Supracostal Upper Pole Endoscopic-Guided Prone Tubeless "maxi-Percutaneous Nephrolithotomy": A Contemporary Evaluation of Complications

Objective: To develop a contemporary complication profile for supracostal upper pole endoscopic-guided prone tubeless "maxi-PCNL" to evaluate the need for change. Materials/Methods: We identified patients undergoing supracostal upper pole percutaneous nephrolithotomy (PCNL) by a single surgeon at a high volume tertiary care stone center between October 2010 and April 2017. Access was obtained with ureteroscopic guidance. The tract was dilated to 30F through radial balloon dilation. All cases were tubeless with ureteral stent for 5-7 days. Preoperative, operative, and postoperative variables were recorded. We recorded need for blood transfusion, angioembolization, thoracentesis and/or chest tube insertion, intensive care unit (ICU) admission, and 30-day readmission. Results: A total of 375 patients were included. Mean age was 57 years and 59% were women. Mean body mass index was 33 kg/m ² . Mean stone burden was 35 mm. The mean operative time was 99 minutes. Median stay was 1 day. There were no complications because of prone position. Postoperative complications included pleural drain (4%), transfusion (6.7%), and angioembolization (0.5%). Transfusion rates were higher in patients with preoperative hemoglobin <10 mg/dL (28% vs 5.1%, p < 0.00001). Rate of ICU admission and readmission was 4.5% and 7.5%, respectively. Transfusion (p ≤ 0.001), pleural drain (p = 0.0002), and readmission (p = 0.030) were associated with ICU admission. Male gender was associated with readmission (10.3% vs 5.5%, odds ratio = 3.1, p = 0.012). Conclusions: In supracostal upper pole endoscopic-guided prone tubeless Maxi-PCNL, pulmonary complication rate was lower than previously reported and bleeding complications were comparable with mini-PCNL series. Establishing contemporary complication rates will help to assess the need for evolution to mini-PCNL or lower pole supine PCNL.