Vol.:(0123456789) 1 3 World Journal of Urology https://doi.org/10.1007/s00345-018-2518-x ORIGINAL ARTICLE Supracostal access tubeless percutaneous nephrolithotomy: minimizing complications Michael W. Sourial 1  · Nathaly Francois 1  · Geoffrey N. Box 1  · Bodo E. Knudsen 1 Received: 9 July 2018 / Accepted: 3 October 2018 © Springer-Verlag GmbH Germany, part of Springer Nature 2018 Abstract Introduction and objective 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. Patients and methods 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. Results 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 complica- tions occurred in nine patients (11.8%): bleeding requiring transfusion (1), fever (4), urinary retention (2), and syncope (2). Conclusion 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. Keywords Percutaneous nephrolithotomy · Stent · Pneumothorax · Urinary calculi Introduction Percutaneous nephrolithotomy (PCNL) remains the first-line treatment of choice for large > 2.0 cm renal stones and com- plex stones [1–3]. While the surgical technique has evolved since it was first described by Fernström and Johansson in 1976, the basic principle remains the same with establishing a percutaneous tract into the kidney to facilitate the removal of stones. The location of the tract may be driven by a num- ber of factors including the size and location of the stone, a supine or prone approach, and other patient factors including the position of the kidney, the location of adjacent organs, and the position of the diaphragm. Establishing access into a posterior upper pole of the kidney has some inherent advan- tages as the length of the tract into the posterior upper pole is usually relatively short due to the natural lie and angle of the kidney [4, 5]. Establishing access into the upper pole and maneuvering within the collecting system is somewhat analogous to working downhill. One is able to maneuver effectively, often even into the lower pole, without having to put excessive torque on the nephroscope [6, 7]. How- ever, access into the upper pole has been associated with a higher rate of complications in some reports. When access is established above the 12th rib, the risk of chest complica- tions has been reported as approximately 10% and when the access is above the 11th rib, it may be as high as 25% [8–12]. Complications can include pneumothorax, hydrothorax, and hemothorax as well as nephropleural fistula. Nephrostomy tubes are often placed at the completion of a PCNL to drain the renal unit, monitor for bleeding, and to help gain re-entry in the advent of a second-look nephroscopy. Other exit strategies have evolved including a * Michael W. Sourial Michael.sourial@osumc.edu 1 Department of Urology, The Ohio State University Wexner Medical Center, 915 Olentangy River Road, Columbus, OH 43212, USA