Is the 10th and 11th Intercostal Space a Safe Approach for Percutaneous Nephrostomy and Nephrolithotomy?

Abstract

The aim of this study was to determine the rate of complications in percutaneous nephrostomy (PCN) and nephrolithotomy (PCNL) performed through the 11th and 10th intercostal spaces using our monitoring technique and to discuss the safety of the procedure. Out of 398 PCNs and PCNLs carried out during a 3-year period, 56 patients had 57 such procedures performed using an intercostal approach. The 11th intercostal route was used in 42 and the 10th in 15 cases. One patient had two separate nephrostomies performed through the 10th and 11th intercostal spaces. The technique utilizes bi-planar fluoroscopy with a combination of a conventional angiographic machine to provide anterior-posterior fluoroscopy and a C-arm mobile fluoroscopy machine to give a lateral view, displayed on two separate monitors. None of the patients had clinically significant thoracic or abdominal complications. Two patients had minor chest complications. Only one developed changes (plate atelectasis, elevation of the hemi-diaphragm) directly related to the nephrostomy (2%). The second patient had bilateral plate atelectasis and unilateral congestive lung changes after PCNL. These changes were not necessarily related to the procedure but rather to general anesthesia during nephrolithotomy. The authors consider PCN or PCNL through the intercostal approach a safe procedure with a negligible complication rate, provided that it is performed under bi-planar fluoroscopy, which allows determination of the skin entry point just below the level of pleural reflection and provides three-dimensional monitoring of advancement of the puncturing needle toward the target entry point.

Safety and Efficacy of Supracostal Access in Tubeless Percutaneous Nephrolithotomy

“…A similar low complication rate was reported by Muzrakchi and coworkers. 15 Ng et al 9 evaluated the role of noncontrast, prone-position inspiratory and expiratory three-dimensional CT scans for preoperative planning in patients with complex upper-pole renal calculi. On the basis of their small pilot study, they suggested that global recommendations regarding the safety of upper-pole percutaneous access in the inspiratory or expiratory phase do not appear justified, which may TUBELESS SUPRACOSTAL ACCESS FOR PCNL 1019 explain the conflicting literature in this area.…”

“…3 The most important disadvantage of the supracostal approach is its associated pleural complications, with a rate ranging from 0 to 37%. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15] It is believed that placing a large nephrostomy tube at the end of procedure could limit these complications by allowing free drainage of urine and tamponading the PCNL tract, but such tubes are associated with more postoperative pain and analgesic use. 16 Tubeless PCNL is advocated increasingly in the literature.…”

Demonstration of the course of the posterior intercostal artery (pia) at CT angiography (cta): relevance to interventional radiology (ir) procedures in the chest.

“…Each segmental artery then runs upward to reach the corresponding IS, thus giving a more apparent ascending course in the upper thoracic region. Dissection studies have also demonstrated considerable variation in the position of the neurovascular bundle, which may be located at varying distances below the costal groove within the IS (16,19,20).…”

Supracostal Approach for PCNL: Is 10th and 11th Intercostal Space Safe According to Clavien Classification System?

“…Mousavi-Bahar et al 3 reviewed their complications from supracostal punctures for PCNL in 123 patients, and pneumothorax was found in only 3 cases (2.4%). Similarly, Muzrakchi and coworkers 14 reported complications of PCNL during supracostal 12th rib and supracostal 11th rib access; only 2 patients had minor chest complications in this study.…”