title: Safety and efficacy of supracostal access in percutaneous renal surgery.
abstract: OBJECTIVE
  During percutaneous renal surgery, subcostal access is preferred because it carries no risk of injury to either the lungs or pleura. However, in some situations, a supracostal approach may provide more direct access and achieve a more satisfactory result than the subcostal approach. In this prospective study, we evaluated the safety and efficacy of supracostal approaches in percutaneous renal surgery.
  
  
  METHODS
  Between 2004 and 2006, 30 patients underwent percutaneous renal surgery with a supracostal approach either as the sole or as a secondary access. The indications were staghorn stones, upper caliceal stones, upper ureteral stones, secondary ureteropelvic junction obstruction, disturbed lower caliceal anatomy, and high-lying kidneys. The puncture was above the eleventh rib in six procedures and above the twelfth rib in 24 procedures. All patients were examined for equal air entry on both sides of the chest, and all had chest radiography performed immediately after surgery to exclude pneumothorax or hydrothorax. Bleeding was assessed with evaluation of preoperative and postoperative hemoglobin, levels and vital signs; urine was also examined for gross hematuria. A routine nephrostogram was obtained for all patients.
  
  
  RESULTS
  Supracostal was the sole access in 63.3% of patients and a secondary access in 36.7% of patients. Intraoperatively, bleeding occurred in one patient. Hydrothorax in another patient necessitated insertion of an intercostal chest drain. A renopleural fistula developed in another patient 2 days postoperatively that necessitated placement of a chest drain and Double J stent. Access in both patients with pleural complications had been above the eleventh rib. The mean drop in hemoglobin level was 0.79 +/- 0.72 g/dL. Our overall stone-free rate was 88.9%.
  
  
  CONCLUSIONS
  Supracostal access above the twelfth rib is relatively safe; however, access above the eleventh rib should be limited to necessity because a higher incidence of pleural complications can be expected. A chest radiograph should be obtained immediately postoperatively for early detection of hydrothorax or pneumothorax.
authors: Department of Urology, Cairo University, 14 Abedf El Hady Street, El Manial, Cairo, Egypt.
authors: A
authors: A
authors: Shaban
authors: A
authors: A
authors: Kodera
authors: Mohamed N
authors: MN
authors: El Ghoneimy
authors: T Z
authors: TZ
authors: Orban
authors: K
authors: K
authors: Mursi
authors: A
authors: A
authors: Hegazy
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D007668:Kidney / Q000000981:diagnostic imaging; D008297:Male; D009403:Nephrostomy, Percutaneous / Q000009:adverse effects / Q000379:methods*; D011859:Radiography; D014513:Ureter / Q000000981:diagnostic imaging