Single-Session DynaCT-PCNL for Renal Access and Intraoperative Stone Clearance Confirmation in Urologic Congenitalism
Michael P. Kurtz, MD, MPH, Bartley G. Cilento, Jr., MD, MPH, Harry M. Padua, MD, Robert D. MacDougall, MS, Mary Landrigan-Ossar, MD, Caleb P. Nelson, MD, MPH.
Boston Children's Hospital, Boston, MA, USA.
BACKGROUND: Patients with urologic congenital disease, especially those with severe scoliosis, present obstacles to renal access. Stone-free rates are known to be low. DynaCT acts as a conventional fluoroscopic c-arm, but can also perform intraoperative cone-beam CT. The two images are fused to allow for mapping of the puncture onto a real-time fluoroscopic image. It also acts as an angiography system, should this be required. We began a program of DynaCT PCNL, in which for select patients renal access is performed under combined CT and fluoroscopic guidance, with endoscopic and CT confirmation of stone clearance.
METHODS: Renal access and PCNL were conducted under one anesthetic with the patients prone. All staff, including anesthesiologists, exit to a shielded portion of the IR suite during CT acquisition. PCNL was performed with 24 and 30Fr sheaths. Radiation dose was estimated from dose-length products.
RESULTS: Two women, aged 28 and 26 years old, with bladder augmentation and extensive GU reconstruction underwent DynaCT-PCNL for renal stone Guy’s Stone Score of 4 (Fig 1). Both patients had severe scoliosis (Fig 2). No residual fragments remained in either kidney (Fig 3), and there were no infectious or bleeding complications. One patient had undergone a PCNL the year prior complicated by large hydrothorax - this did not recur. Effective dose from each cone beam CT run ranged from 1.8 - 10.3 mSv. There was moderate beam-hardening artifact around sheath and wire, but small stone fragments remained visible.
CONCLUSIONS: For patients at highest risk of PCNL complication, single-stage DynaCT PCNL may offer a safe and effective alternative. It requires coordination of radiologists, urologists, and anesthesiologists.
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