Category: Clinical Stones: PCNL

MP12-14 - A dynamic anatomical description of the parietal pleura setting safety limits for intercostal percutaneous access

Fri, Sep 21
2:00 PM - 4:00 PM

Introduction & Objective :

We herein describe a dynamic anatomical study intended to validate the safety of intercostal approach used by our center to access the upper pole of the kidney.

Methods :

39 patients presented to the radiology department for Computed Tomography evaluation of the abdomen and superior pelvis in the month of December 2016. Deep inspiration and expiration sequences in the prone position were evaluated to establish the location of the parietal pleura in relation to different anatomical landmarks. 3D reconstruction was performed to simulate the access needle course through the retroperitoneum.

Results :

Our data shows that the position of parietal pleura is invariably higher on the Right side irrespective of anatomical relation or respiratory changes.

Higher position of the parietal pleura was noted in all considered landmarks upon full expiratory sequences.

Using the midclavicular line as landmark (the most commonly used landmark for percutaneous access in our center), our data shows on the right side:
We can safely puncture the kidney at the level of the 9th intercostal space and below since in 100% of patients, the parietal pleura was higher than the 9th intercostal space.Going up to the level of the 8th intercostal space, the safety margin decreases to 76.9%

Moreover, on the left side, puncturing the 10th intercostal space (using the midclavicular line as landmark), would be 100% safe. Going up to the 9th intercostal space reduces the safety margin to 87.2% and using the 8th intercostal space would convey a safety margin of 43.6%


Conclusions :

According to this study introducing the access needle during full expiration may insure 100% safety in the 11th and 10th intercostal space, 87.2% in the 9th intercostal space, 43.6% in the 8th intercostal pace.

 Although using a relatively small sample size, this study was able to show that it is safe to use intercostal access during PCNL.

Khalil Chalhoub

PGY IV Urology resident
Saint George Hospital University Medical Center
Beirut, Beyrouth, Lebanon

Michel Jabbour

Chairman of surgery, Head of Urology division
Saint George Hospital University Medical Center
Beirut, Beyrouth, Lebanon

Professor Michel Jabbour MD, MBA is the chief of urology division and the Chairman of Surgery Department at Saint George Hospital University Medical Center, Balamand University faculty of medicine, Beirut, Lebanon. He pursued his medical studies in Lebanon than in New York, Albert Einstein College of Medicine where he got a Fellowship in Endo-Urology under Professor Arthur Smith. He, then, moved to Paris where he received an AFSA degree in Urology and then worked as an Assistant in Saint Louis Hospital, Paris under Professor Alain Le Duc. The main focus of his work was Oncologic Urology and Neuro-Urology. He started teaching in Paris in The School of surgery of the APHP. He returned to Lebanon in 2000. He joined Saint Joseph and Balamand universities and worked in Hotel Dieu and Saint Georges university hospitals. He developed a large activity in the fields of Endo-Urology, stone disease, Uro-oncology, Male infertility and Erectile dysfunction. He is in charge of many research projects. He has around 40 scientific articles published in international peer review journals along with hundreds of oral presentations on different topics in urology.

Edward Assaf

PGY III Urology resident
Saint Georges Hospital University Medical Center
Beirut, Beyrouth, Lebanon

Elie Lteif

PGY IV Radiology resident
Saint George Hospital University Medical Center
Beirut, Beyrouth, Lebanon

Rami Aoun

Surgery resident
Saint George Hospital University Medical Center
Beirut, Beyrouth, Lebanon

Raja Ashou

Chairman department of medical imaging
Saint George Hospital University Medical Center
Beirut, Beyrouth, Lebanon