**3.2.4.2 Fluoroscopic guidance**

Fluoroscopic guidance is essential for guidewire manipulation especially in patients with non or mild dilatation of renal pelvis. Collecting system can be opacified with contrast following cystoscopic retrograde ureteral catheter placement, injection of intravenous contrast material and direct percutaneous puncture with 22 gauge needle. Pyelotubular and pyelosinus backflow can be avoided by not overinjecting the collecting system.

In difficult cases, with non-dilated collecting system, the collecting system can be distended with retrograde ureteral balloon catheter. Fluoroscopy can demonstrate the position of the nephrostomy tube in the most desirable position (renal pelvis), minimizing the number of complications. To avoid radiation exposure to operator's hand, Amplatz needle holder can be used. (LeRoy., 1996). This equipment keeps the operator's hand out of the x-ray beam. The patient's table should be not so high that the operator's neck and face are too far from the patient. (Fig. 8-11)

Fig. 8. Right renal pelvic stone in patient of right flank pain.

Fig. 9. 21-gauge needle was introduced toward the stone.

Modern Surgical Treatments of Urinary Tract Obstruction 271

Fig. 12. Commercial access systems of needle-guidewire-catheter techniques.

Fig. 13. Basic instruments for percutaneous nephrostomy tube placement.

Fig. 14. Needle and dilators.

Fig. 10. Nephostogram via access needle demonstrated hydronephrosis of right kidney. The second needle was introduced toward the upper calyx for upper pole percutaneous nephrolithotomy.

Fig. 11. The serial dilatation was done for
