© 2011 THE AUTHORS 1346 BJU INTERNATIONAL © 2 0 11 B J U I N T E R N A T I O N A L | 1 0 8 , 1 3 4 6 – 1 3 4 9 | doi:10.1111/j.1464-410X.2010.10002.x PCNL Safety and efficacy of ultrasonography as an adjunct to fluoroscopy for renal access in percutaneous nephrolithotomy (PCNL) Mayank Agarwal, Madhu S. Agrawal, Abhinav Jaiswal, Deepak Kumar, Himanshu Yadav and Prashant Lavania Department of Surgery, SN Medical College, Agra, India Accepted for publication 8 October 2010 • The inclusion criteria were: normal renal functions, American Society of Anesthesiology scores 1 or 2, absence of congenital abnormalities, aged 15–70 years, and anticipated single-tract procedure. The patients in both groups were matched for age, sex, and stone characteristics. • The Student t-test was used for statistical analysis with an allowable error of 5%. RESULTS • The mean time to successful puncture was 3.2 min and 1.8 min in group 1 and group 2, respectively (P < 0.01). • The mean duration of radiation exposure to successful puncture was 28.6 s in group 1 and 14.4 s in group 2 (P < 0.01). • The mean numbers of attempts for successful puncture in the desired calyx was 3.3 in group 1 as compared with 1.5 in group 2 (P < 0.01). • The meantime taken for tract formation in group 1 was 7.4 min with radiation exposure of 82 s, while in group 2 it took 4.8 min with radiation exposure of 58 s (P < 0.01). • Successful access was achieved in all patients. All patients were stone-free at the end of the operation. The hospital stay (2–3 days) was same in both groups. There was no incidence of significant bleeding requiring transfusion during or after surgery. All the patients were followed-up for a ≥6 months. CONCLUSION • US-guided puncture in PCNL helps in increasing accuracy of puncture and decreasing radiation exposure for the surgical team and the patients. KEYWORDS percutaneous nephrolithotomy (PCNL), kidney stone, ultrasonography, flouroscopy Study Type – Therapy (case series) Level of Evidence 4 OBJECTIVE • To evaluate the safety and efficacy of ultrasonography (US)-guided renal access in percutaneous nephrolithotomy (PCNL), as compared with conventional fluoroscopy- guided renal access in a prospective randomized trial. PATIENTS AND METHODS • From January 2008 to October 2009, 224 patients with renal calculi undergoing PCNL were randomized into two groups. • Group 1 (112 patients) underwent PCNL using only fluoroscopy-guided renal access; while in group 2 (112 patients), US guidance for puncture was used in addition to fluoroscopy. INTRODUCTION The important milestones in the history of percutaneous renal surgery include the description of Goodwin et al. [1] of percutaneous nephrostomy in 1955 and the first publication by Fernstrom and Johannson[2] of percutaneous nephrolithotomy (PCNL) in 1976. The technique we use today is a modification of the method that Wickham and his contemporaries designed and revised [3,4]. Wickham described the staged approach starting with a percutaneous nephrostomy under local anaesthesia, followed by the dilatation of the tract serially over the next few days, with subsequent stone removal under general anaesthesia using a rigid 30° cystoscope. Today of course, PCNL is widely used as the most popular choice to treat patients with all types of renal stones, especially the larger ones [5–7]. To date, fluoroscopy has been the main tool to achieve renal access in PCNL, notwithstanding its inherent hazard of exposing the patient, surgeon and participating staff to the risk of ionizing radiation. The surgeon, in particular, is likely to be exposed to radiation on a regular and cumulative basis. Similarly, certain patients who have recurrent stones may be subjected to repeated radiation exposure during fluoroscopy-based procedures. Thus, radiation dose is an extremely important issue, especially in a young child, who is significantly more radiosensitive and more likely to manifest radiation-induced changes over his or her lifetime [8]. Puncture for renal access can also be achieved using ultrasonography (US) guidance as an alternative to fluoroscopy. The US approach has the advantages of minimizing radiation exposure and also allows imaging of intervening structures between the skin and kidney. US also allows evaluation of the pelvi-calyceal system of kidney in three- dimensional (3D) orientation and helps to BJUI BJU INTERNATIONAL