Abstract
I
Equally we believe that some additional considerations are required.
Giusti rightly quotes Einstein to say that different results are obtained by not doing the same things. 1 Nevertheless, looking at the past, we can find among the medical authors of relevant position in our history, the teaching that explains why it makes little sense to make a supracostal access that produces risks, even if in low but real percentage of pleurisy or pleural complications.
Hippocrates used to say: ἀσκɛĩ ν πɛρì τὰ νοσήματα δύο, ὠϕɛλɛĩν ἢ μὴ βλάπτɛιν “about diseases two things: be of help and then do no harm.” 3
So if we found ourselves having to logically design a percutaneous access route to the kidney, having no precedents to refer to, would we choose a direct renal access (lower or middle calix) or would we pass through the pleura? The question is obviously rhetorical. A similar question was rationally addressed by a great urologist as Terence Millin, who explained why a transprostatic rather than a transvesical access way was better and wrote: “Still convinced that the prostate, being essentially an extravesical organ, should be extirpated by an extravesical route, …… I turned to the retropubic approach.” 4
The evaluation of our techniques cannot escape a critique in terms of logic design. Many times, our surgical technique starts from a previous technique, introducing some modifications. Sometimes relevant, sometimes marginal, sometimes useless. And we proceed in small steps in an empirical way. The same Terence Millin, before reaching the retropubic way, tried the subpubic, which did not give good surgical light. And in the end he was able to code his technique that represents the best, in terms of surgical rationality, for the open removal of prostate adenoma.
Why involve another organ, the pleura and then the lung, when this can be avoided? Finally the teaching that can be drawn from the excellent work of Altschuler et al., being effectively very skilled in the percutaneous technique, is that they are able to greatly reduce pleural complications and accesses in ICU. However we believe that, if their professional skills were applied to Endoscopic Combined Intrarenal Surgery (E.C.I.R.S), they would have absolutely better than average results in terms of complications.
We must be able to critically re-evaluate our work beyond our passions or our habits or our traditions. The technique of supine percutaneous surgery according to Galdakao or E.C.I.R.S. allows only one percutaneous access in almost all cases avoiding multiple punctures, then multiple dilatations and, therefore, multiple risks of bleeding or injury to the kidney. 5
Let us avoid supracostal access.
Avoiding supracostal access in prone position further provides advantages from the respiratory and anesthesiological point of view as well as patients with limited movements that must not be rotated under anesthesia. Even this last aspect deserves relevance because not in expert hands, it could cause damage to the cervical spine.
It is, therefore, a matter of applying the “precautionary principle,” accepted even in the European community legislation for the problems of environmental policies.