Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 32  |  Issue : 4  |  Page : 148-152

Upper-pole infra-costal access for supine percutaneous nephrolithotomy: Advantage or risk?


1 Department of Urology, Mediterraneo Hospital, Athens, Greece; Department of Urology, Monklands, Hospital, NHS Lanarkshire, Glasgow, UK
2 Department of Urology, Monklands, Hospital, NHS Lanarkshire, Glasgow, UK
3 Department of Urology, Sismanoglio Hospital, Athens, Greece

Date of Submission23-Oct-2020
Date of Decision15-Nov-2020
Date of Acceptance24-Dec-2020
Date of Web Publication13-Aug-2021

Correspondence Address:
Stylianos Kontos
Afroditis 14, P. Faliro, Athens

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HUAJ.HUAJ_11_20

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  Abstract 


Objective: There are still disagreements in choosing a better approach to establish a percutaneous tract for percutaneous nephrolithotomy (PCNL), between supine and prone positions. The aim of this study is to investigate the safety, efficacy, and practicability of treating upper-pole renal stones, using an infra-costal puncture in both prone and supine positions. Materials and Methods: Fifteen patients underwent infra-costal puncture for the percutaneous treatment of upper-pole stones at our institution over a 3-year period. Seven patients underwent a prone procedure and six had a supine PCNL. All punctures were undertaken by two consultant urologists. Stone clearance was assessed with a plain X-ray kidney-ureter-bladder on postoperative day 1. We retrospectively analyzed our prospectively maintained database to assess stone clearance, complications, and length of stay of these patients. Results: The overall stone-free rate was 93.3% (all but one patient). One hundred percentage of the prone group were stone free following the procedure. Nearly 87.5% of the supine group had a complete clearance. Complications and length of stay were comparable for both groups. Almost 25% of the supine group and 14% of the prone group required transfusion. The postoperative pyrexia rates were similar for both groups. The overall complication rate was 26.7% (n = 4) – one case of sepsis and three patients required blood transfusion. There were no thoracic complications. Conclusions: Upper-pole renal stones can be safely and effectively treated percutaneously using direct upper-pole puncture via an infra-costal approach in supine position, as well as in prone position.

Keywords: Infra-costal puncture, percutaneous nephrolithotomy


How to cite this article:
Kontos S, Smyth N, Papatsoris A, Nalagatla SK. Upper-pole infra-costal access for supine percutaneous nephrolithotomy: Advantage or risk?. Hellenic Urology 2020;32:148-52

How to cite this URL:
Kontos S, Smyth N, Papatsoris A, Nalagatla SK. Upper-pole infra-costal access for supine percutaneous nephrolithotomy: Advantage or risk?. Hellenic Urology [serial online] 2020 [cited 2021 Sep 24];32:148-52. Available from: http://www.hellenicurologyjournal.com/text.asp?2020/32/4/148/323794




  Introduction Top


Upper-pole calyceal stones are best accessed for fragmentation with a direct upper-pole puncture. The indications for upper-pole stone access for percutaneous nephrolithotomy (PCNL) are staghorn calculi, large upper-calyceal calculi, calculi associated with ureteropelvic junction pathology, calculi in anomalous kidneys, and calculi in special anatomy such as that seen in morbidly obese patients.[1] The advantage of upper-pole access for nephrolithotomy is direct access to most of the intrarenal collecting system and upper ureter. Upper-pole access can be achieved either supracostally or infracostally. Traditionally, PCNL has been performed in the prone position,[2] which allows a wide field for kidney puncture, avoids abdominal visceral injuries, and makes the puncture pathway short and straight. Multiple routes of access and the intraoperative use of C-arm fluoroscopy X-ray machines may contribute to the vertical positioning of the puncture.[3],[4] This position provides posterior access to the collecting system, which theoretically enables the surgeon to puncture a posterior calyx through Brodel's avascular renal plane without significant parenchymal bleeding and peritoneal perforation. However, the prone position also has some disadvantages. For example, the abdominal pressure decreases end-expiratory lung volume and lung capacity, reducing the ability of patients to tolerate prolonged surgery, contraindicating the prone position in morbidly obese patients and individuals with respiratory diseases.[5] An alternative position for PCNL consists of the modified supine position, in which patients are placed in a supine position with a water bag or a specially designed cushion under the flank.[6] The modified supine position has several advantages.[7],[8],[9] Due to greater comfort, the position has a low impact on a patient's blood circulation and respiratory system. This position makes it easier for the anesthetist to monitor the patient, and it may decrease the use of anesthetics.[10],[11],[12] For high-risk patients, the modified supine position can be changed to facilitate endotracheal intubation anesthesia whenever needed. Moreover, the smaller angle between the horizon and the operating channel improves the removal of crushed stones.[13],[14],[15] This position also facilitates simultaneous ureteroscope access when necessary, allowing for the combination of PCNL and the ureteroscope in the management of complex stone diseases. The major disadvantage of the modified supine position is that the kidney is more easily pushed forward by the puncture needle and the fascial dilators, leading to the establishment of a deeper channel.[9],[16],[17],[18] PCNL has been traditionally performed in the prone position, with this still being the most commonly used position. In the past decade, however, several variations in patient positioning for PCNL have been proposed.

Advantages of the supine position include less patient handling, better drainage of the Amplatz sheath, a combination of antegrade and retrograde approaches, the ability of the surgeon to sit, easier change from spinal or regional to general anesthesia, and higher tolerance, especially in patients with pulmonary or cardiovascular disease. The learning curve for the practicing endourologist is minimal.

Furthermore, there were no significant (prone vs. supine) differences in mean blood loss, need for blood transfusion, and mean hospital stay between groups, similar to previous results,[19] suggesting that operations performed in both positions are effective and safe. There were no significant differences in the complication rate and requirements for blood transfusions. However, another randomized study found that the transfusion rate was higher in the supine (27.5%) than in the prone (7.5%) group.[20] Differences between studies may be due to different transfusion thresholds between different centers. Apparently, PCNL in the prone position was thought to exert a longer time because patients are required to be placed in the prone position after ureteral catheterization and to roll back to the supine position after surgery. Supporting evidence has been provided. For example, randomized trials have reported that operation times were significantly shorter in the supine than that in the prone group.[21]

We compared the efficacy and safety of the supra-costal and infra-costal approaches. We present our experience of accessing the upper pole with an infra-costal puncture in both prone and supine positions for the treatment of renal stones and discuss the efficacy and safety thereof.


  Materials and Methods Top


We undertook a retrospective audit of all patients at a single institution who underwent PCNL for upper-pole stones with an infra-costal puncture over a 3-year period, between 2011 and 2014. All punctures were undertaken by two urology consultants under fluoroscopic guidance, one practicing prone PCNL and the other supine, according to surgeon's preference. A retrospective study was carried out for the 15 patients with renal or upper ureteral stones. The inclusion standards were as follows: complete or incomplete staghorn renal stones with sizes ≥2.0 cm; renal calyceal stones with co-existing calyceal obstruction and clinical symptoms; ureteral stones above L4 and >1 cm in size; stone has stayed in the ureter for >2 months complicated by ureteral ectasia above the stone; or patients who have previously failed shock wave lithotripsy or ureteroscopic lithotripsy. The stone burden (cm2) was calculated by multiplying the maximal length and maximal width of the stone in plain film of kidney-ureter-bladder (KUB).

Under general anesthesia (GA), the patients were placed in the supine position with a gel cushion [Figure 1] beneath the ipsilateral flank to elevate and expose the loin for percutaneous access and to reduce the possibility of pleural damage. Legs were supported on stirrups to have access to the urethra for retrograde rigid/flexible ureteroscopy [Figure 2]. All patients received intravenous antibiotics at induction. Flexible ureteroscopy was performed initially to identify the position of the stone and retrograde study was performed. Under fluoroscopy guidance, puncture was performed with an 18G coaxial needle, which was inserted into the desired calyx. Tract dilatation was performed using NephroMax™ balloon dilator. A nephrostomy balloon dilation catheter was inserted and a 30 Fr Amplatz sheath was placed in the proper position, allowing the introduction of a nephroscope. A LithoClast® Master (LithoClast and ultrasonic system) was used to fragment and remove the stone. At the end of the procedure, all patients had ureteric stent insertion that removed about 3-4 weeks later in the outpatient clinic. The targeted point was one of the rear group calyces in the upper pole [Figure 3] and [Figure 4]. For both access approaches, we always minimized the angle between the long axis of our percutaneous tract and the long axis of the collecting system when we were dealing with renal staghorn stones. The point we preferred to target was the calyx with the stone inside that was closest to our puncturing point. When we were dealing with ureteral stones, we always minimized the angle between the long axis of our percutaneous tract and the axis between the proximal and the distal segments of the ureter. The puncture point was in the 11th intercostal space or the 12th subcostal margin.
Figure 1: Gel cushion

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Figure 2: Patient in the supine position – left – percutaneous nephrolithotomy iliac crest, rib cage, and posterior axillary lines marked

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Figure 3: 2.2-cm left upper-pole stone – percutaneous nephrolithotomy – complete clearance with infra-costal access

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Figure 4: Another case of left upper-pole stone percutaneous nephrolithotomy – infra-costal access

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Stone clearance was assessed with a plain X-ray KUB on postoperative day 1 and in the majority of cases, the stent was removed on postoperative day 2 before discharge.


  Results Top


Fifteen patients in total were identified – seven of which underwent a prone PCNL procedure and eight had a supine PCNL. Two patients had complete staghorn calculi – one of whom was treated in the supine position and the other prone. Six had multiple renal stones and seven patients had a single upper-pole stone requiring treatment. The mean stone size was 24.4 mm (range: 19–41 mm). The mean stone density was 937.1 HU (517 HU–1390 HU).

Fourteen/15 patients (93.3%) were left with a ureteric stent postoperatively, and the other one patient who had an incomplete clearance was left with a nephrostomy.

All but one patient had complete clearance, with a stone-free rate (SFR) of 93.3% (n = 14). Four patients developed a postoperative pyrexia, and was treated for sepsis. There were no bowel or pleural injuries. The length of stay ranged from 1 to 8 days (mean = 3.6 days), which was comparable for both groups (3.4 prone, 3.75 supine). Three patients (20%) required a blood transfusion. Complication rates were similar for the two groups. The stone clearance rates were 100% in the prone group and 87.5% in the supine group although the small numbers and heterogeneity of stone burden make a comparison difficult. Nearly 25% of the supine group and 14% of the prone group required transfusion. The postoperative pyrexia rates were similar for both groups. The overall complication rate was 26.7% (n = 4) – one case of sepsis and three patients required blood transfusion. There were no thoracic complications.


  Discussion Top


Large upper-pole renal stones are best accessed for fragmentation with a direct upper-pole calyceal puncture. This is more commonly undertaken via a supra-costal approach above the 12th or 11th rib. Upper-pole calyceal puncture can also be achieved with an infra-costal puncture. The reported thoracic complication rates with supra-costal puncture range from 5% to 29%.[3],[21],[22]

We demonstrate that upper-pole calyces can be safely accessed via an infra-costal puncture in both prone and supine positions. SFRs for infra-costal upper-pole access tend to compare less favorably with supra-costal puncture SFR.

Lang et al. found that higher SFRs with lower complication rates were achieved when using a prone intercostal approach when compared with that of supine infra-costal puncture. The SFR in their series for infra-costal puncture was just 74% compared with 88% for the supra-costal approach.[3] A further series of 464 patients by Lojanapiwat et al. also found higher SFRs in their supra-costal puncture group of 82.2% compared with 77.1% of those treated via an infra-costal puncture. This series did report a significantly higher thoracic complication rate of 15.3% in the supra-costal group however.[5]

Radecka et al. also found a higher complication rate for prone supra-costal puncture when compared with that of supine infra-costal approach.[23]

El-Karamany achieved 78% SFRs in their series of supine supra-costal PCNL for staghorn calculi but reported a 10% hydrothorax rate.[24]

More recently, Ozgor et al. found comparable SFR and complication rate with supra- versus infra-costal punctures using mini-PCNL in their series of 98 patients.[4]

Falahaktar et al. reported an 85% SFR for infra-costal puncture in the supine position in their series with no thoracic complications.[10]

Our series demonstrates that upper-pole stones can be accessed safely and effectively using an infra-costal puncture in both prone and supine positions. Good SFRs which compare favorably with those in the literature were achieved. Our complication rates compare favorably with that of reported series with no major complications.

This is a safe method for treating larger upper-pole stones in select patients and can be used either prone or supine. The main advantage of an infra-costal puncture over a supra-costal puncture is the reduced risk of pleural injury.

PCNL has been traditionally performed in the prone position, with this still being the most commonly used position. In the past decade, however, several variations in patient positioning for PCNL have been proposed. The total cost of performing a supine-combined PCNL is much higher because two endourologists are needed and the costs of using access sheaths and flexible ureteroscope have to be bear in mind, but it is not higher than the cost of a second or third operation to clear all the reaming fragments.[21]

Advantages of the supine position include less patient handling, better drainage of the Amplatz sheath, a combination of antegrade and retrograde approaches, the ability of the surgeon to sit, easier change from spinal or regional to GA, and higher tolerance, especially in patients with pulmonary or cardiovascular disease. The learning curve for the practicing endourologist is minimal.

None of the patients in our study experienced major complications. Complications may occur during or after PCNL and may include extravasation, blood transfusion, and adjacent organ injuries. In other studies, the rates of major complications, however, including septicemia, colonic or pleural injury, and serious bleeding, have been found to vary from 0% to 4.7%.[25] Furthermore, there were no significant (prone vs. supine) differences in the mean blood loss, need for blood transfusion, and mean hospital stay between the groups, similar to that of previous results,[26] suggesting that operations performed in both positions are effective and safe. There were no significant differences in the complication rate and requirements for blood transfusions. However, another randomized study found that the transfusion rate was higher in the supine (27.5%) than in the prone (7.5%) group. Differences between studies may be due to different transfusion thresholds between different centers.[27] Apparently, PCNL in the prone position was thought to exert a longer time because patients are required to be placed in prone position after ureteral catheterization and to roll back to the supine position after surgery. Supporting evidence has been provided. For example, randomized trials have reported that operation times were significantly shorter in the supine than that in the prone group.


  Conclusions Top


The study showed that PCNL in the supine position is an effective and safe method for treating urinary stones. There are numerous advantages for PCNL, including decreasing operating time, evacuation of stone fragment, a more tolerable position for high-risk patients, and sitting position for the surgeon. We hope that this paper could encourage the stone teams to perform PCNL in the supine position. However, we do recognize that our sample size was not large. Larger, prospective studies at multiple clinical centers are warranted to further compare the supra-costal and infra-costal access approaches in treating upper urinary stones using PCNL.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Ozgor F, Tepeler A, Basibuyuk I, Kucuktopcu O, Kayali Y, Yanaral F, et al. Supracostal access for miniaturized percutaneous nephrolithotomy: Comparison of supracostal and infracostal approaches. Urolithiasis 2018;46:279-83.  Back to cited text no. 4
    
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