Incidence of Pleural Injuries in PCNL: Supracostal vs Subcostal Access
Pleural complications occur in approximately 15% of percutaneous nephrolithotomy (PCNL) procedures overall, with supracostal access carrying significantly higher risk than subcostal approaches. 1
Overall Pleural Injury Rates
The Society of Interventional Radiology quality improvement guidelines establish a threshold of 15% for pleural complications (pneumothorax, empyema, or hemothorax) from percutaneous nephrolithotomy, which is substantially higher than the 1% threshold for simple percutaneous nephrostomy procedures. 1
Supracostal Access-Specific Rates
Above the 12th Rib
- Pleural injury incidence: 4.2% when supracostal puncture is performed above the 12th rib 2
- This represents a relatively safe approach when supracostal access is necessary 2
Above the 11th Rib
- Significantly higher complication rates occur with 11th rib access compared to 12th rib access 2
- Should be limited to cases of absolute necessity due to elevated pleural injury risk 2
Combined Supracostal Data
- Prospective studies report 5% chest complication rate requiring chest tube insertion with supracostal access 3
- Another series found 3% overall pleural complication rate in patients undergoing PCNL, with 4.2% in those receiving supracostal punctures 4
Subcostal/Infracostal Access Rates
- 2% pleural injury rate in patients with only infracostal punctures 4
- Subcostal upper calyx access shows 1.9% complication rate, comparable to non-upper pole access (2.9%) 5
- Subcostal approaches carry minimal pleural risk and are preferred when anatomically feasible 2
Risk Factors for Higher Pleural Injury Rates
Patient Factors
- Low BMI is independently associated with higher pleural injury risk on multivariate analysis 4
- Age <27 years significantly increases risk of pleural complications 4
- Right-sided procedures have significantly higher pleural injury incidence (4.0%) compared to left-sided (1.8%) 4
- Non-obese patients (BMI <30) undergoing supracostal access have 25% risk of chest tube insertion versus 6.9% in obese patients 5
Laterality Considerations
- Left supracostal PCNL carries lower risk (7.0%) compared to right supracostal (24.2%) for chest tube requirement 5
Clinical Implications and Monitoring
Immediate postoperative chest radiography is mandatory after any supracostal access to detect pneumothorax or hydrothorax early. 2, 3 Pneumothorax is more common when upper-pole calyceal puncture is used, particularly with intercostal approaches. 1
Delayed Complications
While most pleural injuries present immediately postoperatively or during hospitalization, delayed nephropleural fistulas can occur up to 8 days after the procedure, even after uneventful initial recovery. 6 This underscores the importance of patient education regarding warning signs.
Common Pitfalls
- Failure to obtain postoperative chest X-ray after supracostal access can miss significant but asymptomatic pleural injuries 2, 3
- Assuming subcostal access eliminates pleural risk entirely—while much lower (2%), pleural injury can still occur with infracostal punctures 4
- Underestimating risk in thin, young patients who have anatomically less protective tissue between kidney and pleura 4