TITLE:
High Supracostal Percutaneous Nephrolithotomy Access: Assessing Safety in Access above the Eleventh Rib after Performing Preoperative Planning with Computed Tomography
AUTHORS:
Joel E. Abbott, Anthony D. DiMatteo, Elise Fazio, Samuel G. Deem, Ali K. Sobh, Albert DePolo, Julio G. Davalos
KEYWORDS:
Percutaneous Nephrolithotomy, Calculi, Endoscopic Surgical Procedure
JOURNAL NAME:
Open Journal of Urology,
Vol.5 No.4,
April
15,
2015
ABSTRACT: Objective: To determine if supracostal
renal access above the 11th rib during percutaneous nephrolithotomy (PCNL) is
a safe option in carefully selected patients determined by preoperative
computed tomography (CT) imaging. Patients and Methods: We retrospectively
isolated 142 patients who underwent access above the eleventh rib during PCNL,
which we term “high supracostal renal access.” We then compared these patients
to 113 individuals who underwent access below the twelfth rib. Renal access was
achieved by the operative surgeon with fluoroscopic guidance in conjunction
with pre-operative computed tomography (CT) scan. Outcomes were compared.
Results: Overall surgical outcomes were equivalent when comparing high
supracostal versus subcostal access sites. As expected due to proximity,
pleural complications occurred in 4% of the high supracostal group (n = 6)
compared with 0% of the control (subcostal) group (p = 0.035). Of these six
complications, three were managed conservatively with observation and two required
cardio-thoracic intervention with video-assisted thoracoscopic pleural repair
(1%). In the remaining case, the patient was preoperatively consented for
placement of a thoracostomy tube, which was placed during the procedure, due to
the difficult location of her upper pole stone and closely adjacent low-lying
pleura, and the planned transpleural approach. Hospital stay was not
significantly pro-longed between the high supracostal access and subcostal
access groups, with an average length of stay of 2.2 ± 2.1 days and 2.0 ± 1.9
days (p = 0.59) respectively. Conclusions: Careful, systematic preoperative
planning based on CT and fluoroscopic imaging allows for a confident
understanding of a “safety zone” in placement and dilatation of renal access
points during PCNL. We have shown that planned upper pole renal access above
the 11th rib is achievable with acceptable morbidity and excellent success
rates.