PCNL · supracostal upper-pole access

Into the chest

16.3%overall complication rate, supracostal access vs 4.5% subcostal (Munver 2001)
11th ribthe line above which pleural risk climbs steeply
full expirationwhen the diaphragm sits highest and the puncture is safest
Advanced tier

Teaching only · not for diagnosis or treatment decisions

Case orientation

The normal sequence

Supracostal access reaches the upper-pole calyx along a straight line that lower-pole punctures cannot match. For a full staghorn, an upper-pole stone, or a long calyceal stone, that angle clears the burden through a single tract.

The trade is anatomical: to reach the upper pole from behind, the needle passes close to, or above, the 12th rib, and the pleura lives just there. The operation is a controlled sequence. Retrograde access and a ureteric catheter come first, then the patient is turned prone.

Under fluoroscopy the surgeon defines the target calyx, plans the tract, and times the puncture to the breath. Done well, the needle enters a posterior calyx below the pleural reflection, in full expiration, and the rest of the case is dilation, nephroscopy and stone clearance.

  1. Cystoscopy, place a retrograde ureteric or balloon occlusion catheter, and opacify the collecting system.
  2. Position prone with chest and pelvis supported; confirm the upper-pole target calyx on fluoroscopy.
  3. Plan the supracostal tract onto a posterior calyx, ideally entering the skin lateral to the mid-scapular line at or below the 12th rib.
  4. Ask the anaesthetist to hold ventilation in full expiration, then puncture the calyx with the needle passing just over the upper border of the rib to spare the subcostal neurovascular bundle.
  5. Confirm intracalyceal position, pass the guidewire, and exchange for a stiff working wire down the ureter.
  6. Dilate the tract over the wire and seat the Amplatz sheath under direct vision.
  7. Nephroscopy, lithotripsy and stone clearance; check for residual fragments.
  8. Place a nephrostomy or stent, take an end-of-case image, and inspect the tract.
where it bites
  • The pleura is breached at the puncture itself: a needle taken above the 11th rib, or in inspiration when the diaphragm and lung descend, crosses the pleural reflection on its way to the calyx.
01 The model

Where the danger lives

01  The model
schematic / supracostal access view (fluoroscopic, prone)
posterior skin prone, posterolateral Kidney upper-pole calyx 11th rib 12th rib pleural reflection (thorax above) diaphragm — expiration — inspiration (descends) tract + sheath (safe corridor) hydrothorax above 11th rib → pleura breached
Layers
Spatial caption
  • The posterior pleural reflection sweeps down to about the 12th rib in the mid-scapular line, so a tract aimed above the 11th rib enters the upper pole through pleura and diaphragm rather than below them.
02 The mechanism

How it happens

  • The posterior pleural sac dips below the 12th rib in the mid-scapular line.
  • A high supracostal needle reaches the upper pole only by passing through it.
  • This happens to the patient who needs an upper-pole or staghorn clearance, where the geometry pushes the puncture cephalad.
  • The moment is needle entry, and the breath governs it.
  • In full expiration the diaphragm rises and the lung retracts; in inspiration both descend across the tract.
  • Above the 12th rib the margin is small, above the 11th rib it largely disappears.
  • Once the pleura is open, the consequence depends on what crosses it.
  • Air gives a pneumothorax.
  • Irrigant tracking up the tract gives a hydrothorax, often the larger problem because it builds silently under positive-pressure flow.
  • Diaphragm and lung may be injured together, producing a hydropneumothorax.
  • Puncture above the 11th rib, where the margin is lost, more than above the 12th
  • Puncture timed to inspiration rather than full expiration
  • Upper-pole or staghorn stone forcing a cephalad tract
  • High-volume or high-pressure irrigation tracking up the sheath
  • Tall, thin habitus or deep inspiration lowering the pleural reflection
  • Incidence. Supracostal access carries roughly four times the overall morbidity of subcostal access, and nearly all intrathoracic complications occur in supracostal tracts. The pleural risk follows a rib-level gradient, low above the 12th rib and rising sharply for punctures taken above the 11th. [source traced]
  • Munver R, Delvecchio FC, Newman GE, Preminger GM. Critical analysis of supracostal access for percutaneous renal surgery. J Urol. 2001 Oct;166(4):1242-6.
  • [source traced] Munver R, Delvecchio FC, Newman GE, Preminger GM. Critical analysis of supracostal access for percutaneous renal surgery. J Urol. 2001 Oct;166(4):1242-6.
03 The save

The first moves

  1. Stop irrigation and drop intrarenal pressure: lower the irrigant bag and decompress through the sheath.
  2. Tell the anaesthetist at once. Ask for airway pressures, oxygen saturation and tidal volumes, and request a switch to manual ventilation if needed.
  3. Read the signs together: rising airway pressures, falling saturations, reduced air entry at the base, and fluid or air tracking on screening images.
  4. Image the chest. A formal end-expiratory CXR on table or in recovery sizes any pneumothorax or effusion; bedside ultrasound is a quick adjunct.
  5. A large or symptomatic hydrothorax, a tension picture, or progressive desaturation is the trigger to place an intercostal chest drain and call the senior or thoracic team. A small asymptomatic collection can be observed with serial imaging. escalation trigger
  6. Decide the tract: leave a nephrostomy to drain the kidney away from the chest, and consider abandoning further supracostal work this sitting.
  7. Document the rib level, the breath phase at puncture, the signs, the imaging, the drain or observation decision, and the anaesthetic discussion in the op note.
04 The viva answer

The viva answer

  • Pleural injury is the signature complication of supracostal percutaneous renal access.
  • The posterior pleural reflection extends down to around the 12th rib in the mid-scapular line, so a tract that enters above the 11th rib, or one taken in inspiration when the diaphragm and lung descend, can traverse pleura and diaphragm to reach the upper pole.
  • The result is a pneumothorax from air, a hydrothorax from irrigant tracking up the tract, or a combined hydropneumothorax.
  • Prevention starts before the needle.
  • I would reserve supracostal access for a clear indication such as an upper-pole or staghorn stone, aim for a posterior calyx lateral to the mid-scapular line, and where possible keep the entry at or below the 12th rib.
  • I would puncture in full expiration with the anaesthetist holding ventilation, so the diaphragm sits high and the lung is out of the path, and I would keep irrigation pressure controlled throughout.
  • If I suspected injury intra-operatively I would stop irrigation, decompress the system, and tell the anaesthetist immediately, asking specifically about airway pressures and saturations.
  • I would obtain a chest radiograph.
  • A small asymptomatic collection can be observed with serial imaging.
  • A large or symptomatic hydrothorax, or any tension picture, needs an intercostal chest drain and senior or thoracic involvement.
  • I would leave a nephrostomy to drain the kidney away from the pleural space, and document the rib level, the breath phase, the findings and the plan.
  1. Why is a hydrothorax often more troublesome than a pneumothorax here?
    • Irrigant tracks up the tract under positive flow and accumulates silently, so the effusion can be large by the time it declares as desaturation or reduced air entry, whereas a small pneumothorax is often self-limiting.
  2. How does timing the puncture to expiration reduce the risk?
    • In full expiration the diaphragm rises to its highest point and the lung retracts cephalad, lifting both clear of the supracostal corridor and increasing the distance between the skin entry and the pleural reflection.
  3. When would you observe rather than drain?
    • A small, asymptomatic collection with stable saturations and airway pressures can be managed by serial chest imaging and oxygen.
    • Drainage is for a large or symptomatic hydrothorax, a growing collection, or any sign of tension or respiratory compromise.
Strong pass

Anyone can say chest drain.

  • The strong answer ties the pleural reflection to the 11th versus 12th rib level
  • Explains in mechanical terms why full-expiration puncture is protective
  • Separates hydrothorax from pneumothorax in both cause and behaviour
  • Names early anaesthetic communication and a draining nephrostomy as part of the management
Examiner note
Anyone can say chest drain. The strong answer ties the pleural reflection to the 11th versus 12th rib level, explains in mechanical terms why full-expiration puncture is protective, separates hydrothorax from pneumothorax in both cause and behaviour, and names early anaesthetic communication and a draining nephrostomy as part of the management.
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