57 © Springer Nature Singapore Pte Ltd. 2019 E. S.-y. Chan, T. Matsuda (eds.), Endourology Progress, https://doi.org/10.1007/978-981-13-3465-8_8 Multiple vs. Single Access PCNL Michael Alfred V. Tan and Dennis G. Lusaya Abstract Percutaneous nephrolithotomy (PCNL) is the standard of care for large renal calculi which are no longer suitable for extracorporeal shockwave lithotripsy. The key to suc- cess depends on the urologist’s choice of instruments, preoperative and intraoperative access planning, patience, perseverance, skill and training. Percutaneous renal access is a crucial early step that may ultimately infuence outcomes of PCNL in terms of overall stone-free rate and complications. Several techniques for access and tract dilatation are described in this chapter. Prone, supine or lateral positioning during renal access have inherent advantages and disadvantages. Similarly, various adjunct imaging modalities and instrumentation are available to increase success and decrease the risk of complications. Nonetheless, the most practical and effective approach still depends heavily on stone burden and renal anatomy, available instrumentation and equipment, and the sur- geon’s expertise and level of training. Keywords Percutaneous nephrolithotomy · PCNL · Stone The 2005 American Urological Association guidelines on the management of staghorn calculi has recommended per- cutaneous nephrolithotomy (PCNL) for treatment of renal calculi 2 cm and larger. Success of a PCNL procedure depends on several factors which include: preoperative plan- ning, the correct choice of puncture site and access tech- nique, and effcacy of tract dilatation, nephroscopy, stone fragmentation, extraction and drainage. Planning of tract placement could never be overemphasized. Meticulous eval- uation of preoperative imaging will dictate the choice of access site and the intrarenal endoscopic route that would yield high stone free rates with minimal morbidity. Access to the kidney is arguably the most crucial step in PCNL as the site of entry will determine the approach and equipment needed for stone clearance. If done properly, it can maximize the effciency of rigid and fexible instruments, minimize morbidity and allow for execution of adjunctive procedures. 8.1 Positioning the Patient Fluoroscopy-guided percutaneous access requires opacifca- tion of the renal collecting system. This is achieved by inject- ing radiographic contrast medium through a ureteral catheter with one end externalized through the urethra. This can be easily performed using rigid instruments with the patient in a dorsal lithotomy position. In certain instances, fexible cys- toscopy with the patient supine or prone may also be done for ureteral catheter placement and retrograde pyelography. Following ureteral catheter placement, a Foley catheter is also routinely placed. The exposed caudal segment of the ureteral catheter is secured to the Foley catheter to prevent misplacement of the cephalic segment inside the collecting system as the patient is re-positioned and re-draped for per- cutaneous access. The patient can be positioned either prone, supine or lat- erally (with further variations such as split-leg, slightly oblique, etc.) for percutaneous renal access depending on the preference of the surgeon. The prone position offers direct and shorter access to the collecting system with minimal interference from other intraabdominal organs. It also poten- tially exposes multiple calyces for easier percutaneous access. These may be circumvented in supine and lateral M. A. V. Tan (*) University of Santo Tomas Hospital, Manila, Philippines D. G. Lusaya Department of Surgery, Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines Department of Urology, Faculty of Medicine and Surgery, University of Santo Tomas, Manila, Philippines St. Luke’s Medical Center Institute of Urology, Quezon City, Philippines 8