Complications in Percutaneous Nephrolithotomy

Department of Urology, Medical School Mannheim, University of Heidelberg, Germany.
European Urology (Impact Factor: 13.94). 05/2007; 51(4):899-906; discussion 906. DOI: 10.1016/j.eururo.2006.10.020
Source: PubMed


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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    • "It is a minimally invasive procedure through which the access to the pelvicalyceal system (PCS) is achieved by the puncture and dilatation of the tract under fluoroscopic guidance. This step is an important one that can significantly affect the outcome of the procedure (Osman et al. 2005; Michel et al. 2007). However one of its major disadvantages is the risk of exposing the operators and patients to radiation. "
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    ABSTRACT: To assess the safety and effectiveness of pure ultrasound-guided percutaneous nephrolithotomy. Three hundred fifty-seven patients were treated; 139 women and 218 men, with a mean age of 33.7 years (range 21-69 years) and a mean stone size of 33.5 mm in maximum diameter (range 20-52 mm). Stone locations were renal pelvis (174), lower calyx (68) or both (115) with mild to moderate hydronephrosis seen on excretory urography. A ureteral stent was inserted by cystoscope, and saline was injected for better localization of the pelvicaliceal system (PCS), if needed. Puncture of the PCS was done by an 18-gauge nephrostomy needle through the lower pole calyx, and all the steps, including dilatation, were done under the guidance of ultrasonography. The day after the operation, 318 (89.07%) patients were stone-free in the kidneys, ureters, and bladder x-rays. Nineteen patients (5.3%) had multiple fragments that measured equal or less than 5 mm and passed them spontaneously in 2-4 weeks (total stone-free rate 94.4%). Access failure occurred in ten obese patients (2.8%) and fluoroscopy was required. Residual fragments with sizes of 10-12 mm were seen in seven patients, all of who underwent shock wave lithotripsy. In one patient, a fragment measuring 7-8 mm migrated into the distal part of the ureter. It was fragmented with ureteroscopy and pneumatic lithoclast 2 days after the operation. In two patients who had large (>15 mm) residual stone redo percutaneous nephrolithotomy was performed 48 h after the first procedure. Percutaneous nephrolithotomy guided by ultrasonography seems to be as effective as fluoroscopy in selected cases and poses no risk of surgeon and patient exposure to radiation; however, more experience is required.
    SpringerPlus 07/2015; 4(1):313. DOI:10.1186/s40064-015-1078-4
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    • "Another common complication is hemorrhage. The overall transfusion rate in this study was 1.6%, which was less than reported in many other studies [17] [18] [19]. "
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    ABSTRACT: Objective: The aim of this study was to evaluate the outcome and determine the complications of ultrasound-guided 16 F tract percutaneous nephrolithotomy (PCNL) by review of over 1000 cases in a Chinese hospital. Material and methods: A total of 1368 patients underwent 16 F tract PCNL in the hospital between March 2007 and July 2013. Surgery was performed under general anesthesia in all cases. Central venous puncture was chosen as a puncture device. Complications, residual stones, stone clearance and the need for auxiliary treatments were evaluated. Management experience was evaluated with respect to the complications. Results: Complications occurred in 275 out of 1368 patients (20.1%). There were 102 Clavien grade 1 (7.4%), 121 grade 2 (8.8%) and 48 grade 3 (3.5%) complications, but no grade 4 or 5 complications. Access to the kidney was established in 99.7% of cases and 82.0% of cases had complete stone clearance without undergoing further PCNL. Auxiliary treatments included shockwave lithotripsy in 135 patients, second-phase PCNL in 49 patients and ureteroscopy in 63 patients. Three cases of rare complications occurred, including a double-J stent translocated to the chest, and intraoperative acute pulmonary edema and heart failure. Severe intraoperative or postoperative complications should be managed immediately. Conclusion: An ultrasound-guided mini-tract PCNL is safe and convenient, even for patients with complicated stones.
    Scandinavian Journal of Urology 09/2014; 49(2). DOI:10.3109/21681805.2014.961545 · 1.25 Impact Factor
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    • "Regarding the complications of PNL, it may be classified into either access related or stone retrieval related. Of these, hemorrhagic complication that requires blood transfusion is the most important (range from 0% to 23%) [12] [13] [14]. In the present study, only five patients had minimal bleeding (11.4%) that was managed conservatively without need for blood transfusion. "
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    ABSTRACT: Objectives The aim of the present study is to evaluate the feasibility and safety of performing PNL under local anesthesia in a selected group of patients who are at high risk for general anesthesia. Patients and methods Forty seven patients underwent PNL under local anesthesia. There were 38 males and 9 females with a mean age of 62 years. All patients were at medical high-risk for general anesthesia, with an American Society of Anesthesiologists (ASA) score of 3. The indications for local anesthesia in this study were obstructed single functioning kidney with azotemia in 29 patients, hepatic insufficiency in 8 patients, cardiac problems in 7 patients and 3 patients had hepatocellular carcinoma. The mean stone size was 2.7 cm (range 2–3.1 cm). Local infiltration with 10–20 cc of 2% lidocaine at the site of puncture was used in all cases. Narcotics were given 30 min prior to the procedure and medazolam was given intraoperatively upon demand. Utrasound guided puncture was performed in all cases and tract dilatation was then done under fluoroscopy using high pressure balloon catheter in 35 and Alken's metal dilators in 12 cases. Stones were then retrieved after disintegration in the same cession in 33 patients, while the other 14 patients underwent staged PNL, where a 12 Fr. nephrostomy tube was placed in the first stage, followed by tract dilatation and stone retrieval one week later. Results Out of 47 patients included, 44 had successful PNL either one stage (30 patients) or two stages (14 patients). Only 3 patients could not tolerate pain and the procedure was terminated after placement of nephrostomy tube and stone retrieval was completed later under general anesthesia. Conclusion Our results demonstrated that PNL under local anesthesia with narcotics and sedatives seems to be a satisfying solution for the treatment of a selected group of patients with renal pelvic stones and who have high anesthetic risk. However, additional studies with different groups of patients are required to validate our results.
    African Journal of Urology 12/2013; 19(4):184–187. DOI:10.1016/j.afju.2013.05.003
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