Endourology and Stones Percutaneous Nephrolithotomy in Pelvic Kidneys: Is the Ultrasound-guided Puncture Safe? Natalia Ota~ no, Ankush Jairath, Shashikant Mishra, Arvind Ganpule, Ravindra Sabnis, and Mahesh Desai OBJECTIVE To demonstrate our experience with the use of ultrasound (USG) for puncture guidance while performing percutaneous nephrolithotomy in ectopic pelvic kidneys. METHODS From January 1990 to December 2013, we have performed percutaneous nephrolithotomy in 26 patients with USG-guided punctures. The stones were solitary in 15 patients (58%) and multiple in 11 patients (42%). The mean stone size was 22 mm (range, 10-50 mm), including 3 staghorn calculi. All procedures were performed in an oblique-supine position, and the intraoperative complications as the postoperative outcome were reviewed. RESULTS The mean operative time was 93 minutes, achieving complete stone clearance in 22 (88%) of the patients. One of the patients had urine leakage after removing nephrostomy, needing post- operative double J stenting. One patient had significant intraoperative bleeding requiring staging of the procedure and blood transfusion. No bowel injuries were identified. Mean hospitalization time was 5.6 days. CONCLUSION USG-guided puncture is a safe and effective approach to the collecting system even in renal anomalies like in pelvic ectopic kidneys when performed in experienced hands. UROLOGY 85: 55e58, 2015. Ó 2015 Elsevier Inc. T he pelvic kidney has an incidence of 1 in 2200 to 1 in 3000, and it occurs owing to a failure of its ascent during development that makes it to stay below the pelvic brim, 1 laying over the sacrum and caudal to the aortic bifurcation. 2 Generally, they have a high insertion of the ureter and are malrotated, predisposing to urinary stasis and nephrolithiasis. 1-3 This abnormal situ- ation creates altered spatial relations with the adjacent organs (lies anterior to sacrum, caudal to aortic bifurca- tion, and posterior to peritoneum), abnormal calyceal orientation, and anomalous vascular patterns (deriving blood supply from iliac vessels or distal aorta), making the approach to the pelvic kidney a big challenge. 3 Under- standing this anatomic and spatial orientation would help the urologist to create a road map for percutaneous access. Extracorporeal shockwave lithotripsy (ESWL) has variable results in different series, reporting stone-free outcomes from 25% to 82%. 4 The main factors that reduce its efficacy are the surrounding bony pelvis and the loops of bowel, both interfering with the transmission of the shock waves; additionally, in many cases, drainage of the kidney is impaired, reducing the clearance of the fragments. 5,6 The retrograde intrarenal surgery (RIRS) approach counts only a small case series 7 with stone-free rates of around 75%, always related to the accessibility of the pelvicalyceal system through the tortuous ureter, its insertion, and the stone burden. The percutaneous nephrolithotomy (PCNL) has become the most common approach for the management of large stone burden, and in pelvic kidneys, it has proved to be as effective as in normal kidneys. 3 As many authors support the need for laparoscopic guidance 8,9 to guar- antee the safety of the procedure, it becomes more chal- lenging and time and resource consuming. Here, we present the single-center largest series of PCNL in pelvic kidneys, demonstrating that the ultrasound (USG)- guided puncture performed by experienced hands is a safe and effective technique. METHODS Patients Twenty-six patients presented to our hospital from January 1990 to December 2013 and were diagnosed to have stones in ectopic pelvic kidney. Of those, 22 were men and 4 women, with mean age of 46 years (range, 24-70 years), and in 73% of the cases, the ectopic kidney was located on the left side. The most common symptom was pain (69%), followed by fever (12%), hematuria (4%), and abdominal mass (4%), whereas 4 patients (15%) were asymptomatic. Stones were multiple in 42% and single in 58% Financial Disclosure: The authors declare that they have no relevant financial interests. From the Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India Address correspondence to: Natalia Ota~ no, M.D., Muljibhai Patel Urological Hospital, Dr. Virendra Desai Road, Nadiad, 387001, Gujarat, India. E-mail: nataliaotano@gmail.com Submitted: February 26, 2014, accepted (with revisions): August 18, 2014 ª 2015 Elsevier Inc. All Rights Reserved http://dx.doi.org/10.1016/j.urology.2014.08.015 0090-4295/15 55