Bulls eye versus free hand ... which is better ?
My preference is bulls eye...
Both techniques have their own pros and cons. Master one technique and follow that. I prefer free hand technique. That is how I got exposed. I have seen bull's technique by some masters. It looks so simple when we see them doing. Bit it is difficult with me. I am more comfortable with free hand technique
Bulls eye -
1. Easier to learn
2. Short tract
3. Easier manouverility
4. Chances of supracoastal puncture more
5. Easier to puncture any calyx
6. Puncture depth can be assessed
Triangulation / Free Hand :
1. Most of the time puncture is subcoastal
2. Longer tract
3. Little more difficult to learn
4. Manouerverility is less as tract are longer
5. Most of the time preferred calyx is LC
6. Torque probably is more when puncture is in upper calyx and wants to navigate to some other calyx
7. Once you master this than it is easier to learn supine
I prefer my Hybrid technique which has been described even in the Smith's textbook of endourology
It is the only technqiue --fluoroscopy guided-- which describes how to determine the site of skin puncture, the angle & even calculate the depth f puncture
We all perform PCNL and in India, PCNL is practiced even at most remote areas making it a very common procedure. There have been considerable discussions on how initial puncture should be achieved. I tend to agree with Kannan when he mentioned that the ideal technique of puncture is the one that the operator is accostomed to and has given him success with least problems.
I have been harbouring a doubt in my mind for long and have not yet received a satisfactory answer. In Bull’s eye technique especially, I understand that the initial puncture and subsequent dilatation passes though the pyramid (Papilla) though which the Collecting ducts open. Each papilla has several collecting ducts opening and each collecting duct drains a lobule of the kidney (A lobule is defined as a potion of the kidney containing those Nephrons that are drained by a common Collecting Duct - Picture of lobule provided).
When the Puncture and following dilatation of the tract for PCNL is being carried out, am I to understand that the Lobules of that portion of the Kidney will remain unaffected. The US Picture Provided by Prof. Laxman Prabhu showing scar and the DMSA scan picture taken from S Yalcinkaya, M Yuksel* et al (2017) showing reduced function at site of puncture and dilatation bear testimony to the fact that Renal damage occurs with Puncture Dilatation for PCNL and this is more so when Bull’s Eye Technique is used.
Kidney with ~1million Nephrons, have enough reserve that loss of some Nephrons do not overtly affect the function of the kidney. But Multiplicity of Punctures and dilatation as is needed at times for Staghorn calculi can affect consequent functional deterioration. This coupled with Infection and added comorbidity like Diabetes can at times leads to profound deterioration to Renal Functional Status. An article published by Ram Yadav, Samarth Agarwal*, Apul Goel et al (2019) addresses this issue well.
But generally it is considered that Renal functional deterioration is usually minimal and do not have much consequences. Abdullah Demirta? et al (2013) pointed to slight deterioration in the very early term after PCNL, but after a while it recovers. They mentioned that PCNL does not cause any harm to the kidney locally or generally. It is generally stipulated that 6 months should elapse after PCNL for an exact assessment. In the late term renal functions are preserved in a huge group of patients.
I hope this will invite discussions from our Pundits of PCNL and we can have a meaningful answer.
With warm regards,