Complications of Percutaneous Nephrolithotomy

  • Shadi Al EkishEmail author
  • Sammy Elsamra
  • Gyan Pareek


Since the initial description of “percutaneous pyelolithotomy” by Fernstrom and Johansson in 1976, percutaneous nephrolithotomy (PCNL) has become the standard for the treatment of large renal or proximal ureteral stones [Fernström and Johansson (Scand J Urol Nephrol 10(3):257–259, 1976)]. Recently, various versions of the procedure have expanded indications to treat a variety of stone burdens and have rendered open nephrolithotomy as a historic procedure. With shorter procedure times, lower transfusion rates, lower narcotic requirements, shorter hospital stay, faster convalescence, and lower cost, PCNL can be applied to nearly any stone burden or location [Snyder and Smith (J Urol 136(2):351–354, 1986)]. Despite overall safety and effectiveness of PCNL for the therapy of renal stones [Preminger et al. (J Urol 173(6):1991–2000, 2005)], PCNL can still be associated with significant morbidity, especially when complications are monitored in a standardized fashion. One recent study cited a nearly 60 % complication rate [de la Rosette et al. (J Urol 180(6):2489–2493, 2008)]. While the majority of these complications are mild, the urologist must be ready to prevent, appropriately identify, and treat any complication that he/she could encounter during or after PCNL.

The focus of this chapter is to provide the reader with an appreciation for the complications associated with PCNL. A review of recent literature pertaining to the prevention, early identification, and proper management of issues that may arise during or after PCNL will be discussed followed by a case presentation used to highlight lessons learned during this summary.


Solitary Kidney Nephrostomy Tube Stone Burden Tubeless PCNL Perinephric Hematoma 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Fernström I, Johansson B. Percutaneous pyelolithotomy. A new extraction technique. Scand J Urol Nephrol. 1976;10(3):257–9.PubMedGoogle Scholar
  2. 2.
    Snyder JA, Smith AD. Staghorn calculi: percutaneous extraction versus anatrophic nephrolithotomy. J Urol. 1986;136(2):351–4.PubMedGoogle Scholar
  3. 3.
    Preminger GM, Assimos DG, Lingeman JE, Nakada SY, Pearle MS, Wolf JS, et al. Chapter 1: AUA guideline on management of staghorn calculi: diagnosis and treatment recommendations. J Urol. 2005;173(6):1991–2000.PubMedCrossRefGoogle Scholar
  4. 4.
    de la Rosette JJ, Zuazu JR, Tsakiris P, Elsakka AM, Zudaire JJ, Laguna MP, et al. Prognostic factors and percutaneous nephrolithotomy morbidity: a multivariate analysis of a contemporary series using the Clavien classification. J Urol. 2008;180(6):2489–93.PubMedCrossRefGoogle Scholar
  5. 5.
    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(2):205–13.PubMedCrossRefGoogle Scholar
  6. 6.
    Tefekli A, Ali Karadag M, Tepeler K, Sari E, Berberoglu Y, Baykal M, et al. Classification of percutaneous nephrolithotomy complications using the modified Clavien grading system: looking for a standard. Eur Urol. 2008;53(1):184–90.PubMedCrossRefGoogle Scholar
  7. 7.
    de la Rosette JJ, Assimos D, Desai M, Gutierrez J, Lingeman J, Scarpa R, et al. 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.PubMedCrossRefGoogle Scholar
  8. 8.
    Stanger MJ, Thompson LA, Young AJ, Lieberman HR. Anticoagulant activity of select dietary supplements. Nutr Rev. 2012;70(2):107–17.PubMedCrossRefGoogle Scholar
  9. 9.
    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
  10. 10.
    de la Rosette JJ, Laguna MP, Rassweiler JJ, Conort P. Training in percutaneous nephrolithotomy – a critical review. Eur Urol. 2008;54(5):994–1001.PubMedCrossRefGoogle Scholar
  11. 11.
    Allen D, O’Brien T, Tiptaft R, Glass J. Defining the learning curve for percutaneous nephrolithotomy. J Endourol. 2005;19(3):279–82.PubMedCrossRefGoogle Scholar
  12. 12.
    Tanriverdi O, Boylu U, Kendirci M, Kadihasanoglu M, Horasanli K, Miroglu C. The learning curve in the training of percutaneous nephrolithotomy. Eur Urol. 2007;52(1):206–11.PubMedCrossRefGoogle Scholar
  13. 13.
    Sahin A, Atsü N, Erdem E, Oner S, Bilen C, Bakkaloğlu M, et al. Percutaneous nephrolithotomy in patients aged 60 years or older. J Endourol. 2001;15(5):489–91.PubMedCrossRefGoogle Scholar
  14. 14.
    Okeke Z, Smith AD, Labate G, D’Addessi A, Venkatesh R, Assimos D, et al. Prospective comparison of outcomes of percutaneous nephrolithotomy in elderly patients versus younger patients. J Endourol. 2012;26(8):996–1001.PubMedCrossRefGoogle Scholar
  15. 15.
    Resorlu B, Diri A, Atmaca AF, Tuygun C, Oztuna D, Bozkurt OF, et al. Can we avoid percutaneous nephrolithotomy in high-risk elderly patients using the Charlson comorbidity index? Urology. 2012;79(5):1042–7.PubMedCrossRefGoogle Scholar
  16. 16.
    Carson 3rd CC, Danneberger JE, Weinerth JL. Percutaneous lithotripsy in morbid obesity. J Urol. 1988;139(2):243–5.PubMedGoogle Scholar
  17. 17.
    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
  18. 18.
    Koo BC, Burtt G, Burgess NA. Percutaneous stone surgery in the obese: outcome stratified according to body mass index. BJU Int. 2004;93(9):1296–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Bagrodia A, Gupta A, Raman JD, Bensalah K, Pearle MS, Lotan Y. Impact of body mass index on cost and clinical outcomes after percutaneous nephrostolithotomy. Urology. 2008;72(4):756–60.PubMedCrossRefGoogle Scholar
  20. 20.
    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
  21. 21.
    Bucuras V, Gopalakrishnam G, Wolf JS Jr, Sun Y, Bianchi G, Erdogru T, et al. The Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study: nephrolithotomy in 189 patients with solitary kidneys. J Endourol. 2012;26(4):336–41.PubMedCrossRefGoogle Scholar
  22. 22.
    Husmann DA, Miliner DS, Segura JW. Ureteropelvic junction obstruction with a simultaneous renal ­calculus: long-term followup. J Urol. 1995;153:1399–402.PubMedCrossRefGoogle Scholar
  23. 23.
    Tunc L, Tokgoz H, Tan MO, Kupeli B, Karaoglan U, Bozkirli I. Stones in anomalous kidneys: results of treatment by shock wave lithotripsy in 150 patients. Int J Urol. 2004;11(10):831–6.PubMedCrossRefGoogle Scholar
  24. 24.
    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
  25. 25.
    Rana AM, Bhojwani JP. Percutaneous nephrolithotomy in renal anomalies of fusion, ectopia, rotation, hypoplasia, and pelvicalyceal aberration: uniformity in heterogeneity. J Endourol. 2009;23(4):609–14.Google Scholar
  26. 26.
    Gupta NP, Mishra S, Seth A, Anand A. Percutaneous nephrolithotomy in abnormal kidneys: single-center experience. Urology. 2009;73(4):710–4.PubMedCrossRefGoogle Scholar
  27. 27.
    Krambeck AE, Leroy AJ, Patterson DE, Gettman MT. Percutaneous nephrolithotomy success in the transplant kidney. J Urol. 2008;180(6):2545–9.PubMedCrossRefGoogle Scholar
  28. 28.
    Basiri A, Karrami H, Moghaddam SM, Shadpour P. Percutaneous nephrolithotomy in patients with or without a history of open nephrolithotomy. J Endourol. 2003;17(4):213–6.PubMedCrossRefGoogle Scholar
  29. 29.
    Sofikerim M, Demirci D, Gülmez I, Karacagil M. Does previous open nephrolithotomy affect the outcome of percutaneous nephrolithotomy? J Endourol. 2007;21(4):401–3.PubMedCrossRefGoogle Scholar
  30. 30.
    Yuruk E, Tefekli A, Sari E, Karadag MA, Tepeler A, Binbay M, et al. Does previous extracorporeal shock wave lithotripsy affect the performance and outcome of percutaneous nephrolithotomy? J Urol. 2009;182(5):2534–5.CrossRefGoogle Scholar
  31. 31.
    Xue W, Pacik D, Boellaard W, Breda A, Botoca M, Rassweiler J, et al. Management of single large nonstaghorn renal stones in the CROES PCNL global study. J Urol. 2012;187(4):1293–7.PubMedCrossRefGoogle Scholar
  32. 32.
    Desai M, De Lisa A, Turna B, Rioja J, Walfridsson H, D’Addessi A, et al. The clinical research office of the endourological society percutaneous nephrolithotomy global study: staghorn versus nonstaghorn stones. J Endourol. 2011;25(8):1263–8.PubMedCrossRefGoogle Scholar
  33. 33.
    Singla M, Srivastava A, Kapoor R, Gupta N, Ansari MS, Dubey D, et al. Aggressive approach to staghorn calculi-safety and efficacy of multiple tracts percutaneous nephrolithotomy. Urology. 2008;71(6):1039–42.PubMedCrossRefGoogle Scholar
  34. 34.
    Duty B, Okhunov Z, Smith A, Okeke Z. The debate over percutaneous nephrolithotomy positioning: a comprehensive review. J Urol. 2011;186(1):20–5.PubMedCrossRefGoogle Scholar
  35. 35.
    Tomaszewski JJ, Ortiz TD, Gayed BA, Smaldone MC, Jackman SV, Averch TD. Renal access by urologist or radiologist during percutaneous nephrolithotomy. J Endourol. 2010;24(11):1733–7.PubMedCrossRefGoogle Scholar
  36. 36.
    Wang KJ, Jiang LH, Wang L, Li H. 356 Urologist versus radiologist for percutaneous nephrolithotomy access under fluoroscopic guidance: a systematic review. Eur Urol. 2010;9(2):135.Google Scholar
  37. 37.
    Watterson JD, Soon S, Jana K. Access related complications during percutaneous nephrolithotomy: urology versus radiology at a single academic institution. J Urol. 2006;176(1):142–5.PubMedCrossRefGoogle Scholar
  38. 38.
    Safak M, Gögüş C, Soygür T. Nephrostomy tract dilation using a balloon dilator in percutaneous renal surgery: experience with 95 cases and comparison with the fascial dilator system. Urol Int. 2003;71(4):382–4.PubMedCrossRefGoogle Scholar
  39. 39.
    Davidoff R, Bellman GC. Influence of technique of percutaneous tract creation on incidence of renal hemorrhage. J Urol. 1997;157(4):1229–31.PubMedCrossRefGoogle Scholar
  40. 40.
    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
  41. 41.
    Benway BM, Nakada SY. Balloon dilation of nephrostomy tracts. J Endourol. 2008;22(9):1875–6.Google Scholar
  42. 42.
    Yamaguchi A, Skolarikos A, Buchholz NP, Chomón GB, Grasso M, Saba P, et al. Operating times and bleeding complications in percutaneous nephrolithotomy: a comparison of tract dilation methodsin 5537 patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study. J Endourol. 2011;25(6):933–9.PubMedCrossRefGoogle Scholar
  43. 43.
    Berrington de González A, Mahesh M, Kim KP, Bhargavan M, Lewis R, Mettler F, et al. Projected cancer risks from computed tomographic scans performed in the United States in 2007. Arch Intern Med. 2009;169(22):2071–7.Google Scholar
  44. 44.
    Berrington de González A, Mahesh M, Kim KP, Bhargavan M, Lewis R, et al. Factors affecting patient radiation exposure during percutaneous nephrolithotomy. J Urol. 2010;184(6):2373–7.PubMedCrossRefGoogle Scholar
  45. 45.
    Amer T, Ahmed K, Bultitude M. Standard versus tubeless percutaneous nephrolithotomy: a systematic review. Urol Int. 2012;88(4):373–82.PubMedCrossRefGoogle Scholar
  46. 46.
    Bellman C, Davidoff R, Candela J, Gerspach J, Kurtz S, Stout L. Tubeless percutaneous renal surgery. J Urol. 1997;157(5):1578–82.PubMedCrossRefGoogle Scholar
  47. 47.
    Stoller ML, Wolf Jr JS, St Lezin MA. Estimated blood loss and transfusion rates associated with ­percutaneous nephrolithotomy. J Urol. 1994;152(6 Pt 1):1977–81.PubMedGoogle Scholar
  48. 48.
    Duvdevani M, Razvi H, Sofer M, Beiko DT, Nott L, Chew BH, et al. Third prize: contemporary percutaneous nephrolithotripsy: 1585 procedures in 1338 consecutive patients. J Endourol. 2007;21(8):824–9.PubMedCrossRefGoogle Scholar
  49. 49.
    Sampaio FJB. Surgical anatomy of the kidney. In: Smith AD, Badlani GH, Kavoussi LR, editors. Smith’s textbook of endourology. St Louis: Quality Medical Publishing; 1996. p. 153–84.Google Scholar
  50. 50.
    Martin X, Murat FJ, Feitosa LC, Rouvière O, Lyonnet D, Gelet A, et al. Severe bleeding after nephrolithotomy: results of hyperselective embolization. Eur Urol. 2000;37(2):136–9.PubMedCrossRefGoogle Scholar
  51. 51.
    Lam HS, Lingeman JE, Mosbaugh PG, Steele RE, Knapp PM, Scott JW, et al. Evolution of the technique of combination therapy for staghorn calculi: a decreasing role for extracorporeal shock wave lithotripsy. J Urol. 1992;148(3 Pt 2):1058–62.PubMedGoogle Scholar
  52. 52.
    Dore B, Conort P, Irani J, Amiel J, Ferriere JM, Glemain P, et al. Percutaneous nephrolithotomy (PCNL) in subjects over the age of 70: a multicentre retrospective study of 210 cases. Prog Urol. 2004;14:1140–5.PubMedGoogle Scholar
  53. 53.
    Turna B, Nazli O, Demiryoguran S, Mammadov R, Cal C. Percutaneous nephrolithotomy: variables that influence hemorrhage. Urology. 2007;69(4):603–7.PubMedCrossRefGoogle Scholar
  54. 54.
    El-Nahas AR, Shokeir AA, El-Assmy AM, Mohsen T, Shoma AM, Eraky I, et al. Postpercutaneous nephrolithotomy extensive hemorrhage: a study of risk ­factors. J Urol. 2007;177(2):576–9.PubMedCrossRefGoogle Scholar
  55. 55.
    Kerbl K, Picus DD, Clayman RV. Clinical experience with the Kaye nephrostomy tamponade catheter. Eur Urol. 1994;25(2):94–8.PubMedGoogle Scholar
  56. 56.
    Munver R, Delvecchio FC, Newman GE, Preminger GM. Critical analysis of supracostal access for percutaneous renal surgery. J Urol. 2001;166(4):1242–6.PubMedCrossRefGoogle Scholar
  57. 57.
    Lojanapiwat B, Prasopsuk S. Upper-pole access for percutaneous nephrolithotomy: comparison of supracostal and infracostal approaches. J Endourol. 2006;20(7):491–4.PubMedCrossRefGoogle Scholar
  58. 58.
    Hopper KD, Sherman JI, Williams MD, Ghaed N. The variable anteroposterior position of the retropertoneal colon to the kidneys. Invest Radiol. 1987;22(4):298–302.PubMedCrossRefGoogle Scholar
  59. 59.
    Hadar H, Gadoth N. Positional relations of colon and kidney determined by perirenal fat. AJR Am J Roentgenol. 1984;143(4):773–6.PubMedCrossRefGoogle Scholar
  60. 60.
    Neustein P, Barbaric ZL, Kaufman JJ. Nephrocolic fistula: a complication of percutaneous nephrostolithotomy. J Urol. 1986;135(3):571–3.PubMedGoogle Scholar
  61. 61.
    Appel R, Musmanno MC, Knight JG. Nephrocolic fistula complicating percutaneous nephrostolithotomy. J Urol. 1988;140(5):1007–8.PubMedGoogle Scholar
  62. 62.
    Culkin DJ, Wheeler Jr JS, Canning JR. Nephro-duodenal fistula: a complication of percutaneous nephrolithotomy. J Urol. 1985;134(3):528–30.PubMedGoogle Scholar
  63. 63.
    Kumar A, Banerjee GK, Tewari A, Srivastava A. Isolated duodenal injury during relook percutaneous nephrolithotomy. Br J Urol. 1994;74(3):382–3.PubMedCrossRefGoogle Scholar
  64. 64.
    Hopper KD, Yakes WF. The posterior intercostal approach for percutaneous renal procedures: risk of puncturing the lung, spleen, and liver as determined by CT. AJR Am J Roentgenol. 1990;154(1):115–7.PubMedCrossRefGoogle Scholar
  65. 65.
    Kondás J, Szentgyörgyi E, Váczi L, Kiss A. Splenic injury: a rare complication of percutaneous nephrolithotomy. Int Urol Nephrol. 1994;(4)26:399–404.Google Scholar
  66. 66.
    Thomas AA, Pierce G, Walsh RM, Sands M, Noble M. Splenic injury during percutaneous nephrolithotomy. JSLS. 2009;13(2):233–6.PubMedGoogle Scholar
  67. 67.
    Kontothanassis D, Bissas A. Biliary peritonitis complicating percutaneous nephrostomy. Int Urol Nephrol. 1997;29(5):529–31.PubMedCrossRefGoogle Scholar
  68. 68.
    Saxby MF. Biliary peritonitis following percutaneous nephrolithotomy. Br J Urol. 1996;77(3):465–6.PubMedCrossRefGoogle Scholar
  69. 69.
    Fisher MB, Bianco Jr F, Carlin AM, Triest JA. Biliary peritonitis complicating percutaneous nephrolithomy requiring laparoscopic cholecystectomy. J Urol. 2004;171(2 Pt 1):791–2.PubMedCrossRefGoogle Scholar
  70. 70.
    Roberts S, Bolton DM, Stoller ML. Hypothermia associated with percutaneous nephrolithotomy. Urology. 1994;44(6):832–5.PubMedCrossRefGoogle Scholar
  71. 71.
    Lee WJ, Smith AD, Cubelli V, Badlani GH, Lewin B, Vernace F, et al. Complications of percutaneous nephrolithotomy. AJR Am J Roentgenol. 1987;148(1):177–80.PubMedCrossRefGoogle Scholar
  72. 72.
    Lingeman JE, Coury TA, Newman DM, Kahnoski RJ, Mertz JH, Mosbaugh PG, et al. Comparison of results and morbidity of percutaneous nephrostolithotomy and extracorporeal shock wave lithotripsy. J Urol. 1987;138(3):485–90.PubMedGoogle Scholar
  73. 73.
    Cadeddu JA, Arrindell D, Moore RG. Near fatal air embolism during percutaneous nephrostomy placement. J Urol. 1997;158(4):1519.PubMedCrossRefGoogle Scholar
  74. 74.
    Segura JW, Patterson DE, LeRoy AJ, Williams HJ Jr, Barrett DM, Benson RC Jr, et al. Percutaneous removal of kidney stones: review of 1,000 cases. J Urol. 1985;134(6):1077–81.PubMedGoogle Scholar
  75. 75.
    Lang EK. Percutaneous nephrostolithotomy and lithotripsy: a multi-institutional survey of complications. Radiology. 1987;162(1 Pt 1):25–30.PubMedGoogle Scholar
  76. 76.
    Cadeddu JA, Chen R, Bishoff J, Micali S, Kumar A, Moore RG, et al. Clinical significance of fever after percutaneous nephrolithotomy. Urology. 1998;52(1):48–50.PubMedCrossRefGoogle Scholar
  77. 77.
    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
  78. 78.
    Bag S, Kumar S, Taneja N, Sharma V, Mandal AK, Singh SK. One week of nitrofurantoin before percutaneous nephrolithotomy significantly reduces upper tract infection and urosepsis: a prospective controlled study. Urology. 2011;77(1):45–9.PubMedCrossRefGoogle Scholar
  79. 79.
    Mariappan P, Smith G, Moussa SA, Tolley DA. One week of ciprofloxacin before percutaneous nephrolithotomy significantly reduces upper tract infection and urosepsis: a prospective controlled study. BJU Int. 2006;98(5):1075–9.PubMedCrossRefGoogle Scholar
  80. 80.
    Gutierrez J, Smith A, Geavlete P, Shah H, Kural AR, de Sio M, et al. Urinary tract infections and post-operative fever in percutaneous nephrolithotomy. World J Urol. 2012. [Epub ahead of print].Google Scholar
  81. 81.
    Srivastava A, Singh KJ, Suri A. Vascular complications after percutaneous nephrolithotomy: are there any predictive factors? Urology. 2005;66(1):38–40.PubMedCrossRefGoogle Scholar
  82. 82.
    Patterson DE, Segura JW, LeRoy AJ, Benson RC Jr, May G. The ­etiology and treatment of delayed bleeding following percutaneous lithotripsy. J Urol. 1985;133(3):447–51.PubMedGoogle Scholar
  83. 83.
    Sacha K, Szewczyk W, Bar K. Massive haemorrhage presenting as a complication after percutaneous nephrolithotomy. Int Urol Nephrol. 1996;28(3):315–8.PubMedCrossRefGoogle Scholar
  84. 84.
    Roth RA, Beckmann CF. Complications of extracorporeal shock-wave lithotripsy and percutaneous nephrolithotomy. Urol Clin North Am. 1988;15(2):155–66.PubMedGoogle Scholar
  85. 85.
    Parsons JK, Jarrett TW, Lancini V, Kavoussi LR. Infundibular stenosis after percutaneous nephrolithotomy. J Urol. 2002;167(1):35–8.PubMedCrossRefGoogle Scholar
  86. 86.
    Chichakli R, Krause R, Voelzke B, Turk T. Incidence of perinephric hematoma after percutaneous nephrolithotomy. J Endourol. 2008;22(6):1227–32.PubMedCrossRefGoogle Scholar

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© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Department of UrologyRhode Island & The Miriam HospitalProvidenceUSA
  2. 2.Division of UrologyThe Warren Alpert Medical School of Brown UniversityProvidenceUSA

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