Complications associated with percutaneous nephrolithotripsy: supra- versus subcostal access. A retrospective study

Percutaneous nephrolithotripsy is an essential procedure for treating complex urinary calculi. To achieve optimal access to a large and complicated stone, an upper calyx puncture is often preferable. However, when performing a puncture above the 12th rib there is risk of an increased number of complications. In this retrospective study, we assessed the kind and frequency of complications after sub- and supracostal punctures of the collecting system of the kidney.

Between 1996 and 2001, 85 patients were treated with percutaneous nephrolithotripsy. In 63 patients a subcostal track, below the 12th rib was established. Puncture was performed under ultrasonic or fluoroscopic guidance in 61 patients and CT-guided in 2 patients. In 17 patients a supracostal puncture, above the 12th rib, was performed under CT guidance and in 5 patients with US or fluoroscopic guidance.

The main difference regarding preoperative complications was the number of patients complaining of respiratory correlated pain, 7 (32%) in the supracostal puncture group compared with 3 (5%) in the subcostal puncture group. No significant difference regarding peroperative complications was found. Postoperatively, there were 2 major bleedings, one in each group, which had to be treated with arterial embolization. In the supracostal puncture group there were 2 patients with pleural effusion and 2 patients with pneumothorax.

The complication rate was slightly higher after supracostal puncture as compared with a subcostal approach, especially regarding respiratory correlated pain. When performing a supracostal puncture there is an increased risk that the track passes through the pleural space, which might explain the difference in the panorama of complications.