Percutaneous nephrolithotomy for kidney stone removal - DVM
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Percutaneous nephrolithotomy for kidney stone removal
A minimally invasive option to treat this common occurrence in pets


DVM360 MAGAZINE


Minimally invasive options

In people, the treatment of choice is typically minimally invasive, consisting of extracorporeal shockwave lithotripsy (ESWL) for nephroliths smaller than 2 cm and PCNL for nephroliths larger than 2 cm. Open surgery and laparoscopy are usually considered necessary after other less invasive options have failed or have been deemed inappropriate. These and many other human studies have shown ESWL and PCNL to have a minimal effect on the GFR of clinical stone forming patients, particularly when compared with traditional surgical nephrotomy. These procedures, particularly PCNL, have been shown to be highly effective in removing all stone fragments, as endoscopic calyceal inspection is superior for visualization and fragment retrieval.

In small animals, PCNL is considered if ESWL fails, ESWL is not available, cystine stones are present (which are ESWL-resistant) or the stone is larger than 15 mm. PCNL has been performed in a handful of dogs to date, as well as in a cat. Typically, this is done by using a combination of ultrasonographic, endoscopic and fluoroscopic guidance. Patient size is less of a factor for PCNL than for ureteroscopy, as the smallest dog that had successful PCNL was only 3.1 kg.

PCNL procedure


Figure 2: An endoscopic image during intracorporeal lithotripsy for removal of a large struvite nephrolith. Note the large yellow stone inside the renal pelvis. The lithotrite is fragmenting the stone into small pieces for removal.
Typically, for PCNL, the renal pelvis is accessed through the greater curvature of the kidney with ultrasound guidance using a renal access needle. Subsequently, with fluoroscopic guidance, a sheath (12- to 30-Fr) and balloon dilation catheter combination is advanced through the renal parenchyma into the renal pelvis over a guide wire and onto the offending nephrolith. A mini-PCNL approach using an 18- or 24-Fr access kit is used.


Figure 3: Fluoroscopic images during a PCNL procedure: A) A patient with sheath (black arrow) inside the kidney onto large nephrolith (white asterisk). A safety guide wire is down the ureter (white arrows). B) A nephroscope (white arrow) inside the renal sheath as the large nephrolith is fragmented (black arrowheads). C) Image after the nephrolith is removed. D) A ureteral stent (white arrows) in place to protect the ureter.
Once the sheath is in the renal pelvis, a nephroscope is used to identify the stone or stones. If small enough, a stone-retrieval basket is used to remove the stone. If the stone or stones are larger than the sheath, then intracorporeal lithotripsy is used for stone fragmentation (ultrasonic, electrohydraulic or Hol:YAG laser) (Figure 2). This is all performed with fluoroscopic (Figure 3) and endoscopic guidance. Once the stones are small enough to fit through the sheath, they are removed, and a locking-loop nephrostomy tube (5- or 6-Fr) is left in place to allow the small hole to seal and form a nephropexy.


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Source: DVM360 MAGAZINE,
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