© 2 0 0 5 B J U I N T E R N A T I O N A L | 9 6 , 8 7 5 – 8 7 8 | doi:10.1111/j.1464-410X.2005.05749.x 875 Original Article ULTRASONOGRAPHY-GUIDED PNL OSMAN et al. Percutaneous nephrolithotomy with ultrasonography- guided renal access: experience from over 300 cases MAHMOUD OSMAN, GUNNAR WENDT-NORDAHL, KATRIN HEGER, MAURICE S. MICHEL, PETER ALKEN and THOMAS KNOLL Department of Urology, Mannheim University Hospital, Germany Accepted for publication 24 May 2005 pole calyx whenever possible. The working channel was dilated using an Alken dilator under X-ray control. If necessary, a flexible renoscope was used. Ultrasonic, pneumatic and laser probes were used for lithotripsy. RESULTS Four weeks after treatment the total stone- free rate was 96.5%; 45.7% of all patients were primarily stone-free, 21.3% had clinically insignificant residual stones that passed spontaneously within 4 weeks after PNL, and 33% of the patients needed auxiliary measures (a second PNL, ESWL, ureterorenoscopy). Overall, the early complication rate was 50.8%, the most common complications being transient fever (27.6%), clinically insignificant bleeding (7.6%) or both (3.2%); 3.5% of the patients developed urinary tract infections (with no signs of urosepsis), 3.2% had renal colic and 2.9% upper urinary tract obstruction. One patient (0.3%) developed acute pancreatitis after PNL; one died from urosepsis and one needed selective angiographic embolization of the punctured kidney due to bleeding. No patient required transfusions and there were no injuries to neighbouring organs. CONCLUSIONS These results show that PNL causes no significant blood loss or major complications in almost all patients. Two aspects may especially reduce the potential complications: ultrasonography-guided renal puncture and using PNL in an experienced centre. PNL is a highly efficient procedure that provides fast and safe stone removal. KEYWORDS urinary calculi, percutaneous nephrolithotomy, lithotripsy OBJECTIVE To report our experience with over 300 patients treated with percutaneous nephrolithotomy (PNL), for although PNL was established as a treatment in the 1970s, its use diminished with the introduction of extracorporeal shockwave lithotripsy (ESWL); clinical experience with ESWL showed its limitations, and the role of PNL for treating urolithiasis was redefined, which with improvements in instruments and lithotripsy technology has expanded the capability of percutaneous stone disintegration. PATIENTS AND METHODS The study included 315 patients (156 males, 159 females, aged 13–85 years) treated with PNL in our department between 1987 and 2002. The mean (range) stone diameter was 27 (7–52) mm. The kidney was punctured under ultrasonography guidance via a lower- INTRODUCTION Percutaneous nephrolithotomy (PNL) was established as minimally invasive treatment option for removing kidney stones in the 1970s and was further developed over the following years [1]. However, the use of PNL diminished with the introduction of ESWL in the early 1980s [2]. In recent years, as clinical experience with ESWL revealed its limitations, the role of PNL for treating urolithiasis was redefined. Urologists realized that, for several patients, PNL offers advantages over ESWL; PNL is especially better for treating large or multiple kidney stones, and stones in the inferior calyx [3]. Furthermore, improvements in instruments and lithotripsy technology (including ultrasound, pneumatic devices, the holmium:yttrium-aluminium-garnet (Ho:YAG) laser and flexible nephroscopes) have expanded the capability of percutaneous stone disintegration, with stone-free rates of >90% [4]. PNL is generally a safe treatment option and is associated with a low complication rate. Complications may develop from the initial puncture as surrounding organs (e.g. colon, spleen, liver, pleura, lung) can be injured. Other specific complications are postoperative bleeding, UTIs and fever. Renal access can be established by fluoroscopic and/or ultrasonography (US) guidance. Although in North America PNL is mostly done under fluoroscopic guidance only, we think that the additional use of US is beneficial and may prevent complications. We report our experience in using US-guided PNL in over 300 patients. PATIENTS AND METHODS After a routine preoperative evaluation, 315 patients (156 males, 159 females; mean age 54.7 years, range 13–85) with renal and/or impacted proximal ureteric stones underwent PNL in our department between 1987 and 2002. The data were collected retrospectively and evaluated. The stone location before PNL is shown in Fig. 1. All procedures were carried out with the patient prone. The whole procedure, including initial puncture, was performed with the patient under general anaesthesia and in the urological radiology department. Each procedure was carried out or supervised by an experienced urologist. Whenever needed, the patient was first placed in the lithotomy position and a retrograde ureteric balloon catheter was advanced to the PUJ and fixed through a urethral catheter. The ureteric balloon catheter was used to inject contrast material or methylene-blue dye to visualize the pelvicalyceal system and to occlude the PUJ, to prevent the passage of small disintegrated stone fragments to the distal part of the ureter. The patient was then