Supracostal access for percutaneous nephrolithotomy: less morbid, more effective

Abstract

The supracostal approach gives high stone clearance rates with acceptable morbidity rates and should be attempted in selected cases. Complications when present may be managed easily with conservative measures.

Risks and benefits of the intercostal approach for percutaneous nephrolithotripsy

“…Infusion of a 200 mL bolus of N-Saline into the pleural space was another modification used to prevent puncture of the lung. Because of the known increased risk of pneumothorax or even calico-pleural fistulae access via the 11th interspace was avoided whenever possible (4,8,(13)(14)(15)(16).…”

“…The incidence of hydropneumothorax occurring with intercostal access has been reported at a rate of 4% to 15.3 %, with subcostal access, 0% to 1.4% (4,7,14,16,24). Similarly, large pleural effusions were reported in 8% to 12.5% with intercostal approach, but virtually absent with subcostal access (6,14,15,24). Moreover, on the basis of anatomic considerations, the intercostal access route might have a higher chance for injury to anterior segmental vessels or even anterior and posterior divisional arteries (4,10,11,14) Figure-6.…”

“…Even the posterior interpolar calyx may be accessible via this path without significant angulation. The potential to advance the Amplatz sheath or nephroscope in a straight path from the posterior upper pole calyx into the renal pelvis, upper ureter, and anterior and posterior inferior calyceal groups is of great advantage to the urologist, and reduces the propensity for injury to the peri-infundibular venous plexus if an angulation of the tract is necessary to reach the stone-bearing region (15,16). While the infundibulum of the superior calyceal group tends to be longer, the vascularity of the peri-papillary and peri-infundibular plexus is less prominent than in the mid calyceal (interpolar calyceal) group (11).…”

“…Access via the posterior superior calyceal group makes calculi in the renal pelvis, upper ureter, and anterior and posterior inferior calyceal groups accessible, and thus makes this an almost universal access route. Only the superior anterior calyceal group and anterior and sometimes posterior interpolar calyceal groups cannot be reached easily via this entry and hence may mandate separate punctures and access routes if calculi are harbored in these regions (5,15). Moreover, access from the superior posterior calyceal group creating a straight path to the pelvis, upper ureter and inferior calyceal group reduces injury to renal parenchyma by the Amplatz sheath or nephroscope during respiratory excursion (12,14).…”

“…Diffuse bleeding from the tract (n = 2) and need for blood transfusions (n = 2) suggest either injury to the peri-infundibular plexus, either during the procedure or due to inadequate postoperative tamponade by the Malecot or Council Catheter. Injury to the peri-infundibular venous plexus is likely to occur when advancing the Amplatz sheath while negotiating the angle formed between the subcostal access tract and the infundibulum and pelvis (8,11,15,16), (Figure-5). Access to the mid-calyx (interpolar calyx) via a subcostal approach shows a similar high incidence rate of minor complications (19%), Table-4.…”