Subcostal Access Research Articles

Subcostal bilateral internal thoracic artery harvesting with the da Vinci Single Port system: an experimental feasibility study.

We evaluated the feasibility of harvesting bilateral internal thoracic arteries with the da Vinci Single Port system (SP)through a single left-sided subcostal incision. Complete bilateral mobilization with sufficiently long conduits for multivessel grafting was possible in 2 human cadavers and 2 live porcine. Creating the subcostal access and docking the SP system took between 14 and 21 min and the total harvest time ranged from 65 to 125 min in all models. No major bleeding was observed in the live porcine and hemostasis was managed with the available instrumentation. One porcine deceased during surgery due to ventricular fibrillation followed by cardiac arrest. The robotic harvesting was technically easily reproduced by the surgeons and required no additional rib-spreading. Further studies will be required to assess if this subcostal approach with the da Vinci SP system yields true clinical benefits in patients.

Comparison of Efficacy of Percutaneous Nephrolithotomy between Supracostal and Subcostal Access in Patients with Renal Stone

Background: Percutaneous Nephrolithotomy (PCNL) is a prevalent surgical procedure for the treatment of large renal stones. The choice between supra-costal and sub-costal access is pivotal in optimizing patient outcomes. This study provides an in-depth comparison of these two approaches, contributing to the evolving discourse in urological surgery. Objective: To compare the efficacy and safety of supra-costal and sub-costal access in PCNL for the treatment of renal stones. Methods: A randomized controlled trial was conducted at the Department of Urology, Pakistan Institute of Medical Sciences, from May to October 2023. Sixty-four patients with renal stones larger than 2cm were enrolled and divided into two groups based on the access point: supra-costal (Group A) and sub-costal (Group B). Variables such as age, gender, duration of surgery, stone size, clearance rate, and complications were analyzed using Statistical Package for the Social Sciences (SPSS) Version 25. Results: The average age of participants was 37.20 ± 13.0 years, with surgery duration averaging 45.75 ± 4.98 minutes. The majority of participants were male (59.4%). Stone clearance rates were high in both groups (93.8% in Group A and 90.6% in Group B), with no statistically significant difference (P-value > 0.05). Complication rates were 9.4% in Group A and 15.6% in Group B, also showing no significant difference. Conclusion: Both supra-costal and sub-costal accesses in PCNL are effective for renal stone clearance, with comparable success rates and complication profiles. The choice between these approaches can be based on individual patient anatomy and surgeon preference. Further research could explore long-term outcomes and patient-specific factors influencing the choice of access point.

A Preclinical Feasibility Study of Single-Port Robotic Subcostal Anatomical Lung Resection and Subxiphoid Thymectomy Using the da Vinci® SP System.

Despite the recent introduction of technologically advanced single-port (SP) robotic systems, their use in the field of thoracic surgery has been rarely explored. Here, we report our preclinical experience concerning SP robotic thoracic surgery using the da Vinci® SP system. The da Vinci® SP system was used to perform subcostal anatomical lung resection and subxiphoid thymectomy in three cadavers. The operative settings that best met the surgeon's requirements for each resection were also determined. Four subcostal anatomical lung resections and two subxiphoid thymectomies were completed. While both procedures did not require additional incisions, the use of an observation port in the intercostal spaces was strongly recommended to safely create subcostal access. Dissection of hilar structures and mediastinal lymph nodes was feasible. However, due to the current unavailability of a robotic stapler, a handheld stapling instrument was required to perform a transection of vital structures. When the stapling process proved to be difficult, the table surgeon temporarily removed a robotic arm to acquire the necessary space to complete the procedure. Our data represent a promising preclinical step in understanding the feasibility of using the da Vinci® SP system to perform an SP subcostal anatomical lung resection and a subxiphoid thymectomy.

Transventricular Left Bundle Branch Pacing

Background. Implementation of conduction system permanent pacing methods in patients with cardiac bradyarrhythmias allows to maintain the physiological sequence of excitation and contraction of the ventricles and to avoid the development of heart failure due to electrical and mechanical dyssynchrony in patients with high rates of ventricular pacing.
 Case description. A 61-year-old female patient was examined and treated at the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine from January 25 to January 27, 2022 at the department of surgical treatment of complex cardiac arrhythmias with a diagnosis of proximal complete atrioventricular block. A two-chamber pacemaker (Vitatron Q50A2) with a ventricular lead to stimulate the His bundle region (Medtronic 3830, 69 cm) was implanted to the patient with a special delivery system (C315HIS). At an X-ray operating room, 12 ECG leads from the electrophysiological station LabSystem Pro (Bard, USA) were connected to the patient to analyze the criteria for capturing the conduction system on stimulation during ventricular lead placement, and a diagnostic quadripolar electrode was inserted into the right ventricle to record the potential of the His bundle as an X-ray reference point. During placement of the ventricular lead in the area of the His bundle due to high pacing thresholds the decision was made to implement an alternative method of conduction system pacing – left bundle branch pacing through the interventricular septum. After gradual passage of the electrode through the septum, capture of the conduction system of the heart was achieved, although no clear potential of the left bundle was registered. The interval from stimulus to peak R wave in lead V6 was 68 ms, and the interval from stimulus to peak R wave in lead V1 was 110 ms. The difference between intervals was 42 ms, which indicated the criteria of nonselective capture of the left bundle branch, with stimulation thresholds below 1 V at a pulse length of 0.5 ms. In the postoperative period, the patient was evaluated for global longitudinal deformity of the left ventricle on constant ventricular stimulation, which was carried out according to standard methods using speckle-tracking echocardiography; no signs of dyssynchrony were found. Also, the location of the endocardial electrode in the middle segments of the interventricular septum on the right ventricular side was visualized and confirmed by performing B-mode transthoracic echocardiography with subcostal access.
 Conclusions. Left bundle branch pacing, like His bundle pacing, maintains electrical and mechanical synchrony of the left ventricle at lower pacing thresholds, greater amplitude of the sensitivity signal and lower risks of lead dislocation.

Efficacy and Safety of Supracostal Access for Mini Percutaneous Nephrolithotomy in Pediatric Patients

To evaluate the efficacy and safety of supracostal percutaneous nephrolithotomy (PCNL) through the 11th intercostal space and compare it with subcostal PCNL in children with renal calculi. Children with renal calculi who underwent PCNL between January 2010 and December 2017 were divided into 2 groups: supracostal PCNL (group 1) and subcostal PCNL (group 2). Stone location, stone burden, location of the access points, operative time, postoperative visual pain score, success rate, hospital stay, and complications according to the modified Clavien classification were compared. Comparison of medians was done using Mann Whitney U test and the means were compared using t test. Group 1 had 50 patients while group 2 had 60 patients. The stone-free rate was 84.0% and 85.0% in groups 1 and 2, respectively after 1 session of PCNL (P=.885). After auxiliary procedures, it increased to 96.0% and 96.6%, respectively (P=.852). The mean fall in hematocrit was 0.9% in group 1 and 1.5% in group 2 (P=.11) whereas the median pain score was 4 in group 1 and 3 in group 2 (P=.37). In all, 54 complications were recorded the commonest among which were grade I (81.5%). Twenty-nine complications were observed in group 1 while 25 complications were observed in group 2 (P=.088). One patient developed nephropleural fistula while another patient developed hydropneumothorax. Both belonged to group 1. Supracostal access for PCNL is an effective and safe alternative to subcostal access for children with renal calculi in terms of stone-free rate and complications.

ОЦЕНКА ПАРАМЕТРОВ ЛАПАРОСКОПИЧЕСКИХ ДОСТУПОВ С ИСПОЛЬЗОВАНИЕМ СПИРАЛЬНОЙ КОМПЬЮТЕРНОЙ ТОМОГРАФИИ

The parameters of a single incision laparoscopic surgery (SILS) to the base of the vermiform process, the neck of the gallbladder and the duodenal bulb were assessed using spiral computed tomography (CT) in 101 patients and in an anatomical study on 98 unfixed corpses. Four median approaches and access in the left iliac region to the base of the vermiform process, umbilical and epigastric accesses to the neck of the gall bladder, the vertical subcostal, left subcostal and umbilical accesses to the duodenal bulb were evaluated. According to the CT and anatomical data, it has been established that the umbilical access to the appendix provides the optimal conditions for performing surgical interventions using the SILS - technology. In addition, access “2” by individual criteria has the most advantageous spatial characteristics and can also be used for minimally invasive access to the appendix. When comparing the umbilical and epigastric accesses to the neck of the gallbladder, it was found that the epigastric approach is appropriate for the introduction of a manipulation trocar, the umbilical approach is for extracting the gallbladder and visualizing it in minimally invasive surgery. According to the CT and anatomical studies, it was found that the vertical subcostal access to the duodenal bulb has the characteristics sufficient to perform surgical interventions using a SILS - technology.

Supra-costal tubeless percutaneous nephrolithotomy is not associated with increased complication rate: a prospective study of safety and efficacy of supra-costal versus sub-costal access

BackgroundTo assess the morbidities of tubeless percutaneous nephrolithotomy (PCNL) using supra-costal access and re-evaluate traditional concept of increased complications with supra-costal access.MethodsFrom January 2010 to December 2014, a single surgeon performed 118 consecutive one-stage fluoroscopic guided PCNL’s for complex renal and upper ureteral stone. Our definition for complex renal stone is defined as partial or complete staghorn stone, multiple renal stones in more than 2 calyxes, obstructive uretero-pelvic stone > 2 cm, and a renal stone in single functional kidney. Inclusion criteria include: staghorn stones, renal calculi > 2 cm in diameter, upper ureteral stone > 1.5 cm in diameter. Exclusion criteria for tubeless PCNL include: significant bleeding or perforation of the collecting system, large residue stone, multiple PCNL tract and obstructive renal anatomy. Morbidity, operation time, analgesia requirement, length of hospital stay, stone- free rate, were analyzed.ResultsOf the 118 consecutive PCNL, eighty-six patients underwent tubeless PCNL (56 supra-costal and 30 sub-costal) and included in our prospective follow-up period. The mean age, operation side, stone locations were similar. The male to female ratio is higher in supra-costal than sub-costal. Large renal stones and staghorn stones makes up for most patients (supra-costal: 75%, sub-costal: 80%). The stone–free rate of supra-costal group was 59% (33/56) and in sub-costal group was 50% (15/30). The operative times, length of stay, post-op analgesic use, hematocrit change was similar in both groups. The overall complication rate is 6% [supra-costal (1/56), sub-costal (4/30)] with the majority being infectious complications.ConclusionsSupra-costal access above 12th rib during tubeless PCNL is safe and effective procedure and is not associated with higher incidence of post-op complications in experience hands.

Standard open operative interventions in surgical treatment of patients, suffering an acute complicated pancreatitis

Objective. To determine the character and optimal volume of standard open surgical interventions in an acute complicated pancreatitis (ACP) with elaboration of the main technical elements of the operations.
 Маterials and methods. There were operated 96 patients, suffering ACP. The main group consisted of 47 patients, in whom open interventions were performed primarily in 19, and as the second-stage procedure after application of miniinvasive interventional technologies (МIТ) – in 28. The comparison group consisted of 49 patients, in whom standard operations were done only.
 Results. Application of MIТ have promoted the indications narrowing for performance of primary open operations more than twice. In the main group the arcuate-like subcostal access was applied predominantly - in 26 (55%) observations (χ²=14.287; р=002), while in a control one – a median upper laparotomy – in 37 (76%) observations (χ²=38.43, р < 0.001). The method of closed draining in accordance to procedure of Beger was used predominantly in the main group of patients – in 43% of observations, comparing with a control group - 9% of observations (χ²=12.965; р=0.003). In 23% patients of the main group and in 26% patients of a control one (χ²=0.0013; р=0.05), when the extended purulent-necrotic inflammation process have presented, a staged sanation was applied, using programmed relaparotomies. Some technical elements of the surgical intervention were improved.
 Conclusion. Application of standard open operations in accordance to elaborated principle is accompanied by improvement of the treatment results in patients, suffering ACP.

Open surgery for aneurysms of the splenic artery at the hilum of the spleen: Report of three cases

IntroductionAneurysms of the splenic artery (SAA) located at the hilum of the spleen are not well fit for endovascular or laparoscopic treatment. Open surgery may still be the best option of treatment. Presentation of casesWe report the cases of 3 female patients of a mean age of 59 years (range, 45–68 years) with a hilar (n = 2) or parahilar (n = 1) SAA undergoing successful open surgical resection, through a short left subcostal access. Recovery was uneventful and mean, postoperative length of stay was 4 days (range, 3–5 days). DiscussionResults of this report support surgical resection and splenectomy for the treatment of SAA located at the hilum of the spleen. For this particular location endovascular treatment may not be advised, as coil embolization can be followed by a massive splenic infarction precipitating the need for splenectomy, due to the exclusion of backflow from the left gastroepiploic artery through the short gastric vessels. As well, endovascular exclusion through insertion of an endograft may not be feasible due to the absence of a distal landing zone, as stent grafting requires a normal caliber artery of sufficient length on each side of the aneurysm. ConclusionSurgical excision and splenectomy, through a short subcostal incision, remains a viable option of treatment for hilar SAA.

Non-Angled Intercostal Percutaneous Access Under Full Expiration: Safety Is Not an Issue Anymore.

Percutaneous nephrolithotomy (PCNL) is a well-established procedure for the management of urinary calculi and can be performed intercostally or subcostally. Favoring one approach vs the other is still debatable, and literature has been inconclusive regarding the efficacy and safety of both approaches. Hence, this study aims to assess the safety and efficacy of direct non-angled intercostal technique performed under full expiration and to compare it to the subcostal approach. PCNL was conducted among 361 patients during 2010-2015 at Saint George Hospital University Medical Center in Beirut, Lebanon. PCNL was done by one operator and by following a standard technique. After reviewing the medical records, 304 patients were included. Data analysis was conducted using Stata/IC 10.0. Bivariate analysis was conducted using Pearson's Chi-square, and logistic regression model was run. Alpha level was set at 0.05. Of the total patients, 54.6% and 45.4% underwent intercostal (Group I) and subcostal (Group II) access, respectively. Mean drop in hemoglobin in Group II was 1.9 g/dL vs 1.48 g/dL in Group I (p-value = 0.0040). The mean difference in operation time between group I (88.61 minutes) and group II (102.58 minutes) was statistically significant (p-value = 0.0064). Patients were stone free in 88.05% of the intercostal cases and 78.52% of the subcostal cases. Group II patients were twice more likely to have residual stones compared to Group I (p-value = 0.029). No statistical significance was observed in postoperative complications among both groups. In addition, no cases of pneumothorax were reported. Compared to subcostal access, intercostal approach under full expiration is a safe technique that provides optimal approach to the intrarenal collecting system and allows less angulation, less bleeding, and yields higher stone clearance with minimal complications. When performed by a well-trained urologist, intercostal access should be advocated in PCNL to obtain a direct non-angled access to the tip of the desired posterior calix.

Transperitoneal Subcostal Access for Urologic Laparoscopy: Experience of a Large Chinese Center

Objective. To present our experience of using transperitoneal subcostal access, Palmer's point (3 cm below the left costal margin in the midclavicular line), and its right corresponding site, in urologic laparoscopy. Methods. We used Palmer's point and the right corresponding site for initial access in 302 urologic surgeries (62 cases with prior surgeries). The record of these cases was reviewed. Results. Success rate of initial access is 99.4%, and complication rate of puncturing is only 3.4% with no serious complication. In the cases with prior surgeries, there were only two cases with access complication on the right side (minor laceration of liver). For people with BMI more than 30 kg/m2 (12, 3.9%), the success rate was also 100 percent. Conclusions. Palmer's point and the corresponding right location are feasible, effective, and safe for initial access in urologic laparoscopic surgeries. This entry technique should be used routinely in urologic laparoscopic surgeries.

Right robotic adrenalectomy for a 8 cm pheochromocytoma (with video)

Please cite this article in press as: Sessa L, et al. Right robotic adrenalectomy for a 8 cm pheochromocytoma (with video). Journal of Visceral Surgery (2015), http://dx.doi.org/10.1016/j.jviscsurg.2015.06.010 Pheochromocytoma; Robotic surgery; Minimally invasive surgery; Robotics CT scan showed a 10 cm right adrenal tumor compatible with a pheochromocytoma. MIBG scintigraphy confirmed a right adrenal tumor single uptake. Routine biomolecular evaluation (SDHx and VHL genes) was negative for a familial disease. A totally robotic lateral transperitoneal right adrenalectomy was performed. The patient was placed in left lateral strict decubitus and flexed at the waist. An ‘‘open’’ right subcostal access was used to introduce a 12 mm optical trocar. Under laparoscopic vision (0◦ scope), 4 other trocars were introduced: two 8 mm right subcostal trocars, one 12 mm and one 10 mm trocars for the first-assistant’s left and right (liver retractor) hand, respectively. The robotic cart (da Vinci® Si Surgical System, Intuitive Surgical) was placed above the patient’s right shoulder and was docked. Intra-abdominal exploration confirmed the presence of a large retroperitoneal mass that completely modified the right suprarenal region. The right triangular ligament was divided and the liver was medially retracted. The right aspect of the vena cava was not initially accessible because of the large adrenal mass volume. Consequently, the tumor was first dissected, en bloc with the periadrenal fat, from the upper pole of the kidney and from lateral attachments to obtain an adequate mobilization of the adrenal mass allowing its rotation to better approach the right lateral and posterior aspects of the vena cava. Then, dissection was carried out progressively upward along the inferior vena cava on the medial margin of the tumor. Four large adrenal veins were consecutively dissected, clipped using nonabsorbable self-locking clips (Hem-o-lok®, Weck-Telefex Europe Ltd.), and divided. The adrenal mass was completely dissected and mobilized from its posterior aspect (iliopsoas muscle). Overall operative time was 90 minutes. No post-operative complication was observed hospitalization duration was 3 days. Pathology confirmed an adrenal pheochromocytoma, 8 cm in diameter with a PASS score 1 with R0 resection without capsular effraction.

Factors affecting complications according to the modified Clavien classification in complete supine percutaneous nephrolithotomy

An increase in percutaneous nephrolithotomy (PCNL) has been accompanied by an increase in complications. We identified the parameters affecting the severity of complications using the modified Clavien classification (MCC). From 2008 to 2013, 330 patients underwent complete supine PCNL using subcostal access, one-shot dilation, rigid nephroscopy, and pneumatic lithotripsy. We assessed the impact of the following factors on complication severity based on the MCC: age, gender, body mass index, hypertension, diabetes, previous stone surgery and extracorporeal shock wave lithotripsy, preoperative hemoglobin, renal dysfunction (creatinine >1.4 mg/dL), preoperative urinary tract infection, anatomic upper urinary tract abnormality (AUUTA), significant (moderate-severe) hydronephrosis, stone-related parameters (opacity, number, burden, location, staghorn, complex stones), anesthesia type, kidney side, imaging and calyx for access, tract number, tubeless approach, operative time, postoperative hemoglobin, and hemoglobin drop and stone-free results. The complication rate was 19.7% (MCC: 0=80.3%, I=6.4%, II=11.2%, ≥III=2.1%). On univariate analyses, only the following factors affected MCC: gender, preoperative hemoglobin, AUUTA, significant hydronephrosis, imaging for access, calyx for access, tract number, postoperative hemoglobin, hemoglobin drop and stone-free result. Renal dysfunction was accompanied by higher complications, yet the results were not statistically significant. Multivariate logistic regression analysis demonstrated renal dysfunction, absence of significant hydronephrosis, AUUTA, multiple tracts, lower postoperative hemoglobin, and higher postoperative hemoglobin drop as the significant parameters which affected MCC and predicted higher grades. The paper's limitations include a low number of cases in the higher Clavien grades and some subgroups of variables, and not applying some techniques due to surgeon preference. Many of the complete supine PCNL complications were in the lower Clavien grades and major complications were uncommon. Renal dysfunction, AUUTA, significant hydronephrosis, tract number, postoperative hemoglobin, and hemoglobin drop were the only factors affecting MCC.

High Supracostal Percutaneous Nephrolithotomy Access: Assessing Safety in Access above the Eleventh Rib after Performing Preoperative Planning with Computed Tomography

Objective: To determine if supracostal renal access above the 11th rib during percutaneous nephrolithotomy (PCNL) is a safe option in carefully selected patients determined by preoperative computed tomography (CT) imaging. Patients and Methods: We retrospectively isolated 142 patients who underwent access above the eleventh rib during PCNL, which we term “high supracostal renal access.” We then compared these patients to 113 individuals who underwent access below the twelfth rib. Renal access was achieved by the operative surgeon with fluoroscopic guidance in conjunction with pre-operative computed tomography (CT) scan. Outcomes were compared. Results: Overall surgical outcomes were equivalent when comparing high supracostal versus subcostal access sites. As expected due to proximity, pleural complications occurred in 4% of the high supracostal group (n = 6) compared with 0% of the control (subcostal) group (p = 0.035). Of these six complications, three were managed conservatively with observation and two required cardio-thoracic intervention with video-assisted thoracoscopic pleural repair (1%). In the remaining case, the patient was preoperatively consented for placement of a thoracostomy tube, which was placed during the procedure, due to the difficult location of her upper pole stone and closely adjacent low-lying pleura, and the planned transpleural approach. Hospital stay was not significantly pro-longed between the high supracostal access and subcostal access groups, with an average length of stay of 2.2 ± 2.1 days and 2.0 ± 1.9 days (p = 0.59) respectively. Conclusions: Careful, systematic preoperative planning based on CT and fluoroscopic imaging allows for a confident understanding of a “safety zone” in placement and dilatation of renal access points during PCNL. We have shown that planned upper pole renal access above the 11th rib is achievable with acceptable morbidity and excellent success rates.

AB89. Transperitoneal subcostal access for urologic laparoscopy: experience of a large Chinese center

IntroductionTo present our experience of using transperitoneal subcostal access (Palmer’s point and the right corresponding site) in urologic laparoscopy.Material and methodsWe used Palmer’s point and the right corresponding site for initial access in 302 urologic surgeries (48 cases with prior surgeries). The record of these cases was reviewed.ResultsSuccess rate of initial access is 99.4%, complication rate of puncturing is only 3.4% and no serious complication. In the cases with prior surgeries, there were only two cases with access complication (minor laceration of liver). For people with BMI more than 30 kg/m (6, 3.4%), the success rate was also 100 percent.ConclusionsPalmer’s point and the corresponding right location are feasible, effective and safe for initial access in urologic laparoscopic surgeries. This entry technique should be used routinely in urologic laparoscopic surgeries.

Percutaneous nephrolithotomy: a cause of specific and iatrogenic thoracic complications

Background: This study aims to evaluate thoracic complications which are usually encountered in percutaneous nephrolithotomy. Methods: Between February 2005 and September 2012, 932 patients (586 males, 346 females; mean age 44.98±16.35 years; range 2 to 85 years) underwent percutaneous nephrolithotomy due to the nephrolithiasis. All patients were evaluated with preoperative posteroanterior chest X-ray while all patients who had supracostal access and who had suspected thoracic complications were evaluated with postoperative posteroanterior chest X-rays. Tube thoracostomy was performed in all patients with thoracic complications. Results: A subcostal access was performed in 849 patients (91%), whereas a supracostal access was performed in 83 patients (9%). Thoracic complications were developed in 18 patients (1.93%). Of them, 13 (1.39%) were in patients with supracostal and five (0.54%) were in patients with subcostal approach. Eleven supracostal accesses were performed above the 12th rib and two supracostal accesses were above the 11th rib. When all complications were evaluated, 12 hemothoraces, four pneumothoraces, and two urinothoraces were detected. Conclusion: Percutaneous nephrolithotomy is a cause of iatrogenic thoracic complications and supracostal approach has a more thoracic complication rate, compared to the subcostal approach. An early postoperative posteroanterior chest X-ray in sitting or standing position following supracostal access in particular is an essential diagnostic tool for early detection of thoracic complications. The tube thoracostomy is usually sufficient for the treatment of such complications.

Our experience with percutaneous nephrolithotomy in pediatric renal stone disease.

In this paper, we present our experience with percutaneous nephrolithotomy (PNL) in a pediatric patient group. From June 2007 to September 2010, we performed PNL on 57 pediatric patients. children with a mean age of 7.56 (1-15) years. Study population consisted of 30 male, and 27 female children with a mean age of 7.56 (1-5) years. Mean stone burden was calculated to be 312.2 (95-1550) mm(2). Percutaneous access was performed under fluoroscopy. Tract dilatation was accomplished with 20 F Amplatz dilators. Pneumatic lithotripsy was used to fragment the renal calculi. Mean operating time was 34 (3-80) minutes. With a single session of PNL, complete stone-free rates were achieved in 55 (96.4%) patients. Residual fragments were remained in 2 (3.5%) patients. Two patients had a febrile episode without signs and symptoms of bacteremia. Subcostal access was used in all of the patients, and none of the patients had any complications. Based on our experience, we conclude that PNL is a safe and effective method in the management of pediatric stone disease.

Tubeless percutaneous nephrolithotomy is effective and safe in short- and long-term urinary drainage

We aimed to investigate the safety and efficacy of tubeless percutaneous nephrolithotomy (PCNL) with ureteral catheter or double-J stent in comparison with standard PCNL in our study. We retrospectively evaluated 707 of 1,469 patients with stone area under 800mm(2) and only one subcostal nephrostomy access that was underwent PCNL between March 2004 and October 2011 in our clinic. Patients with 14F nephrostomy tube (Malecot or Re-entry catheter), with ureteral stent and with antegrade double-J stent were included into Group 1 (n=180), Group 2 (n=148) and Group 3 (n=120), respectively. The mean hospitalization time of patients in Group 1 was significantly longer. The mean VAS was significantly higher in Group 1. On the other hand the mean fluoroscopy and operation time of patients in Group 2 were significantly shorter in comparison with other groups. Number of patients with postoperative transfusion requirement was significantly higher in Group 1. The number of patients with postoperative narcotic analgesic requirement was also significantly higher in Group 1. The most frequent complication in our study was prolonged drainage. The postoperative complications were seen more frequently in Group 1. Both ureter catheter and double j stent were more comfortable, effective and safe in urinary drainage following PCNL with single sub-costal access. On the other hand, double-J stent has a disadvantage as requirement additional cystoscopy for removal. We suggest ureter catheter or double-J stent to preserve short- and long-term urinary drainage.

MP-01.14 Results of Percutaneous Nephrolithotripsy (PCNL) of Upper Calices Stone with Subcostal Access

MP-01.14 Results of Percutaneous Nephrolithotripsy (PCNL) of Upper Calices Stone with Subcostal Access

Totally Tubeless Percutaneous Nephrolithotomy for Upper Pole Renal Stone Using Subcostal Access

To assess the outcome and safety of the totally tubeless percutaneous nephrolithotomy (PCNL) from subcostal access in patients with renal stone in the upper pole of the kidney. Seventy patients with upper pole renal stones were enrolled in a randomized clinical trial from April 2003 to November 2008. The inclusion criteria were the existence of solely upper pole stones, stone size >1.5 cm, extracorporeal shockwave lithotripsy failure or stone in closed calix and diverticulum, and successful subcostal access for reaching the stone. The exclusion criteria were unsuccessful subcostal access, more than two percutaneous accesses, prominent collecting system perforation, intraoperative significant bleeding, ureteral obstruction, and renal anomaly. The totally tubeless procedure was performed on 35 patients (group A); another 35 patients (group B) underwent standard PCNL. The incidence of complications, hospital stay, transfusion rate, stone-free rate, and analgesics use as well as return to normal activity were compared during a 1-month study period. The mean stone burden was 2.81 (standard deviation [SD] = 0.59) in group A vs 2.87 (SD = 0.62) cm(2) in group B. Hospitalization averaged 1.49 (SD = 0.7) vs 2.89 (SD = 0.99) days (P < 0.001), and the average analgesics use was 8.2 (SD = 3.59) mg vs 14.3 (SD = 5.99) mg of morphine, respectively (P < 0.001). The patients returned to normal activity in 11 (SD = 4.2) days in group A vs 17.6 (SD = 4) days in group B (P < 0.001). Operative time, transfusion rate, complications, re-treatment, and the overall stone-free rate were not different significantly, and no major complication was seen in the study as well. Totally tubeless PCNL for the upper pole renal stone from subcostal access is accompanied by decreased hospital stay and analgesics use and a rapid return to normal activity. It can be considered as an accepted and cost-beneficial procedure for upper pole renal stones.