SUPRACOSTAL PUNCTURE : ITS COMPLICATIONS

A supracostal puncture is most of the times employed for staghorn calculi, calculi in the upper calyx and the upper ureteric calculi. The supra-twelfth punctures are fraught with the risk of pulmonary complications if certain precautions are not followed. In our experience we have encountered chest complications in the form of hydrothorax,pneumothorax and hemothorax to the tune of 8-10% of all supracostal punctures and subsequent dilatations. We usually mark the entry point in posterior calyx and skin( when patient in in full inspiration) and then puncture when patient is exhaling till the needle goes into the perinephric space.Again the patient is put into inspiration mode and previous marked points are used for entry into the decided calyx. With this technique we avoid major pulmonary complications.

Percutaneous nephrolithotomy (PCNL) is a new method that has been used in the urinary calculi in the recent years. Although it pretends a large incision and decrease the time of the stay in hospital it carries the risk of some unexpected complications. Especially supracostal approach carries a higher risk of intrathoracic complications. Munver et al used supracostal approach to 98 patients out of 300 PCNL cases between 1993-1999. They have recorded the complications they have observed as bleeding, haemathorax, hydrothorax, sepsis, atrial fibrillation, nephropleural fistula, pulmonary embolism, renal arterial pseudoaneurism , pneumothorax, subcapsuller heamatoma and stated that the rate of intrathoracic complications were 23 %. In our case where we have observed hydrothorax, the subcostal approach was used. Prone position is required for PCNL. Munshi et al. reported that they were also not able to recognize hydrothorax in a similar patient until the end of the operation and blamed the prone position. Hydrothorax was realized after the spontaneous ventilation was achieved and the patient was in supine position. The auscultation was normal during the operation but in the second hour of the operation it was noted that airway pressures had risen and thorax tube was placed and 1500 ml fluid was drained when hydropneumothorax was seen in the X-ray. In our case the only symptom was a decrease in the mean arterial pressure. We were not able to diagnose the hydrothorax during the surgery for the auscultation and the blood gas samples were all normal. After the spontaneous ventilation was achieved and the patient was in supine position, the blood gas samples and the auscultation supported hydrothorax diagnosis so that It was realized. In our case supracostal approach was used in the last period of the surgery so that was when the irrigation fluid started to infiltrate to thorax and that was the reason we misinterpreted the auscultation. As a result PCNL operations carry a risk of hydrothorax and it can be hard to diagnose because of the position of the patient. We also believe that any sign that is not expected in the intraoperative period must be evaluated carefully so that complications can be realized earlier.