Surgeon’s Workshop
C-Arm Laser Positioning Device to Facilitate
Percutaneous Renal Access
Raymond Ko and Hassan Razvi
Renal access is the most crucial step in the performance of percutaneous nephrolithotomy and is a difficult skill to
acquire for novice surgeons. We report on a simple fluoroscopic technique based on the laser positioning device that
emits an aiming beam common to modern fluoroscopy C-arm units. UROLOGY 70: 360 –361, 2007. © 2007 Elsevier Inc.
P
ercutaneous nephrolithotomy is the treatment of
choice for large renal stones. Renal access is criti-
cal to ensuring a successful outcome and requires
the target calix to be precisely punctured. Complex visual
spatial skills are required in performing this task when
using a C-arm fluoroscopy unit, especially by the novice
surgeon. Intuitively, more radiation could be required by
physicians learning percutaneous access, which would
represent an occupational health and safety issue to the
surgeon and staff. Although guidelines have recom-
mended that radiation exposure be kept as low as reason-
ably achievable, no absolute figure can be given to cover
all situations.1–5 In recognition of this problem, most
fluoroscopy units are equipped with a laser aiming guide
that attaches to the side of the receiving end of the
C-arm. The aiming beam creates a parallax-free crosshair
on the patient’s skin in line with the C-arm. This allows
the radiology technician to correctly position the C-arm
without the need for fluoroscopy and helps to minimize
unnecessary radiation exposure. We describe the tech-
nique using the side-mounted laser aiming guide to assist
in percutaneous renal access in the operating room.
Technique
Under general anesthesia and with the patient in the
prone position, flexible cystoscopy and placement of a
retrograde ureteral catheter to opacify the collecting sys-
tem, was performed. A biplanar fluoroscopy unit, with a
multidirectional C-arm and a laser aiming beam unit
attached to the receiving head (Siemens Medical Sys-
tems, Malvern, PA), was used. The receiving head was
draped in a sterile fashion and the foot pedal positioned
for use by the surgeon. The target calix was then imaged
with the fluoroscopy head angled at a 20° to 30° angle
from the vertical toward the surgeon in the axial plane. A
5° to 10° tilt was added in the caudal or cranial direction,
From the Department of Surgery, Division of Urology, University of Western Ontario
Schulich School of Medicine and Dentistry, London, Ontario, Canada
Reprint requests: Hassan Razvi, M.D., Department of Surgery, Division of Urology,
St. Joseph’s Hospital, 268 Grosvenor Street, London, ON N6A 4V2 Canada. E-mail:
hrazvi@uwo.ca
Submitted: February 1, 2007; accepted (with revisions): May 15, 2007
360 © 2007 Elsevier Inc.
All Rights Reserved
depending on whether a lower or upper pole was being
accessed. With this orientation, the desired posterior
calix was near end-on to the C-arm and had the appear-
ance of being oval or circular. The posterior calices can
be correctly identified, because they will appear less
densely opacified with contrast relative to the more de-
pendant anterior calices, when the patient is prone. Al-
ternatively, injection of 10 to 20 mL of air through the
retrograde ureteral catheter can also confirm the desired
calix to be posterior. The tip of a hemostat clamp was
then used to mark the position on the skin overlying the
selected calix, using short bursts of fluoroscopy in end
expiration. An 18-gauge, 15-cm-long, “diamond” point
Cook Angiographic Needle (Cook Urological, Bloom-
ington, Ind) was introduced through the skin at this
position. Figure 1 illustrates the technique of using the
laser device. The crosshair of the laser aiming beam was
positioned at the exact site of skin entry by moving the
whole fluoroscopy unit into position and then locking it
into place. The top of the needle was then aligned so that
the crosshair of the aiming beam was on the barrel of the
stylet, and the needle was advanced at the end of full-
expiration under laser guidance without fluoroscopy for 7
to 10 cm to reach the renal capsule. At this point, we
used a combination of laser and fluoroscopy to give the
bull’s eye effect, such that the needle and the overlying
hub were in the same alignment as the calix. Entry into
the overlying renal parenchyma was evidenced by respi-
ratory-induced movement of the needle in a craniocaudal
direction when fluoroscopy was used. The C-arm was
then rotated back to the vertical position to provide
depth perspective. The needle was then advanced or
withdrawn under fluoroscopy until its tip was in the
collecting system. The stylet was removed from the nee-
dle, allowing guidewire insertion. The remainder of the
percutaneous procedure was performed in the standard
fashion.
COMMENT
The ability to secure fluoroscopic-guided percutaneous
renal access into the target calix can be a difficult task to
master. To gain proficiency with this technique requires
0090-4295/07/$32.00
doi:10.1016/j.urology.2007.05.013

Figure 1. Laser device (inset) provides parallax-free cross-
hair at skin entry site of access needle and on hub of stylet
(arrow). Fluoroscopic view of bull’s-eye effect of access
needle in line with laser aiming beam held in tips of hemo-
stat clip.
the use of more fluoroscopy time and exposes operating
room staff and patients to greater radiation doses. Virtual
reality training simulators such as the Perc Mentor (Sym-
bionix, Cleveland, Ohio) have been developed to teach
trainees the technique of percutaneous renal access with-
out the need for ionizing radiation. At a cost of approx-
imately U.S. $85,000 to purchase, however, the current
simulators are not widely available. A robotic-assisted
device, the PAKY (Percutaneous Access to the KidneY),
has also been developed to facilitate percutaneous renal
access, but it remains a research tool at present.6
The use of a laser aiming guide is a novel idea with
only a few references found in published studies. Its
various uses have been described in facilitating interven-
tional radiologic procedures,7 orthopedic surgery,8,9 neu-
rosurgery,10 and urology.11 Its use in percutaneous renal
access has not been reported to our knowledge. Bilen et
al.11 described the use of an in-line laser pointer to guide
renal access in which it was attached within the field of
the receiving head of the C-arm fluoroscopy unit. They
found a 50% reduction in fluoroscopy times when used by
urology residents during an in vitro testing model. The
major drawback, however, was that the laser aiming beam
used in their study was directly in the x-ray field, blocking
UROLOGY 70 (2), 2007
the fluoroscopic image in the area of interest. The laser
aiming beam we used does not interfere with the receiv-
ing head images. This could be especially crucial in
accessing a nondilated collecting system in which the
diameter of the calix might offer only a very narrow
target point when viewed end on.
CONCLUSIONS
The use of the C-arm laser aiming guide during percuta-
neous renal access is a simple technical modification that
helps guide needle insertion. It is a useful adjunct when
teaching trainees and might serve to reduce radiation
exposure. Most importantly, there are no hazards to
adopting the approach and the technique might facilitate
greater awareness of radiation safety.
References
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