Complications Related with PCNL and Their Management

  • Iliya SaltirovEmail author
  • Kremena Petkova


During the last 30 years, percutaneous nephrolithotomy (PCNL) has become the standard minimally invasive treatment for renal stones. Despite being a safe procedure, PCNL is still associated with specific complications, which can occur during percutaneous access, nephroscopy and lithotripsy or postoperative management. Detailed knowledge on PCNL complications and their management is mandatory in order to reduce procedure-related morbidity without compromising patient outcomes.


Percutaneous nephrolithotomy Complications Percutaneous access Nephroscopy Lithotripsy Endourology 


  1. 1.
    Türk C, Skolarikos A, Neisius A, Petřík A, Seitz C, Thomas K, et al.; Members of the European Association of Urology (EAU) Guidelines Office. Guidelines on urolithiasis. 2019. Accessed 1 May 2019.
  2. 2.
    Clavien PA, Sanabria JR, Strasberg SM. Proposed classification of complications of surgery with examples of utility in cholecystectomy. Surgery. 1992;111:518–26.PubMedGoogle Scholar
  3. 3.
    Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–13.PubMedPubMedCentralCrossRefGoogle Scholar
  4. 4.
    de la Rosette JJ, Opondo D, Daels FP, Giusti G, Serrano A, Kandasami SV, et al.; CROES PCNL Study Group. Categorisation of complications and validation of the Clavien score for percutaneous nephrolithotomy. Eur Urol. 2012;62(2):246–55.Google Scholar
  5. 5.
    Labate G, Modi P, Timoney A, Cormio L, Zhang X, Louie M, et al. The percutaneous nephrolithotomy global study: classification of complications. J Endourol. 2011;25(8):1275–80.PubMedPubMedCentralCrossRefGoogle Scholar
  6. 6.
    Okeke Z, Smith AD, Labate G, D’Addessi A, Venkatesh R, Assimos D, et al.; CROES PCNL Study Group. Prospective comparison of outcomes of percutaneous nephrolithotomy in elderly patients versus younger patients. J Endourol. 2012;26(8):996–1001.Google Scholar
  7. 7.
    Unsal A, Resorlu B, Atmaca AF, Diri A, Goktug HN, Can CE, et al. Prediction of morbidity and mortality after percutaneous nephrolithotomy by using the Charlson Comorbidity Index. Urology. 2012;79(1):55–60.PubMedCrossRefGoogle Scholar
  8. 8.
    Wollin DA, Skolarikos A, Preminger GM. Obesity and metabolic stone disease. Curr Opin Urol. 2017;27(5):422–7.PubMedCrossRefGoogle Scholar
  9. 9.
    Apovian CM. Obesity: definition, comorbidities, causes, and burden. Am J Manag Care. 2016;22(7 Suppl):s176–85.PubMedGoogle Scholar
  10. 10.
    Brodsky JB, Oldroyd M, Winfield HN, Kozlowski PM. Morbid obesity and the prone position: a case report. J Clin Anesth. 2001;13(2):138–40.PubMedCrossRefPubMedCentralGoogle Scholar
  11. 11.
    Fuller A, Razvi H, Denstedt JD, Nott L, Pearle M, Cauda F, et al.; CROES PCNL Study Group. The CROES percutaneous nephrolithotomy global study: the influence of body mass index on outcome. J Urol. 2012;188(1):138–144.Google Scholar
  12. 12.
    El-Assmy AM, Shokeir AA, El-Nahas AR, Shoma AM, Eraky I, El-Kenawy MR, et al. Outcome of percutaneous nephrolithotomy: effect of body mass index. Eur Urol. 2007;52(1):199–204.PubMedCrossRefGoogle Scholar
  13. 13.
    Tomaszewski JJ, Smaldone MC, Schuster T, Jackman SV, Averch TD. Outcomes of percutaneous nephrolithotomy stratified by body mass index. J Endourol. 2010;24(4):547–50.PubMedCrossRefGoogle Scholar
  14. 14.
    Tikkinen KAO, Cartwright R, Gould R, Naspro R, Novara G, Sandset PM, et al.; Members of the European Association of Urology (EAU) Guidelines Office. EAU guidelines on thromboprophylaxis in urological surgery. 2019. Accessed 2 May 2019.
  15. 15.
    Gross AJ, Bach T. Preoperative percutaneous stone surgery in patients receiving anticoagulant therapy. J Endourol. 2009;23(10):1563–5.PubMedCrossRefGoogle Scholar
  16. 16.
    Gutierrez J, Smith A, Geavlete P, Shah H, Kural AR, de Sio M, et al.; CROES PCNL Study Group. Urinary tract infections and post-operative fever in percutaneous nephrolithotomy. World J Urol. 2013;31(5):1135–40.Google Scholar
  17. 17.
    Rivera M, Viers B, Cockerill P, Agarwal D, Mehta R, Krambeck A. Pre- and postoperative predictors of infection-related complications in patients undergoing percutaneous nephrolithotomy. J Endourol. 2016;30(9):982–6.PubMedCrossRefGoogle Scholar
  18. 18.
    Lai WS, Assimos D. Factors associated with postoperative infection after percutaneous nephrolithotomy. Rev Urol. 2018;20(1):7–11.PubMedPubMedCentralGoogle Scholar
  19. 19.
    Mariappan P, Smith G, Bariol SV, Moussa SA, Tolley DA. Stone and pelvic urine culture and sensitivity are better than bladder urine as predictors of urosepsis following percutaneous nephrolithotomy: a prospective clinical study. J Urol. 2005;173(5):1610–4.PubMedCrossRefGoogle Scholar
  20. 20.
    Mosavi-Bahar SH, Amirzargar MA, Rahnavardi M, Moghaddam SM, Babbolhavaeji H, Amirhasani S. Percutaneous nephrolithotomy in patients with kidney malformations. J Endourol. 2007;21(5):520–4.PubMedCrossRefGoogle Scholar
  21. 21.
    Ozden E, Bilen CY, Mercimek MN, Tan B, Sarikaya S, Sahin A. Horseshoe kidney: does it really have any negative impact on surgical outcomes of percutaneous nephrolithotomy? Urology. 2010;75(5):1049–52.PubMedCrossRefGoogle Scholar
  22. 22.
    Osther PJ, Razvi H, Liatsikos E, Averch T, Crisci A, Garcia JL, et al.; Croes PCNL Study Group. Percutaneous nephrolithotomy among patients with renal anomalies: patient characteristics and outcomes; a subgroup analysis of the clinical research office of the endourological society global percutaneous nephrolithotomy study. J Endourol. 2011;25(10):1627–1632.Google Scholar
  23. 23.
    Thomas K, Smith NC, Hegarty N, Glass JM. The Guy’s stone score—grading the complexity of percutaneous nephrolithotomy procedures. Urology. 2011;78:277–81.PubMedCrossRefGoogle Scholar
  24. 24.
    Smith A, Averch TD, Shahrour K, Opondo D, Daels FP, Labate G, et al. A nephrolithometric nomogram to predict treatment success of percutaneous nephrolithotomy. J Urol. 2013;190:149–56.PubMedCrossRefGoogle Scholar
  25. 25.
    Okhunov Z, Friedlander JI, George AK, Duty BD, Moreira DM, Srinivasan AK, et al. S.T.O.N.E. nephrolithometry: novel surgical classification system for kidney calculi. Urology. 2013;81:1154–9.PubMedCrossRefGoogle Scholar
  26. 26.
    Kumar S, Sreenivas J, Karthikeyan VS, Mallya A, Keshavamurthy R. Evaluation of CROES nephrolithometry nomogram as a preoperative predictive system for percutaneous nephrolithotomy outcomes. J Endourol. 2016;30(10):1079–83.PubMedCrossRefGoogle Scholar
  27. 27.
    Vicentini FC, Serzedello FR, Thomas K, Marchini GS, Torricelli FCM, Srougi M, et al. What is the quickest scoring system to predict percutaneous nephrolithotomy outcomes? A comparative study among S.T.O.N.E score, Guy’s stone score and CROES nomogram. Int Braz J Urol. 2017;43(6):1102–9.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Negrete-Pulido O, Molina-Torres M, Castaño-Tostado E, Loske AM, Gutiérrez-Aceves J. Percutaneous renal access: the learning curve of a simplified approach. J Endourol. 2010;24(3):457–60.PubMedCrossRefGoogle Scholar
  29. 29.
    Quirke K, Aydin A, Brunckhorst O, Bultitude M, Khan MS, Dasgupta P, et al. Learning curves in urolithiasis surgery: a systematic review. J Endourol. 2018;32(11):1008–20.PubMedPubMedCentralCrossRefGoogle Scholar
  30. 30.
    Opondo D, Tefekli A, Esen T, Labate G, Sangam K, De Lisa A, et al. Impact of case volumes on the outcomes of percutaneous nephrolithotomy. Eur Urol. 2012;62(6):1181–7.PubMedCrossRefGoogle Scholar
  31. 31.
    Valdivia Uria JG, Valle Gerhold J, Lopez Lopez JA, Villarroya Rodriguez S, Ambroj Navarro C, Ramirez Fabián M, et al. Technique and complications of percutaneous nephroscopy: experience with 557 patients in the supine position. J Urol. 1998;160(6):1975–8.PubMedGoogle Scholar
  32. 32.
    Kerbl K, Clayman RV, Chandhoke PS, Urban DA, De Leo BC, Carbone JM. Percutaneous stone removal with the patient in a flank position. J Urol. 1994;151(3):686–8.CrossRefGoogle Scholar
  33. 33.
    Ibarluzea G, Scoffone CM, Cracco CM, Poggio M, Porpiglia F, Terrone C, et al. Supine Valdivia and modified lithotomy position for simultaneous anterograde and retrograde endourological access. BJU Int. 2007;100(5):233–6.CrossRefGoogle Scholar
  34. 34.
    Bach C, Goyal A, Kumar P, Kachrilas S, Papatsoris AG, Buchholz N, Masood J. The Barts ‘flank-free’ modified supine position for percutaneous nephrolithotomy. Urol Int. 2012;89(3):365–8.Google Scholar
  35. 35.
    Shoma AM, Eraky I, El-Kenawy MR, El-Kappany HA. Percutaneous nephrolithotomy in the supine position: technical aspects and functional outcome compared with the prone technique. Urology. 2002;60(3):388–92.PubMedCrossRefGoogle Scholar
  36. 36.
    DeSio M, Autorino R, Quarto G, Calabrò F, Damiano R, Giugliano F, et al. Modified supine versus prone position in percutaneous nephrolithotomy for renal stones treatable with a single percutaneous access: a prospective randomized trial. Eur Urol. 2008;54:196–203.CrossRefGoogle Scholar
  37. 37.
    Yokoyama M, Ueda W, Hirakawa M, Yamamoto H. Hemodynamic effect of the prone position during anesthesia. Acta Anaesthesiol Scand. 1991;35:741–4.PubMedCrossRefGoogle Scholar
  38. 38.
    Poon KS, Wu KC, Chen CC, Fung ST, Lau AW, Huang CC, Wu RS. Hemodynamic changes during spinal surgery in the prone position. Acta Anaesthesiol Taiwanica. 2008;46(2):57–60.CrossRefGoogle Scholar
  39. 39.
    Lee LA, Roth S, Posner KL, Cheney FW, Caplan RA, Newman NJ, et al. The American Society of Anesthesiologists Postoperative Visual Loss Registry: analysis of 93 spine surgery cases with postoperative visual loss. Anesthesiology. 2006;105:652–9.PubMedCrossRefGoogle Scholar
  40. 40.
    Ho VT, Newman NJ, Song S, Ksiazek S, Roth S. Ischemic optic neuropathy following spine surgery. J Neurosurg Anesthesiol. 2005;17:38–44.PubMedPubMedCentralGoogle Scholar
  41. 41.
    Epstein NE. Perioperative visual loss following prone spinal surgery: a review. Surg Neurol Int. 2016;7(Suppl 13):S347–60.PubMedPubMedCentralCrossRefGoogle Scholar
  42. 42.
    Nasseh H, Pourreza F, Saberi A, Kazemnejad E, Kalantari BB, Falahatkar S. Focal neuropathies following percutaneous nephrolithotomy (PCNL)—preliminary study. Ger Med Sci. 2013;11:Doc07.PubMedPubMedCentralGoogle Scholar
  43. 43.
    Agah M, Ghasemi M, Roodneshin F, Radpay B, Moradian S. Prone position in percutaneous nephrolithotomy and postoperative visual loss. Urol J. 2011;8(3):191–6.PubMedGoogle Scholar
  44. 44.
    Michel MS, Trojan L, Rassweiler JJ. Complications in percutaneous nephrolithotomy. Eur Urol. 2007;51:899–906.PubMedPubMedCentralCrossRefGoogle Scholar
  45. 45.
    Gallucci M, Fortunato P, Schettini M, Vincenzoni A. Management of hemorrhage after percutaneous renal surgery. J Endourol. 1998;12:509–12.PubMedCrossRefGoogle Scholar
  46. 46.
    Kaye KW, Clayman RV. Tamponade nephrostomy catheter for percutaneous nephrostolithotomy. Urology. 1986;27:441–5.PubMedCrossRefGoogle Scholar
  47. 47.
    Srivastava A, Singh KJ, Suri A, Dubey D, Kumar A, Kapoor R, et al. Vascular complications after percutaneous nephrolithotomy: are there any predictive factors? Urology. 2005;66(1):38–40.CrossRefGoogle Scholar
  48. 48.
    Rastinehad AR, Andonian S, Smith AD, Siefel DN. Management of hemorrhagic complications associated with percutaneous nephrolithotomy. J Endourol. 2009;23(10):1763–7.PubMedCrossRefGoogle Scholar
  49. 49.
    Gupta R, Kumar A, Kapoor R, Srivastava A, Mandhani A. Prospective evaluation of safety and efficacy of the supracostal approach for percutaneous nephrolithotomy. BJU Int. 2002;90(9):809–13.PubMedCrossRefGoogle Scholar
  50. 50.
    Radecka E, Brehmer M, Holmgren K, Magnusson A. Complications associated with percutaneous nephrolithotripsy: supra- versus subcostal access. A retrospective study. Acta Radiol. 2003;44(4):447–51.PubMedGoogle Scholar
  51. 51.
    Öztürk H. Gastrointestinal system complications in percutaneous nephrolithotomy: a systematic review. J Endourol. 2014;28(11):1256–67.PubMedCrossRefGoogle Scholar
  52. 52.
    Morse RM, Spirnak JP, Resnick MI. Iatrogenic colon and rectal injuries associated with urological intervention: report of 14 patients. J Urol. 1988;140(1):101–3.PubMedCrossRefGoogle Scholar
  53. 53.
    Neustein P, Barbaric ZL, Kaufman JJ. Nephrocolic fistula: a complication of percutaneous nephrostolithotomy. J Urol. 1986;135(3):571–3.PubMedCrossRefGoogle Scholar
  54. 54.
    Vallancien G, Capdeville R, Veillon B, Charton M, Brisset JM. Colonic perforation during percutaneous nephrolithotomy. J Urol. 1985;134:1185–7.PubMedCrossRefGoogle Scholar
  55. 55.
    Desai AC, Jain S, Benway BM, Grubb RL 3rd, Picus D, Figenshau RS. Splenic injury during percutaneous nephrolithotomy: a case report with novel management technique. J Endourol. 2010;24(4):541–5.PubMedCrossRefPubMedCentralGoogle Scholar
  56. 56.
    Shah HN, Hegde SS, Mahajan AP, Sodha H, Shah R, Bansal M. Splenic injury: rare complication of percutaneous nephrolithotomy: report of two cases with review of literature. J Endourol. 2007;21:919–22.PubMedCrossRefGoogle Scholar
  57. 57.
    Seitz C, Desai M, Häcker A, Hakenberg OW, Liatsikos E, Nagele U, Tolley D. Incidence, prevention, and management of complications following percutaneous nephrolitholapaxy. Eur Urol. 2012;61(1):146–58.PubMedPubMedCentralCrossRefGoogle Scholar
  58. 58.
    Kyriazis I, Panagopoulos V, Kallidonis P, Özsoy M, Vasilas M, Liatsikos E. Complications in percutaneous nephrolithotomy. World J Urol. 2015;33(8):1069–77.PubMedCrossRefGoogle Scholar
  59. 59.
    Rao PN. Fluid absorption during urological endoscopy. Br J Urol. 1987;60(2):93–9.PubMedCrossRefGoogle Scholar
  60. 60.
    Hahn RG. Fluid absorption in endoscopic surgery. Br J Anaesth. 2006;96(1):8–20.PubMedCrossRefGoogle Scholar
  61. 61.
    Kukreja RA, Desai MR, Sabnis RB, Patel SH. Fluid absorption during percutaneous nephrolithotomy: does it matter? J Endourol. 2002;16(4):221–4.PubMedCrossRefGoogle Scholar
  62. 62.
    Guzelburc V, Balasar M, Colakogullari M, Guven S, Kandemir A, Ozturk A, et al. Comparison of absorbed irrigation fluid volumes during retrograde intrarenal surgery and percutaneous nephrolithotomy for the treatment of kidney stones larger than 2 cm. Springerplus. 2016;5(1):1707.PubMedPubMedCentralCrossRefGoogle Scholar
  63. 63.
    Draga RO, Kok ET, Sorel MR, Bosch RJ, Lock TM. Percutaneous nephrolithotomy: factors associated with fever after the first postoperative day and systemic inflammatory response syndrome. J Endourol. 2009;23(6):921–7.PubMedCrossRefGoogle Scholar
  64. 64.
    O’Keeffe NK, Mortimer AJ, Sambrook PA, Rao PN. Severe sepsis following percutaneous or endoscopic procedures for urinary tract stones. Br J Urol. 1993;72:277–83.PubMedCrossRefGoogle Scholar
  65. 65.
    Negrete-Pulido O, Gutierrez-Aceves J. Management of infectious complications in percutaneous nephrolithotomy. J Endourol. 2009;23(10):1757–62.PubMedCrossRefGoogle Scholar
  66. 66.
    Korets R, Graversen JA, Kates M, Mues AC, Gupta M. Post-percutaneous nephrolithotomy systemic inflammatory response: a prospective analysis of preoperative urine, renal pelvic urine and stone cultures. J Urol. 2011;186(5):1899–903.PubMedCrossRefGoogle Scholar
  67. 67.
    Stoller ML, Wolf JS Jr, St Lezin MA. Estimated blood loss and transfusion rates associated with percutaneous nephrolithotomy. J Urol. 1994;152(6 Pt 1):1977–81.PubMedCrossRefGoogle Scholar
  68. 68.
    Kukreja R, Desai M, Patel S, Bapat S, Desai M. Factors affecting blood loss during percutaneous nephrolithotomy: prospective study. J Endourol. 2004;18(8):715–22.CrossRefGoogle Scholar
  69. 69.
    Turna B, Nazli O, Demiryoguran S, Mammadov R, Cal C. Percutaneous nephrolithotomy: variables that influence hemorrhage. Urology. 2007;69(4):603–7.CrossRefGoogle Scholar
  70. 70.
    de la Rosette J, Assimos D, Desai M, Gutierrez J, Lingeman J, Scarpa R, et al.; CROES PCNL Study Group. The Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study: indications, complications, and outcomes in 5803 patients. J Endourol. 2011;25(1):11–7.Google Scholar
  71. 71.
    Yamaguchi A, Skolarikos A, Buchholz NP, Chomón GB, Grasso M, Saba P, et al.; CROES PCNL Study Group. Operating times and bleeding complications in percutaneous nephrolithotomy: a comparison of tract dilation methods in 5,537 patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study. J Endourol. 2011;25(6):933–9.Google Scholar
  72. 72.
    Srivastava A, Singh S, Dhayal IR, Rai P. A prospective randomized study comparing the four tract dilation methods of percutaneous nephrolithotomy. World J Urol. 2017;35(5):803–7.PubMedCrossRefGoogle Scholar
  73. 73.
    Gönen M, Istanbulluoglu OM, Cicek T, Ozturk B, Ozkardes H. Balloon dilatation versus Amplatz dilatation for nephrostomy tract dilatation. J Endourol. 2008;22:901–4.PubMedCrossRefGoogle Scholar
  74. 74.
    Amjadi M, Zolfaghari A, Elahian A, Tavoosi A. Percutaneous nephrolithotomy in patients with previous open nephrolithotomy: one-shot versus telescopic technique for tract dilatation. J Endourol. 2008;22:423–5.CrossRefGoogle Scholar
  75. 75.
    Whitehurst L, Jones P, Somani BK. Mortality from kidney stone disease (KSD) as reported in the literature over the last two decades: a systematic review. World J Urol. 2019;37(5):759–76.PubMedCrossRefGoogle Scholar

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© Springer Nature Singapore Pte Ltd. 2020

Authors and Affiliations

  1. 1.Department of Urology and NephrologyMilitary Medical AcademySofiaBulgaria

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