Supra-twelfth supracostal access: when and where to puncture?

Supracostal access for percutaneous renal surgery raises concern for the intrathoracic complications of the puncture. We analyzed the incidence of pleural transgression and intrathoracic complications after supracostal punctures in relation to the site of puncture (medial v lateral placement) and the respiratory phase during the puncture.

We conducted a prospective study of 28 consecutive supracostal accesses in our department. All the punctures were made by the treating urologist under fluoroscopic guidance. Punctures were made during the normal respiratory cycle, and dilatation was up to 30F. Postoperatively, chest radiography and CT of the chest and upper abdomen were performed for evaluation of complications.

All supracostal accesses were supra-12th rib only. The average distance from midline of the site of puncture on the skin was 8.2 cm (range 5.5-9.1 cm). Complete stone clearance was achieved in 27/28 (96.4%) of the renal units. One patient had symptomatic hydrothorax necessitating chest tube placement. None of the patients had any lung or solid organ (liver or spleen) injury on CT imaging. Three patients had mild pleural effusion without symptoms, which was detected on postoperative CT.

Laterally placed supra-12th rib punctures made during the normal ventilatory cycle have an acceptably low pleural morbidity and no risk of lung injury.