‘‘Angular Percutaneous Renal Access’’ . MultipleTracts Through A Single Incision for Staghorn Calculous Treatment in A Single Session Evangelos N. Liatsikos a, * , Rakesh Kapoor b , Benjamin Lee c , Michel Jabbour d , George Barbalias a , Arthur D. Smith c a Department of Urology, University of Patras, School of Medicine, Rio, Patras 26 500, Greece b Department of Urology & Renal Transplantation, Sanjay Gandhi Postgraduate Institute of Medical Science, Lucknow, India c Department of Urology, Albert Einstein College of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York, USA d Department of Urology, Saint George Hospital, Balamand University, Faculty of Medicine, Beirut, Lebanon Accepted 30 August 2005 Available online 15 September 2005 Abstract Purpose: We herein describe the technique of a single subcostal skin incision with multiple angular punctures to approach the superior, middle and lower pole of the kidney for the management of staghorn calculi. Materials and method: One hundred patients with staghorn calculi were managed between January 1997 and June 2000. The superior calyx was approached by a subcostal triangulation technique and the middle and lower calyces were approached by angular punctures. Correct advancement of the needle was monitored by biplane fluoroscopy. Maximum effort was made for complete stone clearance in a single session. Results: 87% patients were rendered stone free in a single session. The average number of tract dilation per renal unit was 2.4 with an average anesthesia time of 110 minutes and the average blood loss of 450 ml. The average hospital stay duration was 4.6 days. The secondary procedures required were 0.11 per patient and the complication rate totalled 7% with one case of excessive hemorrhage requiring embolization. Conclusions: We therefore propose the triangulation technique as a safe and appealing method for the percutaneous management of staghorn calculi. # 2005 Elsevier B.V. All rights reserved. Keywords: Percutaneous tract; Angular access; Staghorn calculi 1. Introduction Percutaneous nephrolithotomy (PNL) is a safe and minimally invasive approach when compared to open surgery for patients with complete staghorn calculi [1–4]. The American Urolological Association Nephrolithiasis Clinical Guidelines (AUA-NCG) panel recommended percutaneous stone removal as the first treatment choice for the management of staghorn calculi patients [3]. A superior calyceal approach is considered ideal for approaching the renal system in the management of staghorn calculi because the posterior upper pole calyx is in the most posterior portion of the kidney and thus provides the most direct access to the renal pelvis, upper ureter, upper pole calyces, and usually the lower pole calyces. The superior calyx is situated above the 12th rib most of the time as on maximum expiration 80% of right renal upper pole calyces and 85% left renal upper pole calyces are located above the 12th rib [5]. Preminger et al. demonstrated cephalad movement European Urology European Urology 48 (2005) 832–837 * Corresponding author. Present address: University of Patras Medical School, Department of Urology, Rio, Patras, 26 500 Greece. Tel. +30 2610 999 385; Fax: +30 2610 993 981. E-mail address: Liatsikos@yahoo.com (E.N. Liatsikos). 0302-2838/$ – see front matter # 2005 Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2005.08.009