Effect of four-quadrant pre-positioning method in assisting the establishment of percutaneous nephrolithotomy access
Objective To investigate the effect of using"Four-Quadrant Pre-Positioning Method"combined with synchronous CT imaging to assist color doppler ultrasound in establishing an ideal puncture access for percutaneous nephrolithotomy(PCNL).Methods A retrospective analysis was conducted on 113 patients with renal stones treated at the First Affiliated Hospital of Zhengzhou University from May 2021 to July 2023.Patients were divided into two groups based on the surgical method:the study group and the control group.The study group consisted of 64 patients who,from June 2022 to July 2023,underwent PCNL with the assistance of the four-quadrant pre-positioning method and color doppler ultrasound for puncture point localization.The control group consisted of 49 patients who underwent PCNL from May 2021 to May 2022.Based on the distribution of stones,both groups were further divided into three subgroups:subgroup 1:single renal pelvis or single renal calyx stones(study group:27 patients,control group:20 patients).Stone length was(34.27±7.69)mm vs.(39.77±11.34)mm,respectively.Subgroup2:renal pelvis combined with a single renal calyx stone,or multiple stones in more than two renal calyces(study group:19 patients,control group:15 patients).Stone length was(45.77±9.50)mm vs.(40.94±11.34)mm,respectively.Subgroup 3:staghorn or cast stones(study group:20 patients,control group:17 patients).Stone length was(60.03±11.59)mm vs.(58.41±15.01)mm,respectively.There were no significant differences in gender,age,height,weight,side of the stone,stone length,or stone CT values between the subgroups(P＞0.05).The use of four-quadrant pre-positioning method results from multi-slice spiral CT imaging and the patients anatomical characteristics.The 12th rib apex is taken as the origin,and the body's transverse and longitudinal axes are defined as the X and Y axes,respectively,to create the"Four Quadrants."The ideal puncture point is located within these quadrants.During the procedure,based on surface markings of the 12th rib apex,the"Four Quadrants"and ideal puncture point are identified on the patient's body surface,assisting the color doppler ultrasound in guiding the establishment of the puncture access.The puncture access establishment time,puncture first calyx success rate(criteria:for single renal pelvis or calyx stones,the first puncture access should achieve a stone-free rate＞90％;for multiple renal calyx stones or staghorn stones,the first puncture access should achieve a stone-free rate＞50％),surgical time,intraoperative blood loss,stone-free rate,and postoperative complications were compared between the study and control groups in each subgroup.Results In subgroup 1,the puncture access establishment time was(4.74±2.25)minutes in the study group vs.(7.00±3.13)minutes in the control group(P=0.006).In subgroup 2,the puncture access establishment time was(6.94±2.12)minutes in the study group vs.(9.80±2.83)minutes in the control group(P=0.002),with the first calyx success rate being 94.7％(18/19)in the study group vs.60.0％(9/15)in the control group(P=0.028).The surgical time was(97.68±26.22)minutes vs.(136.29±33.00)minutes(P=0.001).In subgroup 3,the puncture access establishment time was(8.00±2.69)minutes in the study group vs.(12.59±3.54)minutes in the control group(P=0.001),with the first calyx success rate being 100.0％(20/20)in the study group vs.76.5％(13/17)in the control group(P=0.036).Intraoperative blood loss was(238.00±176.74)ml vs.(388.57±219.89)ml(P=0.043).No significant differences were found between the two groups in terms of immediate postoperative stone-free rate(subgroup 1:92.6％(25/27)vs.95.0％(19/20),P=0.739;subgroup 2:78.9％(15/19)vs.73.3％(11/15),P=1.000;subgroup 3:75.0％(15/20)vs.70.5％(12/17),P=0.703)or complication rates(subgroup 1:25.9％(7/27)vs.25.0％(5/20),P=0.943;subgroup 2:26.3％(5/19)vs.40.0％(6/15),P=0.475;subgroup 3:40.0％(8/20)vs.41.2％(7/17),P=1.000).Conclusions The four-quadrant pre-positioning method effectively assists in the use of color doppler ultrasound to establish an ideal puncture access during PCNL,reducing puncture access establishment time and improving the rationality of the puncture path.It also significantly reduces intraoperative blood loss,particularly for complex renal stones such as those in multiple renal calyces or staghorn stones,thereby enhancing the safety of the procedure.
Four-quadrant pre-positioning methodIdeal puncture pathwayPercutaneous nephrolithotomyDesigned puncture point
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