World Journal of Urology

, Volume 36, Issue 6, pp 963–969 | Cite as

Ureteroscopic holmium laser-assisted retrograde nephrostomy access: a novel approach to percutaneous stone removal

  • Kamaljot S. Kaler
  • Egor Parkhomenko
  • Zhamshid Okunohov
  • Roshan M. Patel
  • Jaime Landman
  • Ralph V. Clayman
  • Carlos A. Uribe
Original Article


Introduction and objectives

Percutaneous nephrolithotomy remains a challenging procedure primarily due to difficulties obtaining access. Indeed, few urologists obtain their own access due to difficulties using a fluoroscopic or ultrasonic based antegrade puncture technique. Herein we report the first experience using holmium laser energy to obtain access in a retrograde fashion.


After a pretreatment week of tamsulosin 0.4 mg/day (one center only) and following a documented sterile urine, a total of ten patients underwent retrograde holmium laser-assisted endoscopic-guided nephrostomy access in a prone split leg position.


In nine of ten patients, ureteroscopic guided, holmium laser access via an upper pole posterior calyx was achieved. In one patient, the laser tract could not be safely dilated and antegrade endoscopic and fluoroscopic guided access was performed. The mean operative time was 202 min; the mean fluoroscopy time was 32 s (6/9 cases). The mean pre-operative stone volume was 14,420 mm3. CT imaging on post-operative day 1 revealed 6/6 patients had residual stone fragments with total mean volume of 250 mm3 (96% reduction); there were no residual fragments in three patients who were evaluated with non-CT radiographic imaging (KUB). There was a single complication requiring angioembolization due to a subcapsular hematoma with associated secondary tearing of an inter-polar vessel remote from the nephrostomy site.


Holmium laser-assisted endoscopic-guided retrograde access in a prone split-leg position was successfully performed at two institutions. The accuracy of nephrostomy placement and lessening of fluoroscopy time are two potential benefits of this approach.


Retrograde nephrostomy Holmium laser Percutaneous nephrolithotomy Nephrolithiasis Technique Nephrostomy access 


  1. 1.
    Scales CD, Smith AC, Hanley JM, Saigal CS (2012) Prevalence of kidney stones in the United States. Eur Urol 62(1):160–165CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Assimos D, Krambeck A, Miller NL, Monga M, Murad MH, Nelson CP et al (2016) Surgical management of stones: American urological association/endourological society guideline, part II. J Urol 196(4):1161–1169CrossRefPubMedGoogle Scholar
  3. 3.
    Bird VG, Fallon B, Winfield HN (2003) Practice patterns in the treatment of large renal stones. J Endourol 17(6):355–363CrossRefPubMedGoogle Scholar
  4. 4.
    Jayram G, Matlaga BR (2014) Contemporary practice patterns associated with percutaneous nephrolithotomy among certifying urologists. J Endourol 28(11):1304–1307CrossRefPubMedGoogle Scholar
  5. 5.
    Tomaszewski JJ, Ortiz TD, Gayed BA, Smaldone MC, Jackman SV, Averch TD (2010) Renal access by urologist or radiologist during percutaneous nephrolithotomy. J Endourol 24(11):1733–1737CrossRefPubMedGoogle Scholar
  6. 6.
    Watterson JD, Soon S, Jana K (2006) Access related complications during percutaneous nephrolithotomy: urology versus radiology at a single academic institution. J Urol 176(1):142–145CrossRefPubMedGoogle Scholar
  7. 7.
    Hosking DH (1986) Retrograde nephrostomy: experience with 2 techniques. J Urol 135(6):1146–1149CrossRefPubMedGoogle Scholar
  8. 8.
    Lawson RK, Murphy JB, Taylor AJ, Jacobs SC (1983) Retrograde method for percutaneous access to kidney. Urology 22(6):580–582CrossRefPubMedGoogle Scholar
  9. 9.
    Kaler KS, Kim W (2017) V2-8 a new twist on an old technique: endoscopic-guided lawson retrograde nephrostomy access for percutaneous nephrolithotomy in prone position. J Endourol 31(S2):A420Google Scholar
  10. 10.
    Kawahara T, Ito H, Terao H, Yoshida M, Ogawa T, Uemura H et al (2012) Ureteroscopy assisted retrograde nephrostomy: a new technique for percutaneous nephrolithotomy (PCNL). BJU Int 110(4):588–590CrossRefPubMedGoogle Scholar
  11. 11.
    Wynberg JB, Borin JF, Vicena JZ, Hannosh V, Salmon SA (2012) Flexible ureteroscopy-directed retrograde nephrostomy for percutaneous nephrolithotomy: description of a technique. J Endourol 26(10):1268–1274CrossRefPubMedGoogle Scholar
  12. 12.
    Kaler KS, Safiullah SM, Patel RM et al (2017) MP75-14 the impact of one week of preoperative Tamsulosin on deployment of 16-French ureteral access sheaths. J Urol 197:e1008–e1009CrossRefGoogle Scholar
  13. 13.
    de la Rosette JJ, Laguna MP, Rassweiler JJ, Conort P (2008) Training in percutaneous nephrolithotomy—a critical review. Eur Urol 54(5):994–1001CrossRefPubMedGoogle Scholar
  14. 14.
    Lee CL, Anderson JK, Monga M (2004) Residency training in percutaneous renal access: does it affect urological practice? J Urol 171(2 Pt 1):592–595CrossRefPubMedGoogle Scholar
  15. 15.
    Tanriverdi O, Boylu U, Kendirci M, Kadihasanoglu M, Horasanli K, Miroglu C (2007) The learning curve in the training of percutaneous nephrolithotomy. Eur Urol 52(1):206–211CrossRefPubMedGoogle Scholar
  16. 16.
    Wong HY, Hinson JL, Griffith DP (1995) Retrograde nephrostomy: advantages, disadvantages, and the learning curve. J Endourol 9(6):461–463CrossRefPubMedGoogle Scholar
  17. 17.
    Wynberg JB, Paik LJ, Odom BD, Kruger M, Atalla CS (2014) Body mass index predicts outcome of ureteroscopy-assisted retrograde nephrostomy for percutaneous nephrolithotomy. J Endourol 28(9):1071–1077CrossRefPubMedGoogle Scholar
  18. 18.
    Patel RM, Okhunov Z, Clayman RV, Landman J (2017) Prone versus supine percutaneous nephrolithotomy: what is your position? Curr Urol Rep 18(4):26CrossRefPubMedGoogle Scholar
  19. 19.
    Uribe CA, Osorio HD, Benavides JA, Martinez CH (2017) V2-5 laser assisted retrograde ureteroscopy for percutaneous nephrostomy: a new and safer technique for percutaneous nephrolithotomy. J Endourol 31(S2):A418Google Scholar
  20. 20.
    Agarwal M, Agrawal MS, Jaiswal A, Kumar D, Yadav H, Lavania P (2011) Safety and efficacy of ultrasonography as an adjunct to fluoroscopy for renal access in percutaneous nephrolithotomy (PCNL). BJU Int 108(8):1346–1349CrossRefPubMedGoogle Scholar
  21. 21.
    Elkoushy MA, Shahrour W, Andonian S (2012) Pulsed fluoroscopy in ureteroscopy and percutaneous nephrolithotomy. Urology 79(6):1230–1235CrossRefPubMedGoogle Scholar
  22. 22.
    Lantz AG, O’Malley P, Ordon M, Lee JY (2014) Assessing radiation exposure during endoscopic-guided percutaneous nephrolithotomy. Can Urol Assoc J 8(9–10):347–351CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Zhang X, Chen C, Chen F, Zhan Z, Xie S, Ye Q (2016) In vitro investigation on Ho: YAG laser-assisted bone ablation underwater. Lasers Med Sci 31(5):891–898CrossRefPubMedGoogle Scholar
  24. 24.
    Smalley PJ (2011) Laser safety: risks, hazards, and control measures. Laser Ther 20(2):95–106CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Villa L, Cloutier J, Comperat E, Kronemberg P, Charlotte F, Berthe L et al (2016) Do we really need to wear proper eye protection when using holmium: YAG laser during endourologic procedures? Results from an ex vivo animal model on pig eyes. J Endourol 30(3):332–337CrossRefPubMedGoogle Scholar
  26. 26.
    Althunayan AM, Elkoushy MA, Elhilali MM, Andonian S (2014) Adverse events resulting from lasers used in urology. J Endourol 28(2):256–260CrossRefPubMedGoogle Scholar
  27. 27.
    Tepeler A, Armagan A, Akman T, Polat EC, Ersoz C, Topaktas R et al (2012) Impact of percutaneous renal access technique on outcomes of percutaneous nephrolithotomy. J Endourol 26(7):828–833CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  • Kamaljot S. Kaler
    • 1
  • Egor Parkhomenko
    • 1
  • Zhamshid Okunohov
    • 1
  • Roshan M. Patel
    • 1
  • Jaime Landman
    • 1
  • Ralph V. Clayman
    • 1
  • Carlos A. Uribe
    • 2
  1. 1.Department of UrologyUniversity of California Irvine (UCI)IrvineUSA
  2. 2.Department of UrologyHospital Pablo Tobon Uribe (HPTU)MedellinColombia

Personalised recommendations