A supracostal approach for percutaneous nephrolithotomy of staghorn calculi: A prospective study and review of previous reports

Objectives: To evaluate a supracostal approach for percutaneous nephrolithotomy (PCNL) of staghorn calculi through a prospective study and review of previously reported cases. Methods: From June 2009 to November 2011, 40 patients with staghorn calculi were scheduled for supracostal S-PCNL in a prospective study. Of the 40 renal units, 16 (40%) had a complete staghorn and 24 (60%) had a partial staghorn calculus. Perioperative complications were stratified according to the modified Clavien system. Univariate and multiple logistic regression analyses were used to determine statistically significant variables affecting the stone-free rate and development of complications. Results: In all, 57 tracts were established in the 40 renal units; 23 (58%) renal units were approached through one supracostal upper pole calyx, while 13 (33%) and four (10%) required a second middle-or lower-pole puncture, respectively. Overall, 78% of patients were rendered stone-free or had clinically insignificant residual fragments with PCNL monotherapy, and this increased to 88% with auxiliary procedures. In the logistic regression analysis, a complete staghorn stone was the only independent variable for residual stones (P = 0.005). There was an overall complication rate of 38%. Independent variables with an influence on complications were staghorn stone burden (P = 0.007), and operative duration (P = 0.045). Conclusion: The supracostal upper calyceal approach provides optimum access for the percutaneous removal of staghorn stones. Appropriate attention to the tech- nique and to monitoring before and after surgery can detect thoracic complications, and these can be managed easily with intercostal chest tube drainage, with no serious morbidity.