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surgery illustrated
KNOLL
et al.
1 2 3 4 5 6 7 8
Surgical Atlas
Percutaneous nephrolithotomy:
the Mannheim technique
Thomas Knoll, Maurice S. Michel and Peter Alken
Department of Urology, University Hospital Mannheim, Mannheim, Germany
liver, pleura or ribs and, most importantly, if the access to the stone can be established
simultaneously the needle during puncture. with no problems, is essential for planning of
The advantage of this combined visualization the procedure. Ideally, the urologist who will
is to obtain real-time pseudo-three- do the PNL should also do this.
c
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Figure 1
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Equipment for PNL includes:
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Figure 2
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Figure 3
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Figure 4
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Figure 5
US of the kidney.
a b
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Figure 6
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Figure 7
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3
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Figure 8
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Figure 9
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Figures 10 and 11
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Figure 12
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Figure 13
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Figure 14
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Figure 15
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Figure 16
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Figure 17
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FROM SURGEON TO SURGEON fit together, from the beginning with the 9/ Buck C, Conort P, Gallucci M; Working
11 F dilator, to the end with the slotted sheath Party on Lithiasis, European
The crucial step in PNL is establishing the for placing the nephrostomy. Association of Urology. Guidelines on
percutaneous tract after careful identification urolithiasis. Eur Urol 2001; 40: 362–71
of the anatomy and stone configuration. All procedures like infra- or supracostal 8 Matlaga BR, Shah OD, Zagoria RJ, Dyer
During the whole procedure, imaging should access are possible, safety guidewires can be RB, Streem SB, Assimos DG.
be done whenever necessary. Difficult cases used or not, just as a ‘no-tube’ technique is Computerized tomography guided access
are patients with former percutaneous possible. The low complication rate makes the for percutaneous nephrostolithotomy.
operations and a distorted CS, peripheral described PNL procedure our preferred J Urol 2003; 170: 45–7
stone mass, and renal malformations that technique for large renal calculi. 9 Ogan K, Pearle MS. Oops we got in the
require extra care. The beginner should avoid chest: fluoroscopic chest tube insertion
performing PNL in situations where only a REFERENCES for hydrothorax after percutaneous
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When vision is poor due to bleeding during Access related complications during Urol 2000; 37: 136–9
the procedure, it is advisable to terminate the percutaneous nephrolithotomy: urology
procedure to prevent septicaemia and to versus radiology at a single academic Correspondence: Thomas Knoll, Department
postpone stone removal, after placing a institution. J Urol 2006; 176: 142–5 of Urology, University Hospital Mannheim,
nephrostomy tube, to a safer session with 6 Osman M, Wendt-Nordahl G, Heger K, Theodor-Kutzer-Ufer 1–3, 68135 Mannheim,
better vision. Michel MS, Alken P, Knoll T. Germany.
Percutaneous nephrolithotomy with e-mail: t.knoll@uro.ma.uni-heidelberg.de
The technique described increases the ultrasonography-guided renal access:
information of the individual anatomy by experience from over 300 cases. BJU Int Abbreviations: CS, collecting system; US,
making use of two imaging methods, adding 2005; 96: 875–8 ultrasonography; PNL, percutaneous
safety to the procedure. The instruments used 7 Tiselius HG, Ackermann D, Alken P, nephrolithotomy.
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