V6-08: Large upper-calyx stone: Can supra-twelfth PCNL approach be avoided?

Video

Introductions and Objectives
A large renal stone is considered any calculi larger than 2 cm. When this burden is located in the upper calyx, a supracostal PCNL approach has to be considered. However, many urologists hesitate to use this access because of the potential for intrathoracic complications. As a result, other techniques to avoid the supracostal approach and access the upper pole have been described. Most of them required staged or auxiliary procedures. We present our series of large upper calyx stone, and we will evaluate if it is a good option to avoid a supracostal approach in terms of efficacy.

Methods
We will illustrate in the videotape, the decision process in the treatment of a large upper calyx stone. We have applied this evaluation to 22 consecutive patients with a mean stone burden of 3529 mm3. We outlined the method with a 48 years old male and a large upper calyx stone burden. After evaluating all the endourological alternatives to treat a stone with this feature, we decided to offer him a supracostal PCNL approach. Following informed consent, the patient was placed prone after an open end ureteral catheter was introduced. A supra twelfth rib puncture was accomplished, and sequential metal dilation was done. It was followed by insertion of a 24 french amplatz sheath. A direct access to the stone was observed. Initially, laser lithotripsy was applied for debulking the stone. It was followed by ultrasonic lithotripsy, and removal of the fragments. A nephrostomy tube was placed at the end of the surgery.

Results
Supracostal access was performed in all 22 patients in this series. Mean operating time was 74.4 minutes. A high stone clearance of 86.3% was achieved. Not major complications were observed. There were just two pleural effusions demonstrated on posoperative X rays, that did not require interventions.

Conclusions
The concern for potential morbidity associated with supracostal punctures, precludes many endourologists from performing these approaches. In some cases like large upper calyx stones, the supracostal access is the most effective option, and the surgeon has to be prepared to offer this procedure within a safe margin.

Funding: None