Upper-Pole Access for Percutaneous Nephrolithotomy
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Access Upper-Pole Access for Percutaneous Nephrolithotomy Renato N. Pedro, M.D., 1 and Nelson Rodrigues Netto, Jr., M.D., Ph.D. 2 Abstract Although the supracostal approach is thought to increase the difficulties and patient morbidity of PCNL, it facilitates the management of certain urinary infirmities, such as UPJ obstruction, staghorn stone, upper pole stone, proximal ureteral abnormalities, impacted UPJ stone and upper calix diverticulum. Hereby the authors briefly comment on the technical aspects of the supracostal approach, and also discuss the possible complica- tions of this technique and how to avoid them. Introduction A lthough the supracostal approach is thought to increase the difficulties and patient morbidity of percu- taneous nephrolithotomy (PCNL), it facilitates the manage- ment of certain urinary infirmities, such as ureteropelvic junction (UPJ) obstruction with or without renal calculus, staghorn stone, upper-pole stone, proximal ureteral abnor- malities, impacted UPJ stone, and upper calix diverticulum. In our practice, a supracostal approach is always performed under these circumstances, because the upper calix provides a straight path to all sites of the upper collecting system for the rigid nephroscope and therefore provides ‘‘favorable anatomy.’’ Technique We usually put patients in the prone position and pad them on the shoulders and knees (two oblique pads on each shoul- der and a transverse cushion under both knees). Pyelography is performed either by a direct puncture of the renal pelvis or by a retrograde contrast injection. A thorough evaluation of the collecting system anatomy is mandatory for a safe su- pracostal puncture. The caliceal anatomy should be examined in full expiration before picking the preferred upper calix. In this situation, the lungs are in their farthest location from the puncture point. The ideal calix is the one that sits more laterally to the posterior midline (line that runs along with the paravertebral muscle). The anatomic landmark used as reference to the optimal puncture point is the midscapular line, usually lo- cated two to three fingertips lateral to the paravertebral muscle line (Figures 1 and 2). Once identified, the ideal calix and the skin are marked on the midscapular line. Before needle insertion, we have the an- esthesiologist hold the patient’s respiration on full expiration. Then, a diamond tip needle is advanced toward the upper calix guided by fluoroscopy, which is initially tilted to a 30-degree angle. The puncture should be performed avoiding the area underneath the superior (11th) rib to prevent in- juries to intercostal vessels and postoperative pain. We take extra care to follow the ‘‘bull’s-eye’’ principle. The needle is directed into the tip of the calix; then, we place the C-arm back at 90 degrees to check if the tip of the needle is in the collecting system. At this time, the anesthesiologist resumes ventilating the patient, whose respiration was held on full expiration. Once the collecting system is entered, a ‘‘road runner’’ guidewire is placed, and the tract is dilated. Operative Complications Supracostal access is related to a higher rate of complication—mainly intrathoracic—compared with the subcostal approach (18.2% vs 4.4%, respectively). It is even more pronounced (up to 25%) when the targeted calix is sit- ting above the 11th rib. In this case, and particularly if the posterior calix is located too medially, we generally perform an extra puncture (middle posterior calix) and dilate the tract up to 20F with an Amplatz dilator to gently tilt the kidney down, displacing the upper calix to a less risky position. The first assistant keeps the kidney under traction while the sur- geon accesses the upper calix. The 20F interpolar access will eventually harbor a nephrostomy tube for drainage. On the other hand, if the desired calix is above the 11th rib but runs laterally off the posterior midline (in full expiration), we in- sert the needle under fluoroscopic guidance without the aid of an extra puncture. Because there are considerably high complication rates, we routinely check for pleural infusions during (fluoroscopy) and after the procedure (chest radiography). For the supra-12th rib 1 Faculty of Medical Sciences, University of Campinas, Unicamp, Brazil. 2 Hospital Israelita Albert Einstein – Sa ˜o Paulo, Sa ˜ o Paulo, Brazil. JOURNAL OF ENDOUROLOGY Volume 23, Number 10, October 2009 ª Mary Ann Liebert, Inc. Pp. 1645–1647 DOI: 10.1089=end.2009.1531 1645
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Transcript of Upper-Pole Access for Percutaneous Nephrolithotomy
Access
Upper-Pole Access for Percutaneous Nephrolithotomy
Renato N. Pedro, M.D.,1 and Nelson Rodrigues Netto, Jr., M.D., Ph.D.2
Abstract
Although the supracostal approach is thought to increase the difficulties and patient morbidity of PCNL, itfacilitates the management of certain urinary infirmities, such as UPJ obstruction, staghorn stone, upper polestone, proximal ureteral abnormalities, impacted UPJ stone and upper calix diverticulum. Hereby the authorsbriefly comment on the technical aspects of the supracostal approach, and also discuss the possible complica-tions of this technique and how to avoid them.
Introduction
Although the supracostal approach is thought toincrease the difficulties and patient morbidity of percu-
taneous nephrolithotomy (PCNL), it facilitates the manage-ment of certain urinary infirmities, such as ureteropelvicjunction (UPJ) obstruction with or without renal calculus,staghorn stone, upper-pole stone, proximal ureteral abnor-malities, impacted UPJ stone, and upper calix diverticulum. Inour practice, a supracostal approach is always performedunder these circumstances, because the upper calix providesa straight path to all sites of the upper collecting system forthe rigid nephroscope and therefore provides ‘‘favorableanatomy.’’
Technique
We usually put patients in the prone position and pad themon the shoulders and knees (two oblique pads on each shoul-der and a transverse cushion under both knees). Pyelographyis performed either by a direct puncture of the renal pelvis orby a retrograde contrast injection. A thorough evaluation ofthe collecting system anatomy is mandatory for a safe su-pracostal puncture. The caliceal anatomy should be examinedin full expiration before picking the preferred upper calix. Inthis situation, the lungs are in their farthest location from thepuncture point.
The ideal calix is the one that sits more laterally to theposterior midline (line that runs along with the paravertebralmuscle). The anatomic landmark used as reference to theoptimal puncture point is the midscapular line, usually lo-cated two to three fingertips lateral to the paravertebralmuscle line (Figures 1 and 2).
Once identified, the ideal calix and the skin are marked onthe midscapular line. Before needle insertion, we have the an-esthesiologist hold the patient’s respiration on full expiration.
Then, a diamond tip needle is advanced toward the uppercalix guided by fluoroscopy, which is initially tilted to a30-degree angle. The puncture should be performed avoidingthe area underneath the superior (11th) rib to prevent in-juries to intercostal vessels and postoperative pain. We takeextra care to follow the ‘‘bull’s-eye’’ principle. The needle isdirected into the tip of the calix; then, we place the C-armback at 90 degrees to check if the tip of the needle is in thecollecting system. At this time, the anesthesiologist resumesventilating the patient, whose respiration was held on fullexpiration.
Once the collecting system is entered, a ‘‘road runner’’guidewire is placed, and the tract is dilated.
Operative Complications
Supracostal access is related to a higher rate ofcomplication—mainly intrathoracic—compared with thesubcostal approach (18.2% vs 4.4%, respectively). It is evenmore pronounced (up to 25%) when the targeted calix is sit-ting above the 11th rib. In this case, and particularly if theposterior calix is located too medially, we generally performan extra puncture (middle posterior calix) and dilate the tractup to 20F with an Amplatz dilator to gently tilt the kidneydown, displacing the upper calix to a less risky position. Thefirst assistant keeps the kidney under traction while the sur-geon accesses the upper calix. The 20F interpolar access willeventually harbor a nephrostomy tube for drainage. On theother hand, if the desired calix is above the 11th rib but runslaterally off the posterior midline (in full expiration), we in-sert the needle under fluoroscopic guidance without the aidof an extra puncture.
Because there are considerably high complication rates, weroutinely check for pleural infusions during (fluoroscopy) andafter the procedure (chest radiography). For the supra-12th rib
1Faculty of Medical Sciences, University of Campinas, Unicamp, Brazil.2Hospital Israelita Albert Einstein – Sao Paulo, Sao Paulo, Brazil.
JOURNAL OF ENDOUROLOGYVolume 23, Number 10, October 2009ª Mary Ann Liebert, Inc.Pp. 1645–1647DOI: 10.1089=end.2009.1531
1645
PCNL, we usually use intraoperative fluoroscopy to rule outpleural injuries, reserving chest radiography for suspiciouscases.
Good stone-free rates, usually around 80% to 90%, are as-sociated with the supracostal approach. There are clear indi-cations for this approach, however, but one must be aware ofthe potential risks and, if not necessary, then a subcostal ap-proach may be preferable.
In the setting of acute bleeding, we usually use the Amplatz28F to 30F axial dilator over the corresponding Amplatzsheath to tamponade the bleeders. The dilator is left in placefor 5 to 10 minutes in most of these cases, which is sufficient torestrain the hemorrhage. Endovascular embolization is indi-cated when active arterial bleeding is suspected and not re-sponsive to the above described technique. In such cases, alarge bore Foley catheter (20F–22F) is placed in the kidney andkept under gentle traction, while the patient is evaluated bythe endovascular surgeon.
Pleural injuries, such as hydrothorax and pneumothorax,may be managed expectantly if there are no clinical problems.
In large hydrothorax=pneumothorax, however, we recom-mend drainage with a chest tube. The chest tube is then with-drawn as the lung freely expands during respiratory incursions(within 24–48 h). It is valid to note that pleural complicationcan be decreased and avoided when the neprosthomy tube isplaced below the 11th rib. Therefore, after a supracostal PCNL(mainly supra-11th rib) the chest drainage tube should beplaced in a new tract, above the nephrostomy site.
We usually do not perform immediate postprocedure im-aging (chest radiography; radiography of the kidneys, ureters,and bladder; stone protocol CT) for noncomplex PCNL. Weusually check stone-free status before discharge, however,and while the Foley catheter is in place.
We conclude that puncture above the 11th rib should beavoided and that puncture above the 12th rib should be re-stricted to relative experts.
Disclosure Statement
No competing financial interests exist.
FIG. 2. (a) Risk of pleural injuries during supracostal puncture. The gray line (marked Low Risk Area) corresponds to themidscapular line around it; the ‘‘gray puncture zone’’ is displayed where the chances of pleural injuries are minimized. Theblack line (marked High Risk Area) is the lateral margin of the paravertebral muscles. (b) Avoid medial access for supracostalpuncture. Always aim for the calix that sits more lateral in the upper pole.
FIG. 1. (a) Posterior aspects of a rightstaghorn calculus. (b) Posterior kidneyaccess. The arrow shows the idealentry for complete stone clearance.
1646 PEDRO AND NETTO
Address correspondence to:Renato N. Pedro, M.D.
Rua Maruba 631, AlphavilleCampinas, SP 13098-340
Brazil
E-mail: [email protected]
Abbreviations Used
CT¼ computed tomographyPCNL¼percutaneous nephrolithotomy
UPJ¼ureteropelvic junction
UPPER-POLE ACCESS 1647
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