WCE 2019: Challenging the Papillary Puncture

Abu Dhabi, United Arab Emirates (UroToday.com) Dr. John Denstedt vs. Dr. Evangelos Liatsikos. Papillary Puncture vs. Infundibular Puncture. Which is best? While these two men are friends in many ways, one major point of disagreement between them stems from whether it is feasible to gain access to the renal collecting system through the infundibulum rather than solely through the papillae.

In this session, the audience was first treated to hearing Dr. Denstedt speak on why papillary puncture is the only safe means of gaining access to the renal collecting system. He argues that the safest access from the skin to the renal collecting system passes through the longer axis of a renal caliceal papilla and that, generally, a lower and posterior path could also be feasible given that it runs parallel to the axis of the infundibulum.

Dr. Denstedt believes that the main drawback of gaining access to the renal collecting system through the infundibulum is extensive bleeding. He stated that a percutaneous nephrolithotomy (PCNL) is truly an operation of millimeters, so much so that he tells his residents that every millimeter they creep closer to the infundibulum corresponds to a 1% increase in blood transfusion rate. Additionally, he explains that medial renal punctures leave little parenchyma for stabilizing the working sheath intraoperatively and are more likely to extend tears into the pelvis.

He concluded his talk by stating that calyceal punctures, as opposed to infundibular punctures, yield the best intraoperative and postoperative results for patients as they minimize bleeding and complication rates.

Dr. Liatsikos followed Dr. Denstedt’s arguments by stating contrasting literature that demonstrated that non-calyceal punctures do not increase complication rates. He was quick to present his own series of data (shown below) that verify these findings.

WCE 2019 complication rates non calyceal punctures

In addition to his own findings, Dr. Liatsikos presented a few more studies, such as Kallidonis et al. 2017, which similarly found that infundibular puncture is safe and is associated with similar stone-free rates, hemoglobin loss, creatinine change, and hospitalization stays as conventional papillary puncture. Dr. Liatsikos concluded his talk by mentioning that many urologists perform infundibular punctures every day without noticing it in the form of percutaneous renal biopsies and nephrostomy tube placements.

While the majority of urologists in the convention room expressed that they still prefer conventional calyceal punctures in their practice, Dr. Liatsikos’ data definitely intrigued some in the audience and created discussion as to the efficacy of infundibular puncture.

Presented by: Mahesh Desai, MBBS,  Muljibhai Patel Urological Hospital Gujarat, India( MODERATOR) & John Denstedt, MD, FRCSC, FACS, FCAHS, Professor of Urology, Department of Surgery, Western University, London, Ontario and Evangelos Liatsikos, MD, PhD, Assistant Professor, University of Patras, Patras, Greece (DEBATORS)