Supracostal access tubeless percutaneous nephrolithotomy: minimizing complications

Supracostal access in percutaneous nephrolithotomy (PCNL) may be avoided due to concern for thoracic complications. The objective of the study is to report the safety and efficacy of supracostal access utilizing a tubeless (stent only) PCNL technique.

Retrospective review of perioperative outcomes of 70 patients (76 renal units) who underwent a supracostal tubeless PCNL. No nephrostomy tubes were left. All patients had a 7F ureteral stent and Foley catheter placed. The nephrostomy sheath was removed with the patient held in end-expiration, and the incision closed.

Median (IQR) age was 62 (48.3-67) years. Median stone size was 20 × 21 mm, and 14 (18%) patients had complete staghorn stones. The upper calyx was the site of access in 52 (68.4%) cases. Access was above the 12th and 11th rib in 63 (83%) and 12 (16%) cases, respectively. Median (IQR) length of stay was 30 (28-32) hours. Fifty (68.5%) patients had no residual fragments (< 2 mm) on postoperative imaging. Eight (11%) patients underwent an ancillary procedure (7 URS and 1 ESWL), with an additional seven patients becoming stone free after this procedure (78%). Thoracic complications occurred in two (2.6%) patients: one small pneumothorax, and one pleural effusion, both managed conservatively. Other complications occurred in nine patients (11.8%): bleeding requiring transfusion (1), fever (4), urinary retention (2), and syncope (2).

Compared to historical controls, our approach to upper tract PCNL utilizing a nephrostomy tube-free approach resulted in an overall low thoracic complication rate and facilitated hospital discharge.