Complications in percutaneous nephrolithotomy

Department of Urology, Medical School Mannheim, University of Heidelberg, Germany.
European Urology (Impact Factor: 12.48). 05/2007; 51(4):899-906; discussion 906. DOI: 10.1016/j.eururo.2006.10.020
Source: PubMed

ABSTRACT This review focuses on a step-by-step approach to percutaneous nephrolithotomy (PNL) and its complications and management.
Based on institutional and personal experience with >1000 patients treated by PNL, we reviewed the literature (Pubmed search) focusing on technique, type, and incidence of complications of the procedure.
Complications during or after PNL may be present with an overall complication rate of up to 83%, including extravasation (7.2%), transfusion (11.2-17.5%), and fever (21.0-32.1%), whereas major complications, such as septicaemia (0.3-4.7%) and colonic (0.2-0.8%) or pleural injury (0.0-3.1%) are rare. Comorbidity (i.e., renal insufficiency, diabetes, gross obesity, pulmonary disease) increases the risk of complications. Most complications (i.e., bleeding, extravasation, fever) can be managed conservatively or minimally invasively (i.e., pleural drain, superselective renal embolisation) if recognised early.
The most important consideration for achieving consistently successful outcomes in PNL with minimal major complications is the correct selection of patients. A well-standardised technique and postoperative follow-up are mandatory for early detection of complications.

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    ABSTRACT: An increase in percutaneous nephrolithotomy (PCNL) has been accompanied by an increase in complications. We identified the parameters affecting the severity of complications using the modified Clavien classification (MCC). From 2008 to 2013, 330 patients underwent complete supine PCNL using subcostal access, one-shot dilation, rigid nephroscopy, and pneumatic lithotripsy. We assessed the impact of the following factors on complication severity based on the MCC: age, gender, body mass index, hypertension, diabetes, previous stone surgery and extracorporeal shock wave lithotripsy, preoperative hemoglobin, renal dysfunction (creatinine >1.4 mg/dL), preoperative urinary tract infection, anatomic upper urinary tract abnormality (AUUTA), significant (moderate-severe) hydronephrosis, stone-related parameters (opacity, number, burden, location, staghorn, complex stones), anesthesia type, kidney side, imaging and calyx for access, tract number, tubeless approach, operative time, postoperative hemoglobin, and hemoglobin drop and stone-free results. The complication rate was 19.7% (MCC: 0=80.3%, I=6.4%, II=11.2%, ≥III=2.1%). On univariate analyses, only the following factors affected MCC: gender, preoperative hemoglobin, AUUTA, significant hydronephrosis, imaging for access, calyx for access, tract number, postoperative hemoglobin, hemoglobin drop and stone-free result. Renal dysfunction was accompanied by higher complications, yet the results were not statistically significant. Multivariate logistic regression analysis demonstrated renal dysfunction, absence of significant hydronephrosis, AUUTA, multiple tracts, lower postoperative hemoglobin, and higher postoperative hemoglobin drop as the significant parameters which affected MCC and predicted higher grades. The paper's limitations include a low number of cases in the higher Clavien grades and some subgroups of variables, and not applying some techniques due to surgeon preference. Many of the complete supine PCNL complications were in the lower Clavien grades and major complications were uncommon. Renal dysfunction, AUUTA, significant hydronephrosis, tract number, postoperative hemoglobin, and hemoglobin drop were the only factors affecting MCC.
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    ABSTRACT: Percutaneous nephrolithotomy (PCNL) is a standard, safe, and efficient method for removing large renal calculi. Despite development of endourologic equipment, complications of the PCNL are still prevalent. Even though therapeutic modalities such as mini-micro PCNL have been developed in recent years, the complications are a serious concern yet. The most important complication is hemorrhage. The hemorrhage may be either arterial or venous. Venous hemorrhage is usually treated conservatively whereas the arterial one might require transarterial embolization (TAE). Arterial hemorrhage may cause serious problems, especially in the patients with solitary kidney. In the presented patient, serious retroperitoneal hemorrhage and hypotension in the preoperative and postoperative periods resulted in acute renal failure (ARF). It was first report of selective TAE in a patient with ARF due to post-PCNL pseudoaneurysm in solitary kidney. Super-selective segmental embolization was performed successfully in this case and was shown to be a reliable and efficient procedure.

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