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An Alternative and Inexpensive Percutaneous Access Needle in Pediatric Patients
Surgical Techniques in Urology An Alternative and Inexpensive Percutaneous Access Needle in Pediatric Patients Necmettin Penbegul, Haluk Soylemez, Yasar Bozkurt, Ahmet Ali Sancaktutar, Mehmet Nuri Bodakci, Namik Kemal Hatipoglu, Murat Atar, and Kadir Yildirim The most important factor that increases the cost of percutaneous surgery is the disposable instruments used for the surgery. In this study we present the advantages of using an intravenous cannula instead of a percutaneous access needle for renal access. TECHNICAL Recently, percutaneous stone surgery has grown in use in pediatric cases and is considered a CONSIDERATIONS minimally invasive surgery. The most important step in this surgery is access to the renal collecting systems. Although fluoroscopy has been used frequently at this stage, the use of ultrasound has recently increased. During percutaneous accesses under all types of imaging techniques, disposable 11- to 15-cm-long 18-ga needles are used. In pediatric cases, these longer needles are difficult to use. Using disposable materials in percutaneous nephrolithotomy increases the cost of the procedure. Therefore, we asserted that percutaneous access especially in pediatric cases could be performed using a 16-ga intravenous cannula (angiocath). Indeed, percutaneous access was performed successfully, especially in pediatric preschool patients. Shorter needle length, easy skin entry, comfort of manipulation, clear visualization of the metal needle on ultrasound, and wide availability can be considered advantages of this method. The angiocath is also less expensive than a percutaneous access needle. CONCLUSION Angiocath is inexpensive, easily available, and practical, and it is the shortest needle to perform percutaneous access in pediatric patients. UROLOGY 80: 938 –940, 2012. © 2012 Elsevier Inc. INTRODUCTION
fter its first use in 1976, percutaneous stone surgery was considered by many centers to be a minimally invasive surgical intervention. It has recently become the most frequently used modality with increasing popularity.1 The most important step affecting the success rate of this surgical method is successful percutaneous access to the renal collecting system from an appropriate calyx. Percutaneous access is frequently performed under fluoroscopic guidance with contrast instillation in the collecting system from a ureteral catheter. The potential exposure to radiation during this procedure has revived interest in the use of alternative access methods. Under these circumstances, one of the most frequently used access methods is access under ultrasound (US) guidance. Publications related to this method have recently increased.2 The advantages of this access method are as follows: the possibility of evaluating surrounding anatomic structures, obtaining 3-D images, easy orientation of the
A
instrument into the appropriate calyx, and decreased exposure to radiation. In pediatric cases, the shorter distance between the skin and the kidney ensures improved quality of images. In our clinic, we also usually use US guidance for percutaneous accesses in pediatric patients. Materials used in percutaneous nephrolithotomy (PNL) surgery are usually designed for single use, which increases the cost of the procedure. The most important step of the operation is to perform access, and for this step 11- to 15-cm-long 18-ga needles are usually used. For obese patients, longer needles are preferred because of longer access tracts; otherwise, shorter needles are generally preferred because they can be easily oriented and manipulated. In addition, in pediatric cases, a mini skin incision is occasionally required to overcome difficulties encountered during insertion of these needles. To eliminate the aforementioned disadvantages, we asserted that because of its availability and minimal cost, a 16-ga angiocath may be a useful armamentarium (Fig. 1A).
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, Dicle University School of Medicine, Diyarbakir, Turkey Reprint requests: Necmettin Penbegul, M.D., Dicle University School of Medicine, Department of Urology, 21280, Diyarbakir, Turkey. E-mail: [email protected] Submitted: May 16, 2012, accepted (with revisions): July 10, 2012
TECHNICAL CONSIDERATIONS
938
© 2012 Elsevier Inc. All Rights Reserved
Because of our experiences with the US technique, in our clinical and professional practice, we were able to successfully use this modality. We have gained adequate experience in US guidance access in PNL, particularly in 0090-4295/12/$36.00 http://dx.doi.org/10.1016/j.urology.2012.07.010
Figure 1. (A) Angiocath and standard access needle. (B) Angiocath inserted from the contact point between the probe and the skin. (C) Angiocath needle entering the targeted calyx is shown on US. (Color version available online.)
pediatric cases and in patients with anatomic abnormalities.3 This method consists of visualization of the direction of the needle during its insertion, using manual manipulations without the aid of any attachment, and entry into the targeted calyx. Patient Preparation After placement of a ureteral catheter, the patient is placed in a prone position and the targeted calyx of the kidney is determined using US. During this maneuver, the longest axis of the kidney is considered and an attempt is made to visualize the posterior border (Brodel line). In patients with normal renal anatomy, a mediolateral axis parallel to the 12th rib coursing at an angle of nearly 30° is visualized using this positioning. At this point, the distance between the cutaneous access site and targeted calyx is measured. This distance should be ⬍45 mm. Percutaneous Access with Angiocath The US probe is immobilized at this position with the left hand and, using the right hand, percutaneous access is made with an angiocath inserted from the contact point between the probe and the skin (Fig. 1B). The ultrasound displays the movement of the needle from the skin through the access tract. The angiocath with a needle is pushed through the same insertion angle of the US probe into an appropriate calyx under US guidance. After entry of the needle tip into the appropriate calyx is visualized (Fig. 1C), the plug at the external end of the angiocath is opened to observe urine flow. Afterward, while removing the metal needle from inside the angiocath, the polytetrafluoroethylenee (PTFE) sheath over the needle is pushed forward a few millimeters. If urine flow from the PTFE sheath persists, a guidewire is pushed forward (Fig. 2A). After successful access, the following stage of the UROLOGY 80 (4), 2012
intervention is maintained as a standard PNL under fluoroscopic guidance (Fig. 2B). We found that the described method can be applied more easily, particularly in pediatric preschool patients. Equipment In addition to the standard PNL set, we have found that the US-guided angiocath technique is best achieved with the following instruments: ● ● ●
Standard PNL set without access needle US probe Angiocath 16-ga
CONCLUSIONS The method described here has several advantages: shorter needle length, easy skin puncture, comfort of manipulation, clear visualization of the metal needle on US, and wide availability. In pediatric cases, using US to aid percutaneous access, instead of fluoroscopy, can be considered an additional advantage. We also investigated the costs of materials according to purchase price of our hospital and found that the angiocath is 100 times less expensive than the percutaneous access needle (Angiocath:0.3 TL, Access needle:32.2 TL). This application can save a lot of money and the cost of this surgery can decrease by using the alternative cheaper materials we suggest. The most important disadvantage of this needle is that it is ineffective for use in older children and adults because the distance from the skin to the renal calyx is more than 45 mm. However, this technique is more readily applicable in cases with dilated renal calices. In conclusion, use of the angiocath to perform percutaneous access in pediatric PNL cases instead of the standard access needle is an easy, safe, inexpensive, practical, and readily available method. Furthermore, with this method 939
Figure 2. (A) A guidewire inserted through the PTFE sheath of the angiocath. (B) Fluoroscopic image of access. (Color version available online.)
use of US during percutaneous access without the use of fluoroscopy is a significant advantage in pediatric cases. References 1. Fernström I, Johansson B. Percutaneous pyelolithotomy. A new extraction technique. Scand J Urol Nephrol. 1976;10:257-259.
940
2. Agarwal M, Agrawal MS, Jaiswal A, et al. Safety and efficacy of ultrasonography as an adjunct to fluoroscopy for renal access in percutaneous nephrolithotomy (PCNL). BJU Int. 2011;108:13461349. 3. Penbegül N, Tepeler A, Sancaktutar AA, et al. Safety and efficacy of ultrasound-guided percutaneous nephrolithotomy for treatment of urinary stone disease in children. Urology. 2012;79: 1015-1019.
UROLOGY 80 (4), 2012
fter its first use in 1976, percutaneous stone surgery was considered by many centers to be a minimally invasive surgical intervention. It has recently become the most frequently used modality with increasing popularity.1 The most important step affecting the success rate of this surgical method is successful percutaneous access to the renal collecting system from an appropriate calyx. Percutaneous access is frequently performed under fluoroscopic guidance with contrast instillation in the collecting system from a ureteral catheter. The potential exposure to radiation during this procedure has revived interest in the use of alternative access methods. Under these circumstances, one of the most frequently used access methods is access under ultrasound (US) guidance. Publications related to this method have recently increased.2 The advantages of this access method are as follows: the possibility of evaluating surrounding anatomic structures, obtaining 3-D images, easy orientation of the
A
instrument into the appropriate calyx, and decreased exposure to radiation. In pediatric cases, the shorter distance between the skin and the kidney ensures improved quality of images. In our clinic, we also usually use US guidance for percutaneous accesses in pediatric patients. Materials used in percutaneous nephrolithotomy (PNL) surgery are usually designed for single use, which increases the cost of the procedure. The most important step of the operation is to perform access, and for this step 11- to 15-cm-long 18-ga needles are usually used. For obese patients, longer needles are preferred because of longer access tracts; otherwise, shorter needles are generally preferred because they can be easily oriented and manipulated. In addition, in pediatric cases, a mini skin incision is occasionally required to overcome difficulties encountered during insertion of these needles. To eliminate the aforementioned disadvantages, we asserted that because of its availability and minimal cost, a 16-ga angiocath may be a useful armamentarium (Fig. 1A).
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, Dicle University School of Medicine, Diyarbakir, Turkey Reprint requests: Necmettin Penbegul, M.D., Dicle University School of Medicine, Department of Urology, 21280, Diyarbakir, Turkey. E-mail: [email protected] Submitted: May 16, 2012, accepted (with revisions): July 10, 2012
TECHNICAL CONSIDERATIONS
938
© 2012 Elsevier Inc. All Rights Reserved
Because of our experiences with the US technique, in our clinical and professional practice, we were able to successfully use this modality. We have gained adequate experience in US guidance access in PNL, particularly in 0090-4295/12/$36.00 http://dx.doi.org/10.1016/j.urology.2012.07.010
Figure 1. (A) Angiocath and standard access needle. (B) Angiocath inserted from the contact point between the probe and the skin. (C) Angiocath needle entering the targeted calyx is shown on US. (Color version available online.)
pediatric cases and in patients with anatomic abnormalities.3 This method consists of visualization of the direction of the needle during its insertion, using manual manipulations without the aid of any attachment, and entry into the targeted calyx. Patient Preparation After placement of a ureteral catheter, the patient is placed in a prone position and the targeted calyx of the kidney is determined using US. During this maneuver, the longest axis of the kidney is considered and an attempt is made to visualize the posterior border (Brodel line). In patients with normal renal anatomy, a mediolateral axis parallel to the 12th rib coursing at an angle of nearly 30° is visualized using this positioning. At this point, the distance between the cutaneous access site and targeted calyx is measured. This distance should be ⬍45 mm. Percutaneous Access with Angiocath The US probe is immobilized at this position with the left hand and, using the right hand, percutaneous access is made with an angiocath inserted from the contact point between the probe and the skin (Fig. 1B). The ultrasound displays the movement of the needle from the skin through the access tract. The angiocath with a needle is pushed through the same insertion angle of the US probe into an appropriate calyx under US guidance. After entry of the needle tip into the appropriate calyx is visualized (Fig. 1C), the plug at the external end of the angiocath is opened to observe urine flow. Afterward, while removing the metal needle from inside the angiocath, the polytetrafluoroethylenee (PTFE) sheath over the needle is pushed forward a few millimeters. If urine flow from the PTFE sheath persists, a guidewire is pushed forward (Fig. 2A). After successful access, the following stage of the UROLOGY 80 (4), 2012
intervention is maintained as a standard PNL under fluoroscopic guidance (Fig. 2B). We found that the described method can be applied more easily, particularly in pediatric preschool patients. Equipment In addition to the standard PNL set, we have found that the US-guided angiocath technique is best achieved with the following instruments: ● ● ●
Standard PNL set without access needle US probe Angiocath 16-ga
CONCLUSIONS The method described here has several advantages: shorter needle length, easy skin puncture, comfort of manipulation, clear visualization of the metal needle on US, and wide availability. In pediatric cases, using US to aid percutaneous access, instead of fluoroscopy, can be considered an additional advantage. We also investigated the costs of materials according to purchase price of our hospital and found that the angiocath is 100 times less expensive than the percutaneous access needle (Angiocath:0.3 TL, Access needle:32.2 TL). This application can save a lot of money and the cost of this surgery can decrease by using the alternative cheaper materials we suggest. The most important disadvantage of this needle is that it is ineffective for use in older children and adults because the distance from the skin to the renal calyx is more than 45 mm. However, this technique is more readily applicable in cases with dilated renal calices. In conclusion, use of the angiocath to perform percutaneous access in pediatric PNL cases instead of the standard access needle is an easy, safe, inexpensive, practical, and readily available method. Furthermore, with this method 939
Figure 2. (A) A guidewire inserted through the PTFE sheath of the angiocath. (B) Fluoroscopic image of access. (Color version available online.)
use of US during percutaneous access without the use of fluoroscopy is a significant advantage in pediatric cases. References 1. Fernström I, Johansson B. Percutaneous pyelolithotomy. A new extraction technique. Scand J Urol Nephrol. 1976;10:257-259.
940
2. Agarwal M, Agrawal MS, Jaiswal A, et al. Safety and efficacy of ultrasonography as an adjunct to fluoroscopy for renal access in percutaneous nephrolithotomy (PCNL). BJU Int. 2011;108:13461349. 3. Penbegül N, Tepeler A, Sancaktutar AA, et al. Safety and efficacy of ultrasound-guided percutaneous nephrolithotomy for treatment of urinary stone disease in children. Urology. 2012;79: 1015-1019.
UROLOGY 80 (4), 2012