Complications of Percutaneous Nephrolithotomy

Abstract

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.

Appendices

Appendix 1: Prevention, Identification, and Treatment of Complications of PCNL

	Preventative measures	Identification	Treatment
Intraoperative complications
Bleeding	Solitary kidney, supracostal access, multiple access at high risk; unideal access at high risk as it may predispose to excessive torqueing	Poor visualization	Tamponade with renal access sheath, if red-out place Kaye tamponade reentry balloon or other large caliber Foley
Collecting system perforation	Avoid excessive pressure with ultrasonic or pneumatic lithotripsy device, ensure there is appropriate visualization and appreciation for anatomy during use of lithotripsy device	Direct visualization of injury or intraoperative antegrade nephrostogram revealing extravasation	Appropriate prolonged decompression of renal pelvis with indwelling JJ ureteral stent vs. PCNU
Colonic injury	Preoperative imaging with CT; prone position may decrease risk for bowel perforation	Stool or gas per PCN, opacification of colon during antegrade nephrostogram	Abort procedure, do not dilate tract (if not already done) withdrawal of PCN to colonic lumen
Liver or splenic injury	Preoperative imaging with CT if hepatomegaly or splenomegaly suspected	Excessive blood loss, hemodynamic instability, and severe abdominal pain	Intravenous fluid support and blood transfusion
	Laparoscopic access to the collecting system		Conservative vs. exploration
Postoperative complications
Fever	Appropriate pain control and activity postoperatively, incentive spirometry	Routine vital check	Obtain cultures and chest X-ray if indicated, encourage incentive spirometry and ambulation, abx as indicated
Urosepsis	Ensure patient has negative or appropriately treated preoperative urine culture, consider prophylaxis with cipro or nitrofurantoin for 1 week prior to surgery	Consider sending urine and stone culture when patient has large stone or history of recurrent infections	Culture-based antibiotics, ICU setting if patient condition requires
Bleeding	Leaving a large-bore nephrostomy tube may not improve bleeding	Persistent drainage of bloody urine from nephrostomy tube, monitor hgb/hct	Transfuse as indicated, consider ongoing drainage, if persistent anemia consider angiography with or without concurrent access tract dilation to identify if bleeding is venous or arterial
Pulmonary
Pleural effusion	Avoid supracostal access.	Intraoperative fluoroscopy of costophrenic angle post lithotomy, CXR for any pulmonary symptoms (SOB, desaturation, etc.)	Conservative if small and asymptomatic
	Chest intraoperative fluoroscopy		Thoracostomy tube if large and symptomatic
Nephro-pleural fistula	Avoid supracostal access	Persistent drainage from the thoracostomy tube placed for hydrothorax	Thoracostomy tube and ureteral stent
		Nephrostogram
		Retrograde pyelogram
Persistent drainage from percutaneous site	Nephrostogram before removing the nephrostomy tube to make sure that there is no distal ureteral obstruction due to stone fragments or blood clots	Prolonged urinary leakage from the nephrostomy tube site	Ureteral stent and antibiotics

Appendix 2: Percutaneous Nephrilithotomy Complications Rate in Different Major Studies

	de la Rosette [7]	Duvdevani et al. [48]	Tefekli et al. [6]
Number of procedures	5,803	1,585	811
No complications	85.50 %	88.50 %	71.00 %
Fever (temp.  >  38.5)	10.50 %	Unknown	2.80 %
Urosepsis	Unknown	1.30 %	0.30 %
Significant bleeding	7.80 %	6.00 %	Unknown
Requiring transfusion	5.70 %	0.80 %	10.90 %
Renal pelvis perforation	3.40 %	1.80 %	1.10 %
Hydrothorax	1.80 %	1.00 %
Failure to complete procedure	1.70 %	Unknown	0.20 %
Pyelocutaneous fistula	Unknown	0.13 %	Unknown
Colonic perforation	Unknown	0.06 %	0.3 % (neighboring organ injury)
Bladder rupture	Unknown	0.06 %	Unknown