UroToday - The morbidly obese patient is not an uncommon presentation for renal stone disease requiring percutaneous nephrolithotomy. These patients can often be a challenge even with the extra long Amplatz sheath to access the intra renal collecting system.

One trick that we have used at our center is to place heavy 0-silk sutures onto the distal edge of the percutaneous access sheath and secure these with a mosquito clamp at the flank in order to retrieve the sheath, even if it is below the skin level. However, this still makes advancing the scope, through the subcutaneous fat, into the top of the sheath challenging during the repeated removal and insertion of the scope required for lithotripsy and stone extraction.

These authors have described a clever technique of using a 10-cc syringe barrel with the luer-lock end excised and inserting the barrel through the subcutaneous tissues to overlap the top of the Amplatz percutaneous sheath. This then allows an easy access directly into the sheath without the problem of the subcutaneous tissues impeding the passage of the scope from the skin level into the sheath buried within the subcutaneous fat. As the authors point out, this is a cheap, safe and effective technique and avoids the need to extend the skin incision which may improve cosmesis and reduce post operative pain. The other advantage of this technique is that the silk stay sutures can still be placed on the distal aspect of the sheath but be placed outside of the modified syringe barrel so that these are less likely to be inadvertently pulled thereby dislodging the Amplatz sheath during the procedure.

Bugeja S, Zammit P, German K

J Endourol. 2009 Nov;23(11):1817-9

UroToday Contributing Editor Elspeth M. McDougall, MD, FRCSC, MHPE

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