PCNL: tips and tricks in targeting, puncture and dilation.

Getting an effective and safe percutaneous access is the cornerstone in performing a successful and uneventful PCNL. The choice of the puncture site, according to our experience, is one of the most important factors that may influence the outcome of the procedure Preoperative imaging has a preliminary role in choosing the kind of approach but the most important role has to be given to intraoperative retrograde pyelography following occlusion balloon catheter placing. Ultrasound-guided renal puncture as well may show adequate anatomic details of the collecting system if a retrograde dilation is performed We routinely perform a single subcostal lower pole access. In our opinion, when the skin incision is located into the four-sided space between 12thrib, spine muscles, iliac crest and posterior axillary line, the risk of most non-haemorrhagic complications may be reduced. When the needle is proceeding towards its target, some radiological sign may confirm its correct insertion Dilation and operative sheath placing are the last steps of the percutaneous tract creation. Amongst the wide offer of dilating devices, our choice usually goes to the Amplatz fascial dilators associated to the "one-shot" technique and to the balloon hydraulic dilators.