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case_images: CT demonstrating patient's intra-abdominal anatomy and stone burden.
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case_images: Americas, Division of Chesapeake Urology, on February 24, 2015, with bilateral nonobstructing large renal calculi, initially diagnosed during hematuria work-up, who was interested in stone removal by PNL. CT showed the right kidney with a 10 x 9 mm stone in the mid-pole calix and a 6 x 5 mm stone in the lower pole calix, and the left kidney with four stones in the lower pole calices, the largest of which measures 9 x 8 mm (Fig. 1). All management options were discussed and provided to the patient, including observation, shock wave lithotripsy, ureteroscopic approach, and percutaneous techniques.
case_images: Transurethral placement of bladder catheter, ureteral access sheath, and safety wire in preparation for ambulatory percutaneous nephrolithotomy.
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case_images: A urethral catheter was then placed into the bladder over wire adjacent to the UAS to provide both ureteral access and bladder drainage (Fig. 2).
case_images: Example of our "skin template" created under fluoroscopic guidance before access showing the patient's renal anatomy and stone burden. This is routinely performed for percutaneous renal cases (Note: photo shown is a left side procedure).
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case_images: Acton, MA), surgical table equipped with a Allen Bow Frame (Allen Medical). Scout fluoroscopy images are obtained followed by retrograde pyelography. A marking pen was used to create a skin template of the renal anatomy and surrounding structures drawing the ribs, kidney stones, renal collecting system, and pleura (location previously determined with careful review of the CT scan) (Fig. 3).
case_images: Example of surgeon performing renal access utilizing a combination of ureteroscopic guidance and fluoroscopic radiographic guidance. (Note: photo shown is a left side procedure).
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case_images: Scientific) was used in obtaining access (Fig. 4) and subsequently cannulated with a 0.035 in