Use of lower pole nephrostomy drainage following endorenal surgery through an upper pole access

PNL via an UP puncture is efficient for treating complex stone disease. Access via the UP can provide better visualization, allowing greater stone clearance with a rigid instrument due to its more favorable alignment with the axis of the intrarenal collecting system. However, the presence of a NT through the upper pole tract, especially with a supracostal puncture, can generate significant patient discomfort. We reviewed our experience with a technique using tubeless UP access for PNL with concomitant placement of a NT via a LP calix.

We performed a retrospective review of our experience using tubeless UP access for PNL with concomitant placement of an LP NT for postoperative drainage. Patient demographics, the number and location of accesses, stone size, stone-free rates, concurrent/additional procedures and complications were recorded.

A total of 63 tubeless UP accesses were performed in 62 patients undergoing PNL, including unilateral access in 61 and bilateral access in 1. Supracostal UP punctures were used in 58 patients, including 40 above the 12th, 17 above the 11th and 1 above the 10th rib. Each patient underwent at least 2 accesses and 3 had 3 or more accesses placed. LP access was nondilated in 37 patients and dilated in 26. Of the patients 56.6% were stone-free after a single procedure, increasing to 96.2% following secondary procedures. Three of the 62 patients (4.8%) required transfusion, 3 (4.8%) required intervention for pleural morbidity and 1 (1.6%) required a stent for a nonsealing upper pole access.

Tubeless UP access provides maximal efficiency for stone clearance during PNL, while minimizing the morbidity of an intercostal tube.