Second-look Percutaneous Nephrolithotomy: Access to the Tract with Direct Vision and Fluoroscopic Guidance

Abstract

Introduction Percutaneous nephrolithotomy (PCNL) is the preferred treatment for large kidney stones. Second-look nephroscopy is one of the methods for removing residual stone fragments after PCNL. During second-look nephroscopy, we pass a guidewire through the previously established nephrostomy tract, which was impossible in this case. Thus, we performed the procedure with direct tract ureteroscopy and simultaneous fluoroscopy. Case presentation A 45-year-old man with full staghorn calculi was the case of this study. We performed PCNL surgery on him, but because of tachycardia and a fall in the patients’ blood pressure, we terminated the surgery after 3 hours. Because of the high possibility of remaining stones, we inserted a Foley 16 catheter as a nephrostomy. In the performed computerized tomography (CT) scan two days after the surgery, a significant volume of stone residue was observed. Four days after surgery, the patient was transferred to the operating room after the improvement of clinical status and hematuria resolved. The procedure was done when the patient was in the prone position and under general anesthesia. After cutting the nephrostomy tube, the attempt to insert the wire was not successful. So, we removed the nephrostomy tube. After retrograde injection of the contrast agent and fluoroscopy, we observed the contrasting agent passage through the nephrostomy tract to the skin surface. We found the main tract with simultaneous ureteroscopy and fluoroscopy. then insert guidewire in the renal pelvis and nephroscopy through the wire. Conclusions With the help of ureteroscopy and direct vision and fluoroscopy, we found the previous tract, entered the pyelocaliceal system, and embedded the guidewire. Thus, we performed nephroscopy from the same tract site without the need to get re-access.

Keywords

• percutaneous nephrolithotomy
• second-look nephroscopy
• kidney stones
• nephrostomy