Supracostal Approach for PCNL: Is 10th and 11th Intercostal Space Safe According to Clavien Classification System?

Renal Location Within the Retroperitoneum in Various Body Positions Using Magnetic Resonance Imaging: Implications for Percutaneous Nephrostolithotomy

OBJECTIVES

To assess the difference in cranio-caudal renal position in both the supine and prone position, as well as the effect of arm position on renal location, using magnetic resonance imaging in subjects with BMI <30.

METHODS

In a prospective IRB approved trial, healthy subjects underwent magnetic resonance imaging in the supine, prone position with arms at the side, and prone position with arms up using vertically placed towel bolsters. Images were obtained with end expiration breath holds. Distances between the kidney and other anatomical landmarks, including the diaphragm (KDD), top of the L1 vertebra (KVD) and lower edge of the 12^th rib (KRD), were recorded. Nephrostomy tract length (NTL) and other measures for visceral injury were also assessed. Wilcoxon signed rank test was used for analysis (p <0.05).

RESULTS

Ten subjects (5 male, 5 female) with median age of 29 years and BMI of 24 kg/m² were imaged. Right KDD was not significantly different between positions, but KRD and KVD noted significant cephalad movement when prone, as compared to supine. Left KDD noted caudal movement with prone positioning with no difference in KRD or KVD. Arm position did not affect any measurements. Right lower NTL was shorter when prone.

CONCLUSIONS

In subjects with BMI<30, prone positioning led to significant cephalad right renal movement, but not left renal movement. Arm position had no effect on anticipated renal position. Pre-operative end expiration supine CT may reliably predict left kidney location and be used to improve pre-operative counseling and/or surgical planning.

Evaluating factors associated with the risk of hydrothorax following standard supracostal percutaneous nephrolithotomy

Objective

To report our experience with supracostal percutaneous nephrolithotomy (SC-PNL) and evaluate factors which could predict the risk of hydrothorax following SC-PNL.

Methods

We reviewed 347 patients who underwent SC-PNL from January 2011 to December 2019. Patients were assessed for demographic characteristics, indication for the supracostal access, level of supracostal access, anatomy of the kidney (normal or malrotated), site of the puncture in relation to the mid-scapular line (medial or lateral), and whether another subcostal tract for stone clearance was required or not. Patients were assessed for the incidence of hydrothorax and requirement of intercostal drain depending on the level of percutaneous access. In addition, a multivariable logistic regression analysis model was developed to identify factors which could predict the occurrence of hydrothorax following SC-PNL.

Results

Of the 347 patients with SC-PNL, 248 (71.5%) underwent a supra-12th rib approach, while the rest needed a supra-11th (n=85; 24.5%) or a supra-10th (n=14; 4.0%) rib tract. Overall, 17 (4.9%) patients developed a hydrothorax, while an intercostal-drain was required in seven of these 17 patients for 48 h. None of the patients with a supra-12th rib puncture required an intercostal-drain. More than a third of the patients with a supra-10th puncture developed a hydrothorax (35.7%) and all of them required an intercostal drain. Factors such as anteriorly malrotated kidney (odds ratio [OR]=2.722; 95% confidence interval [CI]=1.042-5.617, p=0.03), puncture medial to the mid-scapular line (OR=1.669; CI=0.542-1.578, p=0.03), and an access higher than the supra-12th level (OR=5.265; CI=1.292-9.342, p<0.001) proved to be independent predictors of hydrothorax following a SC-PCNL on multivariable analysis.

Conclusion

Incidence of clinically significant hydrothorax requiring an intercostal-drain after SC-PNL is very low. Knowledge of the predicting factors will help to anticipate the risk of hydrothorax in a particular patient and take necessary peri-operative measures.

Unilateral diaphragmatic paresis following supracostal post-percutaneous nephrolithotomy

Unilateral acquired diaphragmatic paresis is a known complication of thoracic surgeries. Direct mechanical injury to the phrenic nerve during surgery results in this complication. However its occurrence post-percutaneous nephrolithotomy (PCNL) has not been described. We report a 43-year-old man who underwent prone PCNL for endourological management of left complete staghorn calculus. Access via the 10^th left intercostal space, under fluoroscopy, was carried out to remove the calculus. Post-operative, the routine chest radiograph revealed left hemidiaphragmatic blunting. Computerized tomography of the chest confirmed left hemidiaphragmatic elevation, suggesting unilateral diaphragmatic paresis. He did not have any respiratory symptoms, was managed conservatively with chest physiotherapy and incentive spirometry and responded extremely well. The absence of reported cases of diaphragmatic paresis post PCNL lends to a dearth in knowledge regarding recognition and management. This case report aims to acquaint urologists with this rare complication associated with supracostal PCNL and provide a rational management plan.

Comparison of the clinical efficacy of sonography-guided percutaneous nephrolithotomy (PCNL) under local and general anesthesia

Objective

This study aimed to compare the effect of percutaneous nephrolithotomy (PCNL) under local infiltration anesthesia (PCNL-LIA) and general anesthesia (PCNL-GA) to treat upper urinary tract calculi on clinical application values.

Methods

Patients were randomly divided into the PCNL-LIA (16 patients) and PCNL-GA (20 patients) groups. Data on safety, cost, complications, rate of residual calculi, and prognosis were compared.

Results

The mean operation time in the PCNL-LIA group was less than that in PCNL-GA group (100±7.7 versus 120±9.0 minutes). The mean length of hospital stay in the PCNL-LIA group was shorter than that in the PCNL-GA group (6.9±0.5 versus 10.5±1.2 days). The rate of patients who required blood transfusion because of blood loss during or after surgery was less in the PCNL-LIN group than in the PCNL-GA group (13% versus 40%). The intervention rate in the PCNL-GA group was higher than that in the PCNL-LIA group. Visual analogue pain scale assessment showed that the PCNL-LIA group showed slightly more pain than the PCNL-GA group.

Conclusion

PCNL-LIA is safer, faster, and more convenient, and it also provides the benefits of a lower rate of blood loss and complications, lower cost, faster recovery, and shorter hospital stay compared with PCNL-GA.

Non-Angled Intercostal Percutaneous Access Under Full Expiration: Safety Is Not an Issue Anymore

OBJECTIVE

Percutaneous nephrolithotomy (PCNL) is a well-established procedure for the management of urinary calculi and can be performed intercostally or subcostally. Favoring one approach vs the other is still debatable, and literature has been inconclusive regarding the efficacy and safety of both approaches. Hence, this study aims to assess the safety and efficacy of direct non-angled intercostal technique performed under full expiration and to compare it to the subcostal approach.

METHODS

PCNL was conducted among 361 patients during 2010-2015 at Saint George Hospital University Medical Center in Beirut, Lebanon. PCNL was done by one operator and by following a standard technique. After reviewing the medical records, 304 patients were included. Data analysis was conducted using Stata/IC 10.0. Bivariate analysis was conducted using Pearson's Chi-square, and logistic regression model was run. Alpha level was set at 0.05.

RESULTS

Of the total patients, 54.6% and 45.4% underwent intercostal (Group I) and subcostal (Group II) access, respectively. Mean drop in hemoglobin in Group II was 1.9 g/dL vs 1.48 g/dL in Group I (p-value = 0.0040). The mean difference in operation time between group I (88.61 minutes) and group II (102.58 minutes) was statistically significant (p-value = 0.0064). Patients were stone free in 88.05% of the intercostal cases and 78.52% of the subcostal cases. Group II patients were twice more likely to have residual stones compared to Group I (p-value = 0.029). No statistical significance was observed in postoperative complications among both groups. In addition, no cases of pneumothorax were reported.

CONCLUSION

Compared to subcostal access, intercostal approach under full expiration is a safe technique that provides optimal approach to the intrarenal collecting system and allows less angulation, less bleeding, and yields higher stone clearance with minimal complications. When performed by a well-trained urologist, intercostal access should be advocated in PCNL to obtain a direct non-angled access to the tip of the desired posterior calix.

Supracostal Punctures for PCNL: Factors that Predict Safety, Success and Stone Free Rate in Stag Horn and Non-Stag Horn Stones: A Single Centre Experience and Review of Literature

INTRODUCTION

Supra-costal Percutaneous Nephrolithotomy (PCNL) procedure has now become an established standard of care in patients with renal stone disease, in terms of morbidity, stone clearance, duration of stay and shorter convalescence period. Gone are the days when supracostal punctures were considered to be associated with a high morbidity. With increased expertise gained in performing multiple punctures and further refinements in focusing techniques, more and more of these procedures are being performed with an intention to achieve a maximum stone clearance with least morbidity.

AIM

To prospectively analyze the various factors that predict the safety, efficacy and stone clearance rate in patients who have undergo supracostal punctures for PCNL procedures.

MATERIALS AND METHODS

Three hundred seventy six patients underwent PCNL for renal stones. Ninety two (n=92) of them needed supra-costal puncture. All patients were subdivided into groups 1 and 2 based on the size, location of the stone and the stone burden. In all, 132 tracts were established.

RESULTS

About 83% of patients achieved a complete stone free rate after initial PCNL. Stones more than 3 centimeters were found to be associated with significant residual stones. Radio opacity under image intensifier also had a significant impact on the ultimate stone free status. About 23% of those (n=5/22) who needed longer duration of surgery had a clinically significant residual stones, needing ancillary procedures. Fifteen patients (16%) had complications related to the procedure, of which 13 were in group 1 (87%). High percentage of complications in patients with larger stone burden was found to be statistically significant. In about 76% (n=70), the procedure required only less than 90 minutes. Also, in those 22 patients in whom the duration of procedure exceeded 90 minutes, 12 of them had complications, with a p-value of <0.0001.

CONCLUSION

Supra-costal punctures are safe and effective options in a selected group of patients. The overall results are almost on par with that of the infra costal punctures, with an acceptable morbidity.

A comparison of supracostal and infracostal access approaches in treating renal and upper ureteral stones using MPCNL with the aid of a patented system

BACKGROUND

There are still disagreements on which is a better approach to choose to establish percutaneous tract for percutaneous nephrolitotomy (PCNL), between supracostal and infracostal approaches. The aim of this study is to investigate the safety, efficacy and practicability of minimally invasive PCNL (MPCNL) with the aid of a patented system either through supracostal or through infracostal access.

METHODS

A retrospective study was carried out for 83 patients with renal or upper ureteral stones. Under the guidance of B ultrasound or C-arm, these patients were treated by MPCNL through either 12th rib infracostal (Group 1, 43 cases) or supracostal (Group 2, 40 cases) access approach. These 2 groups were compared for total number of percutaneous tracts, average time in establishing a given percutaneous tract, the number of percutaneous tract used for each case, the average stone clearance time, the clearance rate of all stones by one surgery, and the amount of bleeding using a single percutaneous tract.

RESULTS

There was a significantly smaller total number of percutaneous tracts needed, a smaller number of cases that needed two percutaneous tracts to clear stones completely, a shorter average time in establishing a percutaneous tract, and a smaller average amount of bleeding in infracostal access group. At the same time, there were a significantly larger number of cases in which stones were cleared completely using a single percutaneous tract and a higher renal stone clearance rate by one surgery.

CONCLUSION

There were several advantages of infracostal access. These included accuracy in establishing a percutaneous tract, safety, quickness, convenience and flexibility in moving the patented sheath, and higher renal and upper ureteral stone clearance rate by one surgery.