الفهرس 
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Abstract
Purpose: Percutaneous renal surgery is currently performed for complex renal calculi as well as for various other endourological indications. In many patients an upper pole nephrostomy tract allows direct access to most of the intrarenal collecting system. Upper pole percutaneous access may be obtained via the supracostal or subcostal approach. The preferred route depends on the location and size of the specific stone or lesion. Others have cautioned against the supracostal approach above the 12th rib and many have discouraged an approach above the 11th rib due to concern about the increased risk of intrathoracic complications. We prospectively assessed the morbidity associated with supracostal percutaneous renal surgery and compared and analyzed the morbidity of the supracostal and subcostal approaches using CT scan.
Materials and Methods: A total of 40 adult consecutive patients (20 patients each group) underwent percutaneous renal surgeries for upper urinary tract lesions using either a supracostal approach (group A) or a subcostal approach (group B). The choice of the approach was dictated by the renal topography, stone location and the surgeon experience and preference. Seventeen patients in each group had renal or upper ureteric stones, and 3 had other different pathologies as PUJO and encrusted stent.
Results: In the supracostal group A, the puncture was above the 12th rib in 17 patients, and above the 11th rib in 3 patients, including 3 cases with combined subcostal punctures. In the subcostal group B, the puncture was below the last rib in all 20 patients, including 2 multiple subcostal punctures cases.
In the supracostal group A, 16 (94.1%) out of the 17 stone patients had a complete clearance and 1 (5.9%) underwent ESWL for residual stones. On the other hand, in the subcostal group B, there were 11 cases (64.7%) with complete clearance, 2 cases (11.8%) needed 2nd look procedure and 4 cases (23.5%) underwent ESWL for residual stones. This difference was statistically significant.
An Amplatz sheath was routinely used in the supracostal group, and double J stent was used in 19 cases. On the other hand, in the subcostal group, an amplatz sheath was used in 12 cases and double J stent in 8 cases.
Group A had statistically insignificant more pleural effusion in CT than in group B. Frequency of neuralgia, and pain amplitude were statistically higher in group A.
In group A, 13 pleural effusions were discovered by the CT scan, 11 subclinical cases (5 ipsilateral & 6 bilateral), only 2 patients had clinical pleural effusion. On the other hand, in group B, 10 subclinical pleural effusion were discovered by the CT scan (3 ipsilateral, 6 bilateral & 1 contralateral). None of group B patients encountered clinical pleural effusion. Bleeding required blood transfusion was almost the same in both groups, while bleeding necessitated abortion of the procedure in 1 patients of subcostal group.
Conclusions: Percutaneous renal surgery remains an important option for managing complex renal calculi and other upper urinary tract lesions. In our experience supracostal approach is generally associated with low morbidity with higher clearance rate than infracostal route.