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HPTX was detected in 6.7% (1 of 15) and 25% (1 of 4) of patients by fluoroscopy and CXR, respectively.

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ADULT UROLOGY

SENSITIVITY OF CHEST FLUOROSCOPY COMPARED WITH CHEST CT AND CHEST RADIOGRAPHY FOR DIAGNOSING HYDROPNEUMOTHORAX IN ASSOCIATION WITH PERCUTANEOUS NEPHROSTOLITHOTOMY
KENNETH OGAN, T. SPARK CORWIN, THOMAS SMITH, LORI M. WATUMULL, MARY ANN MULLICAN, JEFFREY A. CADEDDU, AND MARGARET S. PEARLE

ABSTRACT Objectives. Hydropneumothorax (HPTX) is recognized as a potential complication of percutaneous nephrostolithotomy (PCNL), particularly with supracostal access. Postoperative chest radiography (CXR) is routinely used to evaluate the chest after PCNL. We prospectively compared the sensitivity of intraoperative chest fluoroscopy with immediate postoperative portable CXR and postoperative day 1 chest computed tomography (CT) for the detection of pleural fluid. Methods. A total of 89 consecutive patients (mean age 47.9 13.3 years; 100 renal units) undergoing PCNL were prospectively evaluated with intraoperative fluoroscopy at the conclusion of the procedure and then with anteroposterior CXR in the postanesthesia care unit and postoperative day 1 noncontrast, thin-cut CT of the kidneys and lung bases. CT imaging of the lung bases comprised the reference standard for detecting pleural fluid. Results. A total of 104 percutaneous renal accesses in 100 renal units, 60 above and 44 below the 12th rib, were used. In 16 cases (16%), a second-stage procedure was performed to clear residual stone fragments detected on post-PCNL CT. HPTX was detected in 1, 8, and 38 cases by initial fluoroscopy, immediate postoperative CXR, and CT scan, respectively. Intervention was necessary in 7 patients. In 2 patients with fluoroscopic evidence of pleural fluid (1 at the initial PCNL and 1 during second-look flexible nephroscopy), intraoperative pleural drainage was performed percutaneously. In the other 5 patients, intervention was determined by the size of the HPTX on chest CT scan (n 1) or the presence of symptoms (n 4). In no case was intervention performed on the basis of the immediate postoperative CXR findings when intraoperative chest fluoroscopy was negative. Conclusions. Intraoperative chest fluoroscopy during PCNL is sufficient to detect clinically significant HPTXs, and, therefore, routine postoperative CXRs are not necessary. However, a high index of suspicion based on clinical symptoms postoperatively should prompt chest imaging. UROLOGY 62: 988–992, 2003. © 2003 Elsevier Inc.

upracostal access is often preferred for complex renal calculi because it provides a favorable anatomic approach to the collecting system. However, it is associated with an intrathoracic complication rate of 3.1% to 12.5%, commonly because of
From the Department of Urology, Emory University School of Medicine, Atlanta, Georgia; and Departments of Urology and Radiology, University of Texas Southwestern Medical Center, Dallas, Texas Reprint requests: Margaret S. Pearle, M.D., Ph.D., Department of Urology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9110 Submitted: November 13, 2002, accepted (with revisions): July 28, 2003 © 2003 ELSEVIER INC.
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hydropneumothorax (HPTX).1–3 Typically, hydrothoraces are diagnosed on routine postoperative chest radiography (CXR) or CXR obtained for symptoms. In an effort to reduce the cost of percutaneous nephrostolithotomy (PCNL) by eliminating routine postoperative CXR and to facilitate treatment of hydrothorax while the patient is anesthetized, we prospectively evaluated the sensitivity of intraoperative fluoroscopy for diagnosing HPTX during PCNL. MATERIAL AND METHODS
A total of 102 consecutive PCNLs (11 bilateral) in 91 patients were performed by a single surgeon (M.S.P.). After cys0090-4295/03/$30.00 doi:10.1016/j.urology.2003.07.024

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