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A supracostal approach for percutaneous nephrolithotomy of staghorn calculi: A prospective study and review of previous reports.

El-Karamany T - Arab J Urol (2012)

Bottom Line: Overall, 78% of patients were rendered stone-free or had clinically insignificant residual fragments with PCNL monotherapy, and this increased to 88% with auxiliary procedures.The supracostal upper calyceal approach provides optimum access for the percutaneous removal of staghorn stones.Appropriate attention to the technique and to monitoring before and after surgery can detect thoracic complications, and these can be managed easily with intercostal chest tube drainage, with no serious morbidity.

View Article: PubMed Central - PubMed

Affiliation: Urology Department, Benha Faculty of Medicine, Benha, Egypt.

ABSTRACT

Objectives: To evaluate a supracostal approach for percutaneous nephrolithotomy (PCNL) of staghorn calculi through a prospective study and review of previously reported cases.

Methods: From June 2009 to November 2011, 40 patients with staghorn calculi were scheduled for supracostal S-PCNL in a prospective study. Of the 40 renal units, 16 (40%) had a complete staghorn and 24 (60%) had a partial staghorn calculus. Perioperative complications were stratified according to the modified Clavien system. Univariate and multiple logistic regression analyses were used to determine statistically significant variables affecting the stone-free rate and development of complications.

Results: In all, 57 tracts were established in the 40 renal units; 23 (58%) renal units were approached through one supracostal upper pole calyx, while 13 (33%) and four (10%) required a second middle- or lower-pole puncture, respectively. Overall, 78% of patients were rendered stone-free or had clinically insignificant residual fragments with PCNL monotherapy, and this increased to 88% with auxiliary procedures. In the logistic regression analysis, a complete staghorn stone was the only independent variable for residual stones (P = 0.005). There was an overall complication rate of 38%. Independent variables with an influence on complications were staghorn stone burden (P = 0.007), and operative duration (P = 0.045).

Conclusions: The supracostal upper calyceal approach provides optimum access for the percutaneous removal of staghorn stones. Appropriate attention to the technique and to monitoring before and after surgery can detect thoracic complications, and these can be managed easily with intercostal chest tube drainage, with no serious morbidity.

No MeSH data available.


Related in: MedlinePlus

(a) Landmarks relevant to supracostal access: PSL, paraspinal line; MSL, midscapular line; PAL, posterior axillary line. A small needle points to the upper calyx. The puncture for a supra-12th rib approach at the MSL is in the middle of the intercostal space. (b) The nephrostomy tube placed at conclusion of the procedure.
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f0005: (a) Landmarks relevant to supracostal access: PSL, paraspinal line; MSL, midscapular line; PAL, posterior axillary line. A small needle points to the upper calyx. The puncture for a supra-12th rib approach at the MSL is in the middle of the intercostal space. (b) The nephrostomy tube placed at conclusion of the procedure.

Mentions: Prophylactic antibiotics were given before surgery in every case. All PCNL was performed as a one-stage procedure under C-arm fluoroscopic guidance. Renal access was determined before the procedure after assessing the stone configuration and intrarenal anatomy of the collecting system. The desired calyx and the upper-pole calyx were punctured and guidewires were fixed before dilatation of any tract. For supracostal upper-pole access, the intercostal space between the 11th and 12th rib was used in all cases. The puncture was made above the lateral half of the 12th rib at the mid-scapular line (Fig. 1a). The needle was advanced in the middle of the intercostal space, thus avoiding the intercostal nerve and vessels. The puncture was made during full expiration, to avoid injury to the lung or pleura. The nephrostomy tract was dilated to 30 F using Alken’s coaxial telescopic dilators. A pneumatic lithotripter was used to disintegrate the stone and any stone fragments removed by grasping forceps. When additional access was required, the Amplatz sheath was left in the upper calyx while working through the second access tract, to prevent excessive extravasation from the upper calyx into the pleural cavity. A 20 or 22 F Nelaton catheter was placed as a nephrostomy tube at the end of the procedure (Fig. 1b). If there was any doubt about complete stone clearance or bleeding from the other tract, an additional nephrostomy tube was placed in that tract. All patients had a nephrostogram taken at the end of surgery, and lung fields were imaged fluoroscopically with the patient prone. A chest radiogram was taken immediately after surgery, On the second day after surgery all had a routine plain film radiography, nephrotomography and ultrasonography to check for residual fragments, leakage and infrarenal obstruction. A second stage, if necessary, was scheduled after 2–3 days.


A supracostal approach for percutaneous nephrolithotomy of staghorn calculi: A prospective study and review of previous reports.

El-Karamany T - Arab J Urol (2012)

(a) Landmarks relevant to supracostal access: PSL, paraspinal line; MSL, midscapular line; PAL, posterior axillary line. A small needle points to the upper calyx. The puncture for a supra-12th rib approach at the MSL is in the middle of the intercostal space. (b) The nephrostomy tube placed at conclusion of the procedure.
© Copyright Policy - CC BY-NC-ND
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4442912&req=5

f0005: (a) Landmarks relevant to supracostal access: PSL, paraspinal line; MSL, midscapular line; PAL, posterior axillary line. A small needle points to the upper calyx. The puncture for a supra-12th rib approach at the MSL is in the middle of the intercostal space. (b) The nephrostomy tube placed at conclusion of the procedure.
Mentions: Prophylactic antibiotics were given before surgery in every case. All PCNL was performed as a one-stage procedure under C-arm fluoroscopic guidance. Renal access was determined before the procedure after assessing the stone configuration and intrarenal anatomy of the collecting system. The desired calyx and the upper-pole calyx were punctured and guidewires were fixed before dilatation of any tract. For supracostal upper-pole access, the intercostal space between the 11th and 12th rib was used in all cases. The puncture was made above the lateral half of the 12th rib at the mid-scapular line (Fig. 1a). The needle was advanced in the middle of the intercostal space, thus avoiding the intercostal nerve and vessels. The puncture was made during full expiration, to avoid injury to the lung or pleura. The nephrostomy tract was dilated to 30 F using Alken’s coaxial telescopic dilators. A pneumatic lithotripter was used to disintegrate the stone and any stone fragments removed by grasping forceps. When additional access was required, the Amplatz sheath was left in the upper calyx while working through the second access tract, to prevent excessive extravasation from the upper calyx into the pleural cavity. A 20 or 22 F Nelaton catheter was placed as a nephrostomy tube at the end of the procedure (Fig. 1b). If there was any doubt about complete stone clearance or bleeding from the other tract, an additional nephrostomy tube was placed in that tract. All patients had a nephrostogram taken at the end of surgery, and lung fields were imaged fluoroscopically with the patient prone. A chest radiogram was taken immediately after surgery, On the second day after surgery all had a routine plain film radiography, nephrotomography and ultrasonography to check for residual fragments, leakage and infrarenal obstruction. A second stage, if necessary, was scheduled after 2–3 days.

Bottom Line: Overall, 78% of patients were rendered stone-free or had clinically insignificant residual fragments with PCNL monotherapy, and this increased to 88% with auxiliary procedures.The supracostal upper calyceal approach provides optimum access for the percutaneous removal of staghorn stones.Appropriate attention to the technique and to monitoring before and after surgery can detect thoracic complications, and these can be managed easily with intercostal chest tube drainage, with no serious morbidity.

View Article: PubMed Central - PubMed

Affiliation: Urology Department, Benha Faculty of Medicine, Benha, Egypt.

ABSTRACT

Objectives: To evaluate a supracostal approach for percutaneous nephrolithotomy (PCNL) of staghorn calculi through a prospective study and review of previously reported cases.

Methods: From June 2009 to November 2011, 40 patients with staghorn calculi were scheduled for supracostal S-PCNL in a prospective study. Of the 40 renal units, 16 (40%) had a complete staghorn and 24 (60%) had a partial staghorn calculus. Perioperative complications were stratified according to the modified Clavien system. Univariate and multiple logistic regression analyses were used to determine statistically significant variables affecting the stone-free rate and development of complications.

Results: In all, 57 tracts were established in the 40 renal units; 23 (58%) renal units were approached through one supracostal upper pole calyx, while 13 (33%) and four (10%) required a second middle- or lower-pole puncture, respectively. Overall, 78% of patients were rendered stone-free or had clinically insignificant residual fragments with PCNL monotherapy, and this increased to 88% with auxiliary procedures. In the logistic regression analysis, a complete staghorn stone was the only independent variable for residual stones (P = 0.005). There was an overall complication rate of 38%. Independent variables with an influence on complications were staghorn stone burden (P = 0.007), and operative duration (P = 0.045).

Conclusions: The supracostal upper calyceal approach provides optimum access for the percutaneous removal of staghorn stones. Appropriate attention to the technique and to monitoring before and after surgery can detect thoracic complications, and these can be managed easily with intercostal chest tube drainage, with no serious morbidity.

No MeSH data available.


Related in: MedlinePlus