Management of nephropleural fistula after supracostal percutaneous nephrolithotomy.
OBJECTIVE
Access to complex urinary tract pathology may require supracostal access placing patients at risk for intrathoracic complications. Our objective was to retrospectively review our experience with percutaneous renal surgery with a particular emphasis on identifying the incidence of nephropleural fistula and management of this unusual complication.


METHODS
The records of 375 consecutive patients who underwent percutaneous renal surgery between 1993 and 2001 were reviewed. Supracostal access was placed to address the intrarenal pathologic findings most directly in 120 (26.0%) of the 462 tracts, with 87 (18.8%) above the 12th rib, 32 (6.9%) above the 11th rib, and 1 (0.2%) above the 10th rib.


RESULTS
Of 375 patients, 4 (1%) developed a nephropleural fistula. Of the 87 with supracostal-12th rib access, 2 (2.3%) developed a nephropleural fistula, and 2 (6.3%) of the 32 with supracostal-11th rib access developed the same complication. The overall incidence of nephropleural fistulas in our patient population per access tract placed was 0.87% (4 of 462 percutaneous tracts), which increased to 3.3% (4 of 120) when considering only supracostal access. All patients were treated conservatively, although 1 patient required thoracoscopy with decortication for persistent pleural effusion. No further sequelae developed in any of the other 3 patients, and all fistulas had resolved at 3 months of follow-up.


CONCLUSIONS
As aggressive percutaneous renal surgery with supracostal access to the collecting system becomes more common, the incidence of intrathoracic complications, including nephropleural fistula, may increase. Early recognition and management of a pleural injury is critical to avoid life-threatening situations. Low-morbidity measures are typically successful; however, more aggressive treatment may be required on occasion.
Comprehensive Kidney Stone Center,Division of Urology, Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA.
Costas D
CD
Lallas
Fernando C
FC
Delvecchio
Brian R
BR
Evans
Ari D
AD
Silverstein
Glenn M
GM
Preminger
Brian K
BK
Auge
D000328:Adult; D019299:Decompression, Surgical; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009403:Nephrostomy, Percutaneous; D010996:Pleural Effusion / Q000209:etiology / Q000601:surgery; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology / Q000601:surgery / Q000628:therapy*; D016156:Respiratory Tract Fistula / Q000453:epidemiology / Q000209:etiology / Q000601:surgery / Q000628:therapy*; D012189:Retrospective Studies; D015607:Stents; D013396:Suction; D013906:Thoracoscopy; D014548:Urinary Fistula / Q000453:epidemiology / Q000209:etiology / Q000601:surgery / Q000628:therapy*