracostal access: when and where to puncture? J Endourol. 2008;22(6):1209–12.PubMedCrossRefGoogle Scholar
  18. 18.
    Papatsoris A, Masood J, El-Husseiny T, Maan Z, Saunders P, Buchholz NP. Improving patient positioning to reduce complications in prone percutaneous nephrolithotomy. J Endourol. 2009;23(5):831–2.PubMedCrossRefGoogle Scholar
  19. 19.
    Ko R, Soucy F, Denstedt JD, Razvi H. Percutaneous nephrolithotomy made easier: a practical guide, tips and tricks. BJU Int. 2008;101(5):535–9.PubMedCrossRefGoogle Scholar
  20. 20.
    Steinberg PL, Semins MJ, Wason SE, Matlaga BR, Pais VM. Fluoroscopy-guided percutaneous renal access. J Endourol. 2009;23(10):1627–31.PubMedCrossRefGoogle Scholar
  21. 21.
    Miller NL, Matlaga BR, Lingeman JE. Techniques for fluoroscopic percutaneous renal access. J Urol. 2007;178(1):15–23.PubMedCrossRefGoogle Scholar
  22. 22.
    Desai M. Ultrasonography-guided punctures-with and without puncture guide. J Endourol. 2009;23(10):1641–3.PubMedCrossRefGoogle Scholar
  23. 23.
    Basiri A, Ziaee AM, Kianian HR, Mehrabi S, Karami H, Moghaddam SM. Ultrasonographic versus fluoroscopic access for percutaneous nephrolithotomy: a randomized clinical trial. J Endourol. 2008;22(2):281–4.PubMedCrossRefGoogle Scholar
  24. 24.
    Ghani KR, Patel U, Anson K. Computed tomography for percutaneous renal access. J Endourol. 2009;23(10):1633–9.PubMedCrossRefGoogle Scholar
  25. 25.
    Tzeng BC, Wang CJ, Huang SW, Chang CH. Doppler ultrasound-guided percutaneous nephrolithotomy: a prospective randomized study. Urology. 2011;78(3):535–9.PubMedCrossRefGoogle Scholar
  26. 26.
    Matlaga BR, Shah OD, Zagoria RJ, Dyer RB, Streem SB, Assimos DG. Computerized tomography guided access for percutaneous nephrostolithotomy. J Urol. 2003;170(1):45–7.PubMedCrossRefGoogle Scholar
  27. 27.
    Lopes T, Sangam K, Alken P, Barroilhet BS, Saussine C, Shi L, et al. The clinical research office of the endourological society percutaneous nephrolithotomy global study: tract dilation comparisons in 5537 patients. J Endourol. 2011;25(5):755–62.PubMedCrossRefGoogle Scholar
  28. 28.
    Yamaguchi A, Skolarikos A, Buchholz NP, Chomón GB, Grasso M, Saba P, et al. Operating times and bleeding complications in percutaneous nephrolithotomy: a comparison of tract dilation methods in 5,537 patients in the clinical research office of the endourological society percutaneous nephrolithotomy global study. J Endourol. 2011;25(6):933–9.PubMedCrossRefGoogle Scholar
  29. 29.
    Miller SD, Ng CS, Streem SB, Gill IS. Laparoscopic management of caliceal diverticular calculi. J Urol. 2002;167(3):1248–52.PubMedCrossRefGoogle Scholar
  30. 30.
    Wyler SF, Bachmann A, Jayet C, Casella R, Gasser TC, Sulser T. Retroperitoneoscopic management of caliceal diverticular calculi. Urology. 2005;65(2):380–3.PubMedCrossRefGoogle Scholar
  31. 31.
    Kottász S, Hamvas A. Review of the literature on calyceal diverticula, a hypothesis concerning its etiology and report of 17 cases. Int Urol Nephrol. 1976;8(3):203–12.PubMedCrossRefGoogle Scholar
  32. 32.
    Marshall VR, Singh M, Tresidder GC, Blandy JP. The place of partial nephrectomy in the management of renal calyceal calculi. Br J Urol. 1975;47(7):759–64.PubMedCrossRefGoogle Scholar
  33. 33.
    Turna B, Raza A, Moussa S, Smith G, Tolley DA. Management of calyceal diverticular stones with extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy: long-term outcome. BJU Int. 2007;100(1):151–6.PubMedCrossRefGoogle Scholar
  34. 34.
    Streem SB, Yost A. Treatment of caliceal diverticular calculi with extracorporeal shock wave lithotripsy: patient selection and extended followup. J Urol. 1992;148(3 Pt 2):1043–6.PubMedGoogle Scholar
  35. 35.
    Canales B, Monga M. Surgical management of the calyceal diverticulum. Curr Opin Urol. 2003;13(3):255–60.PubMedCrossRefGoogle Scholar
  36. 36.
    Krambeck AE, Lingeman JE. Percutaneous management of caliceal diverticuli. J Endourol. 2009;23(10):1723–9.PubMedCrossRefGoogle Scholar
  37. 37.
    Mendez-Probst CE, Fuller A, Nott L, Denstedt JD, Razvi H. Percutaneous nephrolithotomy of calyceal diverticular calculi: a single centre experience. J Endourol. 2011;25(11):1741–5.CrossRefGoogle Scholar
  38. 38.
    Kim SC, Kuo RL, Tinmouth WW, Watkins S, Lingeman JE. Percutaneous nephrolithotomy for caliceal diverticular calculi: a novel single stage approach. J Urol. 2005;173(4):1194–8.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Department of SurgeryWestern UniversityLondonCanada
  2. 2.Division of Urology, Department of SurgeryWestern UniversityLondonCanada

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