Removal of stones from renal pelvis and calyces.

1. On preoperative day 1- Placement of ipsilateral ureteral and bladder catheter.
2. Positioning of the patient (prone position, bolsters elevating flank)
3. Opacification of upper urinary tract and identification of stones
4. Planning of access route with fluoroscopy head at 90°
5. Puncture of collecting system with fluoroscopy head at 30° using 18 Ga needle (“bull’s eye”–needle tip and hub superimposition).
6. Assessment of depth of puncture with fluoroscopy head at 90°.
7. Introduction of hydrophilic guidewire (0.035) through needle sheath and passage past UPJ or into calyces.
8. Skin incision at puncture site and dilation of access tract using axial dilators (Amplatz) or dilation balloon (Nephromax) to 30Fr.
9. Introduction of nephroscope, inspection of pelvicalyceal system.
10. Retrieval of proximal end of ureteral catheter with forceps, and introduction of stiff guide wire (0.035) through it.
11. Advancement of stiff guide wire to exteriorization through distal tip of ureteral catheter, and removal of catheter over wire. Stiff guide wire now provides maximum safety and access to urinary tract through distal (urethra) and proximal points (nephrostomy tract).
12. Nephroscope introduced once more, and destruction of stones with ultrasonic lithotripter. Retrieval of stone fragments with endoscopic forceps or basket.
13. If stones are located in calyces that cannot be accessed by rigid nephroscope, then flexible ureteroscope can be used.
14. Upon clearance of stone burden, inspection of pelvicalyceal system for hemorrhage. Removal of nephroscope and sheath, insertion of Malecot self-retaining catheter. In selected cases, nephrostomy tubes inserted.