Editorial Comment

Abstract

This retrospective multi-institutional study aimed to determine whether an intercostal approach to the superior calyx resulted in different outcomes compared with a subcostal approach. Interestingly, of the entire cohort of 581 patients who were treated using a percutaneous technique, only 37% were approached via an upper pole access. Of the 142 patients approached via a superior pole access for which follow-up data were available, 72% underwent an intercostal approach, while 38% had a subcostal upper pole access. The intercostal approach resulted in a statistically significant overall improved stone-free rate for staghorn calculi and “large-burden” superior pole calculi compared with the subcostal approach. Major pulmonary complications between the intercostal vs subcostal approach were surprisingly low with only 1 pneumothorax in the subcostal cohort and 1 hemothorax in the intercostal group for an overall pulmonary complication rate of 1.4%. The authors' experience is significantly better than the 7%-15% pneumothorax or hydrothorax rate reported by others when accessing a superior pole calyx. 1 Shaban A. Kodera A. El Ghoneimy M.N. et al. Safety and efficacy of supracostal access in percutaneous renal surgery. J Endourol. 2008; 22: 29-34 Crossref PubMed Scopus (36) Google Scholar , 2 Lojanapiwat B. Prasopsuk S. Upper-pole access for percutaneous nephrolithotomy: comparison of supracostal and infracostal approaches. J Endourol. 2006; 20: 491-494 Crossref PubMed Scopus (95) Google Scholar Intuitively, the higher the intercostal space used for access, the higher the risk for pulmonary and/or pleural injury. The authors did not elucidate which intercostal space (supra 12th rib vs supra 11th rib vs supra 10th rib) was typically used for access. Their lower reported rates of pulmonary complications may be due to a more inferior intercostal space being used. Regardless, one may conclude that in circumstances when a superior pole access is considered preferable, an intercostal approach can provide good access with more than acceptable stone-free rates and acceptable complication rates. I agree with the authors that preoperative CT imaging with reconstructions may assist in proper tract positioning when superior pole access is entertained and reduce the risk of pulmonary, liver, and splenic injury. ReplyUrologyVol. 74Issue 4PreviewThe reviewer's comments address a most pertinent issue. Of our 103 intercostal access routes, 4 were supra 12th rib, 30 supra 11th rib, and 69 supra 10th rib. The only pulmonary complication occurred in 1 of the 4 supra 12th rib accesses, while 2 AV fistulae arose in the supra 11th rib accesses for staghorn calculi, and only 1 arteriocalyceal fistula occurred in the supra 10th rib access. The probability of a pulmonary or pleural complication seems to increase with a higher point of access and likely also in the presence of obesity, which tends to affect the angle of access trajectory. Full-Text PDF Risks, Advantages, and Complications of Intercostal vs Subcostal Approach for Percutaneous NephrolithotripsyUrologyVol. 74Issue 4PreviewTo establish the efficacy of nephrolithotripsy via intercostal access route vs subcostal access route with respect to attained stone-free status, operating time, and complications. Full-Text PDF