Is Postoperative Routine Thoracic Imaging Necessary to Detect Thoracic Complications in Patients Undergoing Supracostal Mini Percutaneous Nephrolithotomy (M-pcnl) Surgery?

Is Postoperative Routine Thoracic Imaging Necessary to Detect Thoracic Complications in Patients Undergoing Supracostal Mini Percutaneous Nephrolithotomy (M-pcnl) Surgery? | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Is Postoperative Routine Thoracic Imaging Necessary to Detect Thoracic Complications in Patients Undergoing Supracostal Mini Percutaneous Nephrolithotomy (M-pcnl) Surgery? Abdullah Esmeray, Huseyin Burak Yazili, Mucahit Gelmis, Nazim Furkan Gunay, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4008500/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose This study aimed to assess the necessity of routine postoperative thoracic imaging for detecting pulmonary complications in patients undergoing supracostal mini percutaneous nephrolithotomy (m-pcnl) surgery. Materials and Methods Retrospective analysis was conducted on data from patients who underwent supracostal m-pcnl between 2017 and 2022 in a tertiary center. Excluding patients under 18, with kidney/skeletal anomalies, or active thoracic disease, 112 eligible patients were included. Patients were divided into two groups: those with routine postoperative chest X-rays (CXR) (Group 1, n = 40) and those without (Group 2, n = 72). Complications and operative data were compared between groups. Results Mean ages were 44.3 ± 11.4 (Group 1) and 42.6 ± 13.1 years (Group 2), with no significant difference (p = 0.102). Stone sizes were 30.8 ± 8.6 mm (Group 1) and 24.8 ± 8.4 mm (Group 2), also not significantly different (p = 0.313). High fever occurred in 10% of Group 1 and 4% of Group 2 (p = 0.246). Minimal effusion was found in 10% of Group 1, with no treatment due to lack of symptoms. However, subsequent CXR revealed hydropneumothorax in 2.5% of cases, necessitating thoracic tube insertion. In Group 2, 5% developed postoperative respiratory symptoms, with significant pneumothorax in 1.3%, requiring thoracic tube placement. Thoracic tube insertion rates did not significantly differ between groups (Group 1: 2.5% vs Group 2: 1.3%, p = 0.671). Conclusion Routine postoperative thoracic imaging did not show added benefit in detecting pulmonary complications post-supracostal m-pcnl. Chest X-ray Kidney stone Hemothorax PCNL Pneumothorax INTRODUCTION Urinary system stone disease is an important health problem that has a major place in urology practice. In recent years; The incidence of the disease continues to increase due to reasons such as changing climate characteristics, changes in people's diet, and obesity ( 1 ). Percutaneous nephrolithotomy (PCNL), flexible ureterorenoscopy (f-URS), extracorporeal shock wave lithotripsy (ESWL), open and laparoscopic surgery are the methods used in the treatment of kidney stones. Factors affecting treatment selection can be listed as stone characteristics (stone size, stone localization, stone structure), kidney anatomy, patient characteristics (obesity, solitary kidney) and surgeon opinion ( 2 ). Percutaneous nephrolithotomy surgery is the gold standard treatment method for kidney stones larger than 2 cm in the current guideline of the European Association of Urology (EAU) ( 3 ). In the literature, stone-free rates of up to 96% have been reported with PCNL ( 4 ). While PCNL was performed with a 30 Fr sheath at the time it was described, it was planned to reduce complications by using smaller size sheaths over time. m-PCNL surgery is performed with superior success and minimal complication rates with new instruments in sizes below 22 Fr ( 5 ). PCNL surgery can be performed with supracostal and infracostal access methods in accordance with the stone location and kidney anatomy. In PCNL surgeries performed with the supracostal technique, the risks in terms of lung/pleural damage and related complications increase. The usefulness of routine early postoperative lung imaging for the early detection of possible lung/pleural complications is controversial. This study aimed to investigate the usefulness of routine postoperative Chest X-ray radiographs in the diagnosis and treatment stages for the early diagnosis of pleural injury or lung damage that may occur after supracostal m-PCNL surgery. MATERİALS AND METHODS The data of patients who underwent supracostal (between the 11th and 12th ribs) m-PCNL in our hospital's urology clinic between 2017 and 2022 were evaluated retrospectively. Patients under the age of eighteen, with renal and skeletal system anomalies, and with active lung disease were excluded from the study. 112 patients who met the study criteria were included in the study. Written consent was obtained from all patients before the operation. Ethics committee approval was received from Haseki Training and Research Hospital ethics committee (ethics committee date/no: 23.12.2020/2020-69). Demographic and clinical data of the patients, such as ASA score, body mass index, gender, and stone size, were recorded. Renal stone characteristics were evaluated preoperatively using abdominal computed tomography (CT) and/or intravenous pyelography (IVP). All patients underwent supracostal m-PCNL by accessing between the 11th and 12th ribs. Peroperative and postoperative data such as operation time, fluoroscopy time, whether nephrostomy and DJ catheter were applied, hospital stay, postoperative hemoglobin value, development of fever, need for transfusion and need for a thorax tube were recorded. Operation time is defined as the time from the end of the patient's intubation to the skin suturing. The patients were divided into two groups: those who received routine postoperative Chest X-Ray radiographs and those who did not. Routine PA AC radiographs were taken at the bedside in the 4th postoperative hour for 40 patients in Group 1. Chest X-Ray radiographs were taken for 72 patients in Group 2 in the presence of respiratory symptoms such as low saturation, dyspnea, and tachypnea. After discharge, DJ catheter removal was performed in the 3rd postoperative week. Stone-free rates were checked with abdominal CT performed at the 3rd postoperative month. In patients who underwent supracostal percutaneous access, complication and operative data were compared between patients who underwent routine Chest X-Ray radiographs in the postoperative period and those who did not. Technique The PCNL operation was explained to the patients in detail before the operation. All operations were performed by the same team experienced in endourology. Consent was obtained from the patients for the operation. All patients underwent general anesthesia. First of all, cystoscopy was performed on the patients in the lithotomy position, then a guide wire was sent to the side where the operation would be performed, a 5fr ureter catheter was applied and checked with fluoroscopy. The patients were then placed in the prone position and a sterile drape was applied again. Contrast material was administered through the ureteral catheter and an 18-gauge percutaneous access needle was inserted into the calyx, which was deemed appropriate, using the triangulation technique under the guidance of fluoroscopy. Meanwhile, in conjunction with the anesthesiologist, serial dilation was performed up to 16 fr or 21 fr while the patients were in expiration, and the patients were taken into inspiration again. After the dilatation was completed, the access sheath was placed and the calyceal system was accessed under the guidance of a nephroscope. Stones were fragmented using a laser lithotriptor. It was cleaned with the help of a basket and forceps. At the end of the operation, the operation was terminated following the insertion of an antegrade DJ catheter and nephrostomy, if deemed necessary. Statistical analysis Work rates analysis was calculated with the G*Power (Erdfelder, Faul, & Buchner, 1996) program. Statistical Package for the Social Sciences (SPSS) 25 records as a statistical analysis program. Normality assessment of the data status was examined with the Kolmogrov-Simirnov test. Independent persons t test was used to compare variables with normal distribution, and Mann-Whitney U test was chosen for existing data with varying normality. Our quantitative data are shown as mean ± standard deviation values. Those who apply the Chi-square test to meet qualitative leakage. In the comparison of KF-36 data before and after the procedure, paired samples from disabled groups began to be tested. Data were examined at a 95% confidence level and values ​​of p < 0.005 were considered significant. RESULTS The patients' gender, mean age, body mass index (BMI), and ASA score were similar between the two groups (p = 0.951, p = 0.102, p = 0.628, and p = 0.973, respectively). The mean stone size was 30.8 ± 8.6 mm in Group 1 and 24.8 ± 8.4 mm in Group 2 (p = 0.313). The demographic and clinical data of the patients are given in Table 1 in detail. The duration of surgery was 105.5 ± 35.7 minutes in group 1 and 116.1 ± 42.6 minutes in group 2, and there was no significant difference between the groups (p = 0.452). The duration of floroscopy was 3.1 ± 0.8 minutes in group 1 and 2.6 ± 1.1 minutes in group 2, and there was no significant difference between the two groups (p = 0.072). Postoperative nephrostomy was applied to 37 (92%) patients in the first group and 57 (79%) patients in the second group, and they were statistically similar (p = 0.066). There was no statistically significant difference between the two groups in terms of stone-free rates at the postoperative 3rd month (p = 0.973). The duration of hospitalization of the patients in group 1 was statistically significantly longer than group 2 (3.7 ± 1.9 days vs 2.2 ± 1.1 days, respectively, p = 0.03). Table 1 Demographic and Clinical Data Chest X-Ray+ Chest X-ray- P value Age* 44.3 ± 11.4 42.6 ± 13.1 0.102 Sex (Male/Female) 12/28 22/50 0.951 BMI* 26.7 ± 3.7 26.1 ± 3.9 0.628 ASA* 1.3 ± 0.6 1.3 ± 0.5 0.973 Stone size (mm)* 30.8 ± 8.6 24.8 ± 8.4 0.313 Hydronephrosis 33/40 59/72 0.941 Side (Right/Left) 30/10 37/35 0.015 Postoperative double-j stent 28/40 56/72 0.362 Postoperative nephrostomy (Yes/No) 37/40 57/72 0.066 Duration of the operation (min)* 105.5 ± 35.7 116.1 ± 42.6 0.452 Duration of the fluoroskopy (min)* 3.1 ± 0.8 2.6 ± 1.1 0.072 Results in postoperative third month 33/40 59/72 0.973 Duration of hospitalization (day)* 3.7 ± 1.9 2.2 ± 1.1 0.003 *Mean ± standard deviation ASA: American Society of Anesthesiologists, BMI: Body Mass Index When complications were evaluated, postoperative fever developed in 4 (10%) patients in group 1 and in 3 (4%) patients in group 2 (p = 0.246). Postoperative transfusion was applied to 5 (12%) patients in group 1 and 3 (4%) patients in group 2, and angioembolization was applied to 1 (1.3%) patient in group 2 (p = 0.131 vs p = 0.643), respectively. Postoperative hemoglobin decrease was 0.7 ± 0.9 g/dl in group 1 and 1.1 ± 1.0 g/dl in group 2, and there was no significant difference between the groups (p = 0.614). Minimal effusion was detected in the routine postoperative CXR of 4 (10%) patients in Group 1, but no additional intervention or treatment was planned due to the absence of symptoms. In the follow-up of these patients in whom effusion was detected, hydropneumothorax was detected in 1 (2.5%) patient in the postoperative 36th hour due to the development of symptoms. The thorax tube was removed two days later and the patient was discharged on the 5th postoperative day. Other asymptomatic patients were followed up to postoperative 3 and 4 days. Due to the development of postoperative respiratory symptoms in group 2, CXR was performed in 4 (5%) patients. Hydropnomothorax was detected in the CXR of 1 (1.3%) patient in group 2, who developed symptoms at the postoperative 16th hour, and the patient was treated with a thorax tube. The patient was discharged on the 4th postoperative day, with significant resolution of hydropneumothorax in the follow-up CXR. There was no significant difference between the two groups in terms of treatment with a thorax tube (Group 1 2.5% vs group 2 1.3%, p = 0.671). Postoperative data of the patients are given in Table 2 . Table 2 Postoperative results Chest X-Ray+ Chest X-Ray- P value HB Decrease (g/dL) 0.7 ± 0.9 1.1 ± 1.0 0.614 HCT Decrease (%) 2.6 ± 3.9 3.4 ± 2.8 0.058 Postoperative fewer 4/40 3/72 0.246 Postoperative blood transfusion 5/40 3/72 0.131 Anjioembolisation 0/40 1/72 0.643 Thorax tube 1/40 1/72 0.671 Hydropneumothorax 4/40 4/72 0.246 HB:Hemoglobin, HCT:Hematocrit DISCUSSION The success of PCNL surgery is highly dependent on providing direct and optimal access to the collecting system. With the intercostal approach, direct access to upper pole and ureteral stones as well as complicated stones such as staghorn stones can be achieved and stone intervention is greatly facilitated. The upper part of the kidney is located behind the 11th and 12th ribs and is adjacent to the parietal pleura in this region. The pleura is located laterally in the upper part of the ribs, the visceral pleura remains at the level of the 12th rib in deep inspiration and descends to the level of the 8th rib in expiration ( 6 ). This anatomical situation increases the risk of pleural and lung injury in supracostal PCNL compared to the subcostal approach. To reduce this risk, it is recommended that the access be made during expiration and from the lateral midscapular line. Maintaining low-pressure irrigation during surgery can help reduce fluid leakage from the access sheath and minimize the risk of pleural effusion. Access just below the ribs should be avoided to protect the intercostal vessels and reduce hemorrhagic complications ( 7 ). In addition, adequate drainage of the kidney and buffering of the tract with a nephrostomy tube after surgery also reduce the risk of pleural effusion. Standard posteroanterior and lateral chest radiography remains the most important technique for the initial diagnosis of pleural effusion. Blunt costophrenic angle can be seen when 200 mL of fluid accumulates on the posteroanterior radiograph and approximately 50 mL on the lateral radiograph ( 8 ). Ogan et al. reported the sensitivity and specificity of CXR as 18.9% and 98.4%, respectively, in the diagnosis of hydropneumothorax after PNL. However, they reported that most of the intrathoracic fluid collections that could not be detected were clinically meaningless and did not require intervention ( 9 ). In addition, as in our study, the probability of detecting effusion in the CXR radiograph taken in the postoperative supine position is further reduced. Therefore, in the early postoperative period, CXR is insufficient to predict intrathoracic pathology that will require intervention. Intrathoracic complications after percutaneous nephrolithotomy can be seen as hydrothorax, hemothorax, hydropneumothorax or pelvic effusion. Studies have reported higher hydropneumothorax rates with the supracostal approach (0%-12%) compared to the subcostal approach (0.5%-2.6%). In our study, intrathoracic complications were found in 8 (7%) patients, consistent with the literature. However, since these complications were clinically insignificant or asymptomatic in most of the patients, they were followed conservatively and only two (1.7%) of the patients had to be treated with a thoracic tube. In support of these findings, Picus et al. reported that although 20% of their patients had signs on postoperative CXR, only 8% of patients required intervention ( 10 ). Similarly, Semins et al. evaluated all patients with CT after PNL in their study of 197 patients and found pleural effusion in 17, pneumothorax in 3, hemothorax in 2, and hydrothorax in 1 patient. Only one of these patients was treated with a thoracic tube ( 11 ). In the light of these findings, although more intrathoracic complications are detected in postoperative imaging compared to the subcostal approach in PCNL cases with supracostal access, most of them are treated conservatively because they are clinically insignificant. Therefore, in appropriate cases, supracostal pcnl can be safely applied in experienced centers with the appropriate surgical technique. Even if there is no significant finding on CXR taken in the early postoperative period, intrathoracic fluid may accumulate within days or hours later, which may become clinically significant and cause symptoms in patients. In our study, minimal effusion was detected in four (10%) patients with routine postoperative CXR. However, in one (2.5%) patient, respiratory symptoms developed at the postoperative 36th hour, and CXR was repeated and it was decided to treat with a thoracic tube when the effusion was found to increase. In the group in which routine postoperative radiographs were not taken, one (1.3%) patient was treated with a thorax tube when a significant hydropneumothorax was detected in the CXR performed after symptom development at the postoperative 16th hour. In the study of Bjurlin et al., postoperative hydropnomothorax developed in 4.3% (n = 2) of 46 supracostal pcnl cases. The first of these patients was detected during postoperative fluoroscopy, and hydropneumothorax was detected on the 3rd postoperative day in the other patient, although postoperative CXR was normal( 12 ). Similarly, Ogan et al. reported that 2% (n = 2) of the patients were diagnosed with hydropneumothorax by intraoperative fluoroscopy and 5% (n = 5) of the patients were diagnosed by CXR after respiratory symptoms developed ( 13 ). The authors concluded that routine postoperative radiographs do not affect clinical management. In addition, clinically insignificant pleural effusion observed in patients with routine CXRs radiographs may be effective in the clinician's decision to discharge the patient. In our study, the longer hospital stay in the group with routine CXR supports this situation (3.7 ± 1.9 vs. 2.2 ± 1.1 p = 0.003). In addition, reactive effusion can be detected without pleural injury, especially with more sensitive techniques such as CT and may mislead clinicians. In the light of these findings, we believe that it is more appropriate to perform diagnostic procedures and plan treatment by evaluating possible complications in patients who develop symptoms instead of postoperative routine CXR. The limitations of our study include its retrospective nature and the relatively small number of patients. CONCLUSION In our study, no additional benefit of routine postoperative CXR was found in the early diagnosis of possible pulmonary complications in patients who underwent m-pcnl with supracostal access. It seems more appropriate to plan diagnostic tests and treatments by evaluating possible complications in patients who develop respiratory symptoms instead of routine postoperative CXR. Declarations Author Contribution A.E., H.B.Y., M.G., N.F.G., C.D., F.O., Y.P., and U.C. contributed to the conception and design of the study.A.E., H.B.Y., M.G., N.F.G., and C.D. collected and analyzed the data.A.E., H.B.Y., and U.C. drafted the manuscript.A.E., H.B.Y., M.G., N.F.G., C.D., F.O., Y.P., and U.C. critically revised the manuscript for important intellectual content.All authors approved the final version of the manuscript to be published. Conflict of Interest Statement: The corresponding author declares that there are no conflicts of interest regarding the publication of this article. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors declare no financial or non-financial relationships or activities that could appear to have influenced the submitted work. References Raheem OA, Khandwala YS, Sur RL, Ghani KR, Denstedt JD. Burden of Urolithiasis: Trends in Prevalence, Treatments, and Costs. Eur Urol Focus. 2017;3(1):18-26. Marcovich R, Smith AD. Renal pelvic stones: choosing shock wave lithotripsy or percutaneous nephrolithotomy. Int Braz J Urol. 2003;29(3):195-207. Zheng C, Xiong B, Wang H, Luo J, Zhang C, Wei W, et al. Retrograde intrarenal surgery versus percutaneous nephrolithotomy for treatment of renal stones >2 cm: a meta-analysis. Urol Int. 2014;93(4):417-424. Mishra S, Sharma R, Garg C, Kurien A, Sabnis R, Desai M. Prospective comparative study of miniperc and standard PNL for treatment of 1 to 2 cm size renal stone. BJU Int. 2011;108(6):896-900. Ruhayel Y, Tepeler A, Dabestani S, MacLennan S, Petrik A, Sarica K, et al. Tract Sizes in Miniaturized Percutaneous Nephrolithotomy: A Systematic Review from the European Association of Urology Urolithiasis Guidelines Panel. Eur Urol. 2017;72(2):220-235. R Gupta 1, A Kumar, R Kapoor, A Srivastava, A Mandhani Prospective evaluation of safety and efficacy of the supracostal approach for percutaneous nephrolithotomy 10.1046/j.1464-410x.2002.03051.x Marc McAllister 1, Kelvin Lim, Robert Torrey, James Chenoweth, Brent Barker, D Duane Baldwin Intercostal vessels and nerves are at risk for injury during supracostal percutaneous nephrostolithotomy 10.1016/j.juro.2010.09.007 Vinaya S Karkhanisve Jyotsna M Joshi, Pleural effusion: diagnosis, treatment, and management. 2012; 4: 31–52. Kenneth Ogan 1, T Spark Corwin, Thomas Smith, Lori M Watumull, Mary Ann Mullican, Jeffrey A Cadeddu, Margaret S Pearle. Sensitivity of chest fluoroscopy compared with chest CT and chest radiography for diagnosing hydropneumothorax in association with percutaneous nephrostolithotomy. 10.1016/j.urology.2003.07.024 Picus D, Weyman PJ, Clayman RV ve ark. Intercostal space nephrostomy for percutaneous stone removal. AJR Am J Roentgenol. 1986;147:393-397. Semins MJ, Bartik L, Chew BH, et al. Multicenter analysis of postoperative CT findings after percutaneous nephrolithotomy: defining complication rates. Urology. 2011;78:291-294. Marc A Bjurlin 1, Thomas O'Grady, Ronald Kim, Michael D Jordan, Sandra M Goble, Courtney M P Hollowell. Is routine postoperative chest radiography needed after percutaneous nephrolithotomy? 10.1016/j.urology.2011.08.053 Kenneth Ogan 1, T Spark Corwin, Thomas Smith, Lori M Watumull, Mary Ann Mullican, Jeffrey A Cadeddu, Margaret S Pearle. Sensitivity of chest fluoroscopy compared with chest CT and chest radiography for diagnosing hydropneumothorax in association with percutaneous nephrostolithotomy. 10.1016/j.urology.2003.07.024 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4008500","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":276159722,"identity":"43c2717c-fb1e-49c8-a2f7-9778a2dfb292","order_by":0,"name":"Abdullah Esmeray","email":"","orcid":"","institution":"Haseki Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Abdullah","middleName":"","lastName":"Esmeray","suffix":""},{"id":276159723,"identity":"a234de46-fd0d-4de5-92da-881d23c98866","order_by":1,"name":"Huseyin Burak Yazili","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6ElEQVRIiWNgGAWjYJCCAw8MDgApNsYHQJKHjygtCRAtzAYgLWxEWZPAANbCJgHiENRicPz4wwMJBXcSt7cfS6v8mmMnw8bA/PDRDXxaziQkAB32LHHOmbRjt2W3JQMdxmZsnINPy4GEA0AthxNnMKS33ZbcxgzUwsMmjVfL+YcNEC38z9uKJbfVE6HlRjIDRItE2jHGj9sOE9YieeMZSMsz4xkSz5KlGbcd52FjJuAXvvPpjz98+HNHdgZ/muHHn9uq7fnZmx8+xqdF4QASh5kHTOJRDgLyDUgcxh8EVI+CUTAKRsHIBACuV1Dzi4ovXAAAAABJRU5ErkJggg==","orcid":"","institution":"Haseki Training and Research Hospital","correspondingAuthor":true,"prefix":"","firstName":"Huseyin","middleName":"Burak","lastName":"Yazili","suffix":""},{"id":276159724,"identity":"85c53f8a-fe2b-4904-87db-1ecbbe8a24cc","order_by":2,"name":"Mucahit Gelmis","email":"","orcid":"","institution":"Haseki Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mucahit","middleName":"","lastName":"Gelmis","suffix":""},{"id":276159725,"identity":"24c06dd1-c78d-4aa7-bad5-0dc837e220aa","order_by":3,"name":"Nazim Furkan Gunay","email":"","orcid":"","institution":"Haseki Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Nazim","middleName":"Furkan","lastName":"Gunay","suffix":""},{"id":276159726,"identity":"c1ea9f31-9e84-4370-a161-6aa8b9ce2154","order_by":4,"name":"Caglar Dizdaroglu","email":"","orcid":"","institution":"Haseki Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Caglar","middleName":"","lastName":"Dizdaroglu","suffix":""},{"id":276159727,"identity":"58916db7-4fd2-4a33-805f-62240385f7cf","order_by":5,"name":"Faruk Ozgor","email":"","orcid":"","institution":"Haseki Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Faruk","middleName":"","lastName":"Ozgor","suffix":""},{"id":276159728,"identity":"fbd28020-c043-4968-b804-09ae83ac3d92","order_by":6,"name":"Yasar Pazir","email":"","orcid":"","institution":"Haseki Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yasar","middleName":"","lastName":"Pazir","suffix":""},{"id":276159729,"identity":"00e6868a-698a-46ba-960c-c817527dc33f","order_by":7,"name":"Ufuk Caglar","email":"","orcid":"","institution":"Haseki Training and Research Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ufuk","middleName":"","lastName":"Caglar","suffix":""}],"badges":[],"createdAt":"2024-03-03 12:02:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4008500/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4008500/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":53174361,"identity":"e6ee0bec-b8ce-4c3a-a68e-c14d17c1c903","added_by":"auto","created_at":"2024-03-21 14:05:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":230047,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4008500/v1/fadc1a54-8ece-4aaf-af00-98feb44de6e6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eIs Postoperative Routine Thoracic Imaging Necessary to Detect Thoracic Complications in Patients Undergoing Supracostal Mini Percutaneous Nephrolithotomy (M-pcnl) Surgery?\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eUrinary system stone disease is an important health problem that has a major place in urology practice. In recent years; The incidence of the disease continues to increase due to reasons such as changing climate characteristics, changes in people's diet, and obesity (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Percutaneous nephrolithotomy (PCNL), flexible ureterorenoscopy (f-URS), extracorporeal shock wave lithotripsy (ESWL), open and laparoscopic surgery are the methods used in the treatment of kidney stones. Factors affecting treatment selection can be listed as stone characteristics (stone size, stone localization, stone structure), kidney anatomy, patient characteristics (obesity, solitary kidney) and surgeon opinion (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Percutaneous nephrolithotomy surgery is the gold standard treatment method for kidney stones larger than 2 cm in the current guideline of the European Association of Urology (EAU) (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). In the literature, stone-free rates of up to 96% have been reported with PCNL (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). While PCNL was performed with a 30 Fr sheath at the time it was described, it was planned to reduce complications by using smaller size sheaths over time. m-PCNL surgery is performed with superior success and minimal complication rates with new instruments in sizes below 22 Fr (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). PCNL surgery can be performed with supracostal and infracostal access methods in accordance with the stone location and kidney anatomy. In PCNL surgeries performed with the supracostal technique, the risks in terms of lung/pleural damage and related complications increase. The usefulness of routine early postoperative lung imaging for the early detection of possible lung/pleural complications is controversial. This study aimed to investigate the usefulness of routine postoperative Chest X-ray radiographs in the diagnosis and treatment stages for the early diagnosis of pleural injury or lung damage that may occur after supracostal m-PCNL surgery.\u003c/p\u003e"},{"header":"MATERİALS AND METHODS","content":"\u003cp\u003eThe data of patients who underwent supracostal (between the 11th and 12th ribs) m-PCNL in our hospital's urology clinic between 2017 and 2022 were evaluated retrospectively. Patients under the age of eighteen, with renal and skeletal system anomalies, and with active lung disease were excluded from the study. 112 patients who met the study criteria were included in the study. Written consent was obtained from all patients before the operation. Ethics committee approval was received from Haseki Training and Research Hospital ethics committee (ethics committee date/no: 23.12.2020/2020-69). Demographic and clinical data of the patients, such as ASA score, body mass index, gender, and stone size, were recorded. Renal stone characteristics were evaluated preoperatively using abdominal computed tomography (CT) and/or intravenous pyelography (IVP). All patients underwent supracostal m-PCNL by accessing between the 11th and 12th ribs. Peroperative and postoperative data such as operation time, fluoroscopy time, whether nephrostomy and DJ catheter were applied, hospital stay, postoperative hemoglobin value, development of fever, need for transfusion and need for a thorax tube were recorded. Operation time is defined as the time from the end of the patient's intubation to the skin suturing. The patients were divided into two groups: those who received routine postoperative Chest X-Ray radiographs and those who did not. Routine PA AC radiographs were taken at the bedside in the 4th postoperative hour for 40 patients in Group 1. Chest X-Ray radiographs were taken for 72 patients in Group 2 in the presence of respiratory symptoms such as low saturation, dyspnea, and tachypnea. After discharge, DJ catheter removal was performed in the 3rd postoperative week. Stone-free rates were checked with abdominal CT performed at the 3rd postoperative month. In patients who underwent supracostal percutaneous access, complication and operative data were compared between patients who underwent routine Chest X-Ray radiographs in the postoperative period and those who did not.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTechnique\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe PCNL operation was explained to the patients in detail before the operation. All operations were performed by the same team experienced in endourology. Consent was obtained from the patients for the operation. All patients underwent general anesthesia. First of all, cystoscopy was performed on the patients in the lithotomy position, then a guide wire was sent to the side where the operation would be performed, a 5fr ureter catheter was applied and checked with fluoroscopy. The patients were then placed in the prone position and a sterile drape was applied again. Contrast material was administered through the ureteral catheter and an 18-gauge percutaneous access needle was inserted into the calyx, which was deemed appropriate, using the triangulation technique under the guidance of fluoroscopy. Meanwhile, in conjunction with the anesthesiologist, serial dilation was performed up to 16 fr or 21 fr while the patients were in expiration, and the patients were taken into inspiration again. After the dilatation was completed, the access sheath was placed and the calyceal system was accessed under the guidance of a nephroscope. Stones were fragmented using a laser lithotriptor. It was cleaned with the help of a basket and forceps. At the end of the operation, the operation was terminated following the insertion of an antegrade DJ catheter and nephrostomy, if deemed necessary.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eWork rates analysis was calculated with the G*Power (Erdfelder, Faul, \u0026amp; Buchner, 1996) program. Statistical Package for the Social Sciences (SPSS) 25 records as a statistical analysis program. Normality assessment of the data status was examined with the Kolmogrov-Simirnov test. Independent persons t test was used to compare variables with normal distribution, and Mann-Whitney U test was chosen for existing data with varying normality. Our quantitative data are shown as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation values. Those who apply the Chi-square test to meet qualitative leakage. In the comparison of KF-36 data before and after the procedure, paired samples from disabled groups began to be tested. Data were examined at a 95% confidence level and values ​​of p\u0026thinsp;\u0026lt;\u0026thinsp;0.005 were considered significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe patients' gender, mean age, body mass index (BMI), and ASA score were similar between the two groups (p\u0026thinsp;=\u0026thinsp;0.951, p\u0026thinsp;=\u0026thinsp;0.102, p\u0026thinsp;=\u0026thinsp;0.628, and p\u0026thinsp;=\u0026thinsp;0.973, respectively). The mean stone size was 30.8\u0026thinsp;\u0026plusmn;\u0026thinsp;8.6 mm in Group 1 and 24.8\u0026thinsp;\u0026plusmn;\u0026thinsp;8.4 mm in Group 2 (p\u0026thinsp;=\u0026thinsp;0.313). The demographic and clinical data of the patients are given in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e in detail.\u003c/p\u003e \u003cp\u003eThe duration of surgery was 105.5\u0026thinsp;\u0026plusmn;\u0026thinsp;35.7 minutes in group 1 and 116.1\u0026thinsp;\u0026plusmn;\u0026thinsp;42.6 minutes in group 2, and there was no significant difference between the groups (p\u0026thinsp;=\u0026thinsp;0.452). The duration of floroscopy was 3.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8 minutes in group 1 and 2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1 minutes in group 2, and there was no significant difference between the two groups (p\u0026thinsp;=\u0026thinsp;0.072). Postoperative nephrostomy was applied to 37 (92%) patients in the first group and 57 (79%) patients in the second group, and they were statistically similar (p\u0026thinsp;=\u0026thinsp;0.066). There was no statistically significant difference between the two groups in terms of stone-free rates at the postoperative 3rd month (p\u0026thinsp;=\u0026thinsp;0.973). The duration of hospitalization of the patients in group 1 was statistically significantly longer than group 2 (3.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9 days vs 2.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1 days, respectively, p\u0026thinsp;=\u0026thinsp;0.03).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and Clinical Data\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChest X-Ray+\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChest X-ray-\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44.3\u0026thinsp;\u0026plusmn;\u0026thinsp;11.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.6\u0026thinsp;\u0026plusmn;\u0026thinsp;13.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.102\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (Male/Female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12/28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22/50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.951\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.628\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.973\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStone size (mm)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.8\u0026thinsp;\u0026plusmn;\u0026thinsp;8.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.8\u0026thinsp;\u0026plusmn;\u0026thinsp;8.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.313\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHydronephrosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33/40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59/72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.941\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSide (Right/Left)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30/10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37/35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative double-j stent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28/40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56/72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.362\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative nephrostomy (Yes/No)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37/40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57/72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.066\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of the operation (min)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e105.5\u0026thinsp;\u0026plusmn;\u0026thinsp;35.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e116.1\u0026thinsp;\u0026plusmn;\u0026thinsp;42.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.452\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of the fluoroskopy (min)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.072\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResults in postoperative third month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33/40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59/72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.973\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of hospitalization (day)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation\u003c/p\u003e \u003cp\u003eASA: American Society of Anesthesiologists, BMI: Body Mass Index\u003c/p\u003e \u003cp\u003eWhen complications were evaluated, postoperative fever developed in 4 (10%) patients in group 1 and in 3 (4%) patients in group 2 (p\u0026thinsp;=\u0026thinsp;0.246). Postoperative transfusion was applied to 5 (12%) patients in group 1 and 3 (4%) patients in group 2, and angioembolization was applied to 1 (1.3%) patient in group 2 (p\u0026thinsp;=\u0026thinsp;0.131 vs p\u0026thinsp;=\u0026thinsp;0.643), respectively. Postoperative hemoglobin decrease was 0.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9 g/dl in group 1 and 1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0 g/dl in group 2, and there was no significant difference between the groups (p\u0026thinsp;=\u0026thinsp;0.614).\u003c/p\u003e \u003cp\u003eMinimal effusion was detected in the routine postoperative CXR of 4 (10%) patients in Group 1, but no additional intervention or treatment was planned due to the absence of symptoms. In the follow-up of these patients in whom effusion was detected, hydropneumothorax was detected in 1 (2.5%) patient in the postoperative 36th hour due to the development of symptoms. The thorax tube was removed two days later and the patient was discharged on the 5th postoperative day. Other asymptomatic patients were followed up to postoperative 3 and 4 days.\u003c/p\u003e \u003cp\u003eDue to the development of postoperative respiratory symptoms in group 2, CXR was performed in 4 (5%) patients. Hydropnomothorax was detected in the CXR of 1 (1.3%) patient in group 2, who developed symptoms at the postoperative 16th hour, and the patient was treated with a thorax tube. The patient was discharged on the 4th postoperative day, with significant resolution of hydropneumothorax in the follow-up CXR. There was no significant difference between the two groups in terms of treatment with a thorax tube (Group 1 2.5% vs group 2 1.3%, p\u0026thinsp;=\u0026thinsp;0.671). Postoperative data of the patients are given in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative results\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChest X-Ray+\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChest X-Ray-\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHB Decrease (g/dL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.614\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHCT Decrease (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.058\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative fewer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4/40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3/72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.246\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative blood transfusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5/40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3/72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.131\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnjioembolisation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0/40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1/72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.643\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThorax tube\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1/72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.671\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHydropneumothorax\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4/40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4/72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.246\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eHB:Hemoglobin, HCT:Hematocrit\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe success of PCNL surgery is highly dependent on providing direct and optimal access to the collecting system. With the intercostal approach, direct access to upper pole and ureteral stones as well as complicated stones such as staghorn stones can be achieved and stone intervention is greatly facilitated. The upper part of the kidney is located behind the 11th and 12th ribs and is adjacent to the parietal pleura in this region. The pleura is located laterally in the upper part of the ribs, the visceral pleura remains at the level of the 12th rib in deep inspiration and descends to the level of the 8th rib in expiration (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). This anatomical situation increases the risk of pleural and lung injury in supracostal PCNL compared to the subcostal approach. To reduce this risk, it is recommended that the access be made during expiration and from the lateral midscapular line. Maintaining low-pressure irrigation during surgery can help reduce fluid leakage from the access sheath and minimize the risk of pleural effusion. Access just below the ribs should be avoided to protect the intercostal vessels and reduce hemorrhagic complications (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). In addition, adequate drainage of the kidney and buffering of the tract with a nephrostomy tube after surgery also reduce the risk of pleural effusion.\u003c/p\u003e \u003cp\u003eStandard posteroanterior and lateral chest radiography remains the most important technique for the initial diagnosis of pleural effusion. Blunt costophrenic angle can be seen when 200 mL of fluid accumulates on the posteroanterior radiograph and approximately 50 mL on the lateral radiograph (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Ogan et al. reported the sensitivity and specificity of CXR as 18.9% and 98.4%, respectively, in the diagnosis of hydropneumothorax after PNL. However, they reported that most of the intrathoracic fluid collections that could not be detected were clinically meaningless and did not require intervention (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). In addition, as in our study, the probability of detecting effusion in the CXR radiograph taken in the postoperative supine position is further reduced. Therefore, in the early postoperative period, CXR is insufficient to predict intrathoracic pathology that will require intervention.\u003c/p\u003e \u003cp\u003eIntrathoracic complications after percutaneous nephrolithotomy can be seen as hydrothorax, hemothorax, hydropneumothorax or pelvic effusion. Studies have reported higher hydropneumothorax rates with the supracostal approach (0%-12%) compared to the subcostal approach (0.5%-2.6%). In our study, intrathoracic complications were found in 8 (7%) patients, consistent with the literature. However, since these complications were clinically insignificant or asymptomatic in most of the patients, they were followed conservatively and only two (1.7%) of the patients had to be treated with a thoracic tube. In support of these findings, Picus et al. reported that although 20% of their patients had signs on postoperative CXR, only 8% of patients required intervention (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Similarly, Semins et al. evaluated all patients with CT after PNL in their study of 197 patients and found pleural effusion in 17, pneumothorax in 3, hemothorax in 2, and hydrothorax in 1 patient. Only one of these patients was treated with a thoracic tube (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). In the light of these findings, although more intrathoracic complications are detected in postoperative imaging compared to the subcostal approach in PCNL cases with supracostal access, most of them are treated conservatively because they are clinically insignificant. Therefore, in appropriate cases, supracostal pcnl can be safely applied in experienced centers with the appropriate surgical technique.\u003c/p\u003e \u003cp\u003eEven if there is no significant finding on CXR taken in the early postoperative period, intrathoracic fluid may accumulate within days or hours later, which may become clinically significant and cause symptoms in patients. In our study, minimal effusion was detected in four (10%) patients with routine postoperative CXR. However, in one (2.5%) patient, respiratory symptoms developed at the postoperative 36th hour, and CXR was repeated and it was decided to treat with a thoracic tube when the effusion was found to increase. In the group in which routine postoperative radiographs were not taken, one (1.3%) patient was treated with a thorax tube when a significant hydropneumothorax was detected in the CXR performed after symptom development at the postoperative 16th hour. In the study of Bjurlin et al., postoperative hydropnomothorax developed in 4.3% (n\u0026thinsp;=\u0026thinsp;2) of 46 supracostal pcnl cases. The first of these patients was detected during postoperative fluoroscopy, and hydropneumothorax was detected on the 3rd postoperative day in the other patient, although postoperative CXR was normal(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Similarly, Ogan et al. reported that 2% (n\u0026thinsp;=\u0026thinsp;2) of the patients were diagnosed with hydropneumothorax by intraoperative fluoroscopy and 5% (n\u0026thinsp;=\u0026thinsp;5) of the patients were diagnosed by CXR after respiratory symptoms developed (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The authors concluded that routine postoperative radiographs do not affect clinical management. In addition, clinically insignificant pleural effusion observed in patients with routine CXRs radiographs may be effective in the clinician's decision to discharge the patient. In our study, the longer hospital stay in the group with routine CXR supports this situation (3.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9 vs. 2.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1 p\u0026thinsp;=\u0026thinsp;0.003). In addition, reactive effusion can be detected without pleural injury, especially with more sensitive techniques such as CT and may mislead clinicians. In the light of these findings, we believe that it is more appropriate to perform diagnostic procedures and plan treatment by evaluating possible complications in patients who develop symptoms instead of postoperative routine CXR.\u003c/p\u003e \u003cp\u003eThe limitations of our study include its retrospective nature and the relatively small number of patients.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIn our study, no additional benefit of routine postoperative CXR was found in the early diagnosis of possible pulmonary complications in patients who underwent m-pcnl with supracostal access. It seems more appropriate to plan diagnostic tests and treatments by evaluating possible complications in patients who develop respiratory symptoms instead of routine postoperative CXR.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA.E., H.B.Y., M.G., N.F.G., C.D., F.O., Y.P., and U.C. contributed to the conception and design of the study.A.E., H.B.Y., M.G., N.F.G., and C.D. collected and analyzed the data.A.E., H.B.Y., and U.C. drafted the manuscript.A.E., H.B.Y., M.G., N.F.G., C.D., F.O., Y.P., and U.C. critically revised the manuscript for important intellectual content.All authors approved the final version of the manuscript to be published.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe corresponding author declares that there are no conflicts of interest regarding the publication of this article. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors declare no financial or non-financial relationships or activities that could appear to have influenced the submitted work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRaheem OA, Khandwala YS, Sur RL, Ghani KR, Denstedt JD. Burden of Urolithiasis: Trends in Prevalence, Treatments, and Costs. Eur Urol Focus. 2017;3(1):18-26.\u003c/li\u003e\n\u003cli\u003eMarcovich R, Smith AD. Renal pelvic stones: choosing shock wave lithotripsy or percutaneous nephrolithotomy. Int Braz J Urol. 2003;29(3):195-207. \u003c/li\u003e\n\u003cli\u003eZheng C, Xiong B, Wang H, Luo J, Zhang C, Wei W, et al. Retrograde intrarenal surgery versus percutaneous nephrolithotomy for treatment of renal stones \u0026gt;2 cm: a meta-analysis. Urol Int. 2014;93(4):417-424.\u003c/li\u003e\n\u003cli\u003eMishra S, Sharma R, Garg C, Kurien A, Sabnis R, Desai M. Prospective comparative study of miniperc and standard PNL for treatment of 1 to 2 cm size renal stone. BJU Int. 2011;108(6):896-900.\u003c/li\u003e\n\u003cli\u003eRuhayel Y, Tepeler A, Dabestani S, MacLennan S, Petrik A, Sarica K, et al. Tract Sizes in Miniaturized Percutaneous Nephrolithotomy: A Systematic Review from the European Association of Urology Urolithiasis Guidelines Panel. Eur Urol. 2017;72(2):220-235.\u003c/li\u003e\n\u003cli\u003eR Gupta 1, A Kumar, R Kapoor, A Srivastava, A Mandhani Prospective evaluation of safety and efficacy of the supracostal approach for percutaneous nephrolithotomy 10.1046/j.1464-410x.2002.03051.x\u003c/li\u003e\n\u003cli\u003eMarc McAllister 1, Kelvin Lim, Robert Torrey, James Chenoweth, Brent Barker, D Duane Baldwin Intercostal vessels and nerves are at risk for injury during supracostal percutaneous nephrostolithotomy 10.1016/j.juro.2010.09.007\u003c/li\u003e\n\u003cli\u003eVinaya S Karkhanisve Jyotsna M Joshi, Pleural effusion: diagnosis, treatment, and management. 2012; 4: 31\u0026ndash;52.\u003c/li\u003e\n\u003cli\u003eKenneth Ogan 1, T Spark Corwin, Thomas Smith, Lori M Watumull, Mary Ann Mullican, Jeffrey A Cadeddu, Margaret S Pearle. Sensitivity of chest fluoroscopy compared with chest CT and chest radiography for diagnosing hydropneumothorax in association with percutaneous nephrostolithotomy. 10.1016/j.urology.2003.07.024\u003c/li\u003e\n\u003cli\u003ePicus D, Weyman PJ, Clayman RV ve ark. Intercostal space nephrostomy for percutaneous stone removal. AJR Am J Roentgenol. 1986;147:393-397.\u003c/li\u003e\n\u003cli\u003eSemins MJ, Bartik L, Chew BH, et al. Multicenter analysis of postoperative CT findings after percutaneous nephrolithotomy: defining complication rates. Urology. 2011;78:291-294.\u003c/li\u003e\n\u003cli\u003eMarc A Bjurlin 1, Thomas O\u0026apos;Grady, Ronald Kim, Michael D Jordan, Sandra M Goble, Courtney M P Hollowell. Is routine postoperative chest radiography needed after percutaneous nephrolithotomy? 10.1016/j.urology.2011.08.053\u003c/li\u003e\n\u003cli\u003eKenneth Ogan 1, T Spark Corwin, Thomas Smith, Lori M Watumull, Mary Ann Mullican, Jeffrey A Cadeddu, Margaret S Pearle. Sensitivity of chest fluoroscopy compared with chest CT and chest radiography for diagnosing hydropneumothorax in association with percutaneous nephrostolithotomy. 10.1016/j.urology.2003.07.024\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Chest X-ray, Kidney stone, Hemothorax, PCNL, Pneumothorax","lastPublishedDoi":"10.21203/rs.3.rs-4008500/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4008500/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eThis study aimed to assess the necessity of routine postoperative thoracic imaging for detecting pulmonary complications in patients undergoing supracostal mini percutaneous nephrolithotomy (m-pcnl) surgery.\u003c/p\u003e\u003ch2\u003eMaterials and Methods\u003c/h2\u003e \u003cp\u003eRetrospective analysis was conducted on data from patients who underwent supracostal m-pcnl between 2017 and 2022 in a tertiary center. Excluding patients under 18, with kidney/skeletal anomalies, or active thoracic disease, 112 eligible patients were included. Patients were divided into two groups: those with routine postoperative chest X-rays (CXR) (Group 1, n\u0026thinsp;=\u0026thinsp;40) and those without (Group 2, n\u0026thinsp;=\u0026thinsp;72). Complications and operative data were compared between groups.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eMean ages were 44.3\u0026thinsp;\u0026plusmn;\u0026thinsp;11.4 (Group 1) and 42.6\u0026thinsp;\u0026plusmn;\u0026thinsp;13.1 years (Group 2), with no significant difference (p\u0026thinsp;=\u0026thinsp;0.102). Stone sizes were 30.8\u0026thinsp;\u0026plusmn;\u0026thinsp;8.6 mm (Group 1) and 24.8\u0026thinsp;\u0026plusmn;\u0026thinsp;8.4 mm (Group 2), also not significantly different (p\u0026thinsp;=\u0026thinsp;0.313). High fever occurred in 10% of Group 1 and 4% of Group 2 (p\u0026thinsp;=\u0026thinsp;0.246). Minimal effusion was found in 10% of Group 1, with no treatment due to lack of symptoms. However, subsequent CXR revealed hydropneumothorax in 2.5% of cases, necessitating thoracic tube insertion. In Group 2, 5% developed postoperative respiratory symptoms, with significant pneumothorax in 1.3%, requiring thoracic tube placement. Thoracic tube insertion rates did not significantly differ between groups (Group 1: 2.5% vs Group 2: 1.3%, p\u0026thinsp;=\u0026thinsp;0.671).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eRoutine postoperative thoracic imaging did not show added benefit in detecting pulmonary complications post-supracostal m-pcnl.\u003c/p\u003e","manuscriptTitle":"Is Postoperative Routine Thoracic Imaging Necessary to Detect Thoracic Complications in Patients Undergoing Supracostal Mini Percutaneous Nephrolithotomy (M-pcnl) Surgery?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-06 11:30:07","doi":"10.21203/rs.3.rs-4008500/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c1e6408d-f9aa-4640-8d24-d880f2f6a774","owner":[],"postedDate":"March 6th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-03-21T13:57:11+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-06 11:30:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4008500","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4008500","identity":"rs-4008500","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}