MODIFICATION OF STANDARD PERCUTANEOUS NEPHROLITHOTRIPSY TECHNIQUE FORTHE MORBIDLY OBESE PATIENT

Objectives. Urolithiasis in the morbidly obese patient presents severa l unique challenges to the urologist, and its treatment often requires creativity and innovation. We present a new modification of standard percutaneous nephrolithotripsy (PNL) technique, which is very helpful in overcoming some of the problems that are encountered when performin g PNL in this group of patients. Methods, We present 5 patients in who m this new technique has been used. Each had either failed prior extra corporeal shock-wave lithotripsy (ESWL) therapy or their size and abdo minal girth precluded use of ESWL technology. All 5 patients underwent PNL. The radiographically measured skin-to-stone distances (determine d by computed tomography or ultrasonography or both) exceeded the leng ths of the standard percutaneous access sheaths and the 26 F rigid nep hroscope. Thus larger and longer Amplatz access sheaths and a 30 F gyn ecologic laparoscope were used to reach the stones. Standard ultrasoni c lithotripsy was then performed, and extralong bronchoscopic grasping forceps were used to remove stone fragments. Results. All 5 patients were rendered stone-free using this technique. There was no significan t perioperative morbidity. Conclusions, For this very challenging grou p of patients, the use of larger and longer access sheaths and the gyn ecologic laparoscope have been very effective additions to the urologi sts' armamentarium in the treatment of urolithiasis.