Delayed Haematuria after Percutaneous Nephrolithotripsy and its Management

Abstract

Objective: To evaluate the risk factors and management of patients developed delayed haematuria after Percutaneous nephrolithotripsy (PCNL).
Methods: Data taken from 75 patients, who underwent PCNL procedures between January 2013 to June 2017. Among them 53 were male, 22 were female. Five patients presented with delayed haematuria. They were hospitalized and initially managed conservatively by bed rest and conservative treatment. Diagnostic imaging with ultrasound and non-contrast abdominal CT and serial follow up with blood tests were carried on. Angiography was performed, if indicated, to evaluate and treat possible vascular injury. All affected patients had risk factors for haematuria. Out of five, four patient had angiography, in two patients it confirm vascular injury and treated accordingly, while two were normal and one refuse for angiography.
Conclusion: Delayed hematuria is one of rare and serious outcome of PCNL, but can be safely managed without serious consequences. Mostly it is secondary to vascular complication e.g., pseudo aneurysms. Presence of risk factors increases chance of haematuria. Conservative treatment is effective. In responders angiography; and embolization can be done, whenever indicated.

Full text

Delayed Haematuria after Percutaneous Nephrolithotripsy and its
Management
Naresh Kumar Valecha1*, Fariborz Bagheri2, Salam Al Hassani3, Abdulmunem Al Sadi4, Rafe souliman5
1Specialist Urologist, Dubai hospital, Albaraha, Opposite Abuhail post office, Dubai
2Consultant and head of department urology, Dubai hospital, Dubai
3Consultant department of urology, Dubai hospital, Dubai
4Senior specialist urology, Dubai hospital, Dubai
5Specialist urology, Dubai hospital, Dubai
*Corresponding author: Naresh Kumar Valecha, Specialist Urologist, Dubai hospital, Albaraha, Opposite Abuhail post office, Dubai, Tel: 923332081001; E-mail:
drnaresh_valecha@yahoo.co.in
Received date: July 01, 2017; Accepted date: August 21, 2017; Published date: August 29, 2017
Copyright: © 2017 Valecha NK, et al. This is an open-access article distributed under the terms of the creative commons attribution license, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.
Abstract
Objective: To evaluate the risk factors and management of patients developed delayed haematuria after
Percutaneous nephrolithotripsy (PCNL).
Methods: Data taken from 75 patients, who underwent PCNL procedures between January 2013 to June 2017.
Among them 53 were male, 22 were female. Five patients presented with delayed haematuria. They were
hospitalized and initially managed conservatively by bed rest and conservative treatment. Diagnostic imaging with
ultrasound and non-contrast abdominal CT and serial follow up with blood tests were carried on. Angiography was
performed, if indicated, to evaluate and treat possible vascular injury. All affected patients had risk factors for
haematuria. Out of five, four patient had angiography, in two patients it confirm vascular injury and treated
accordingly, while two were normal and one refuse for angiography.
Conclusion: Delayed hematuria is one of rare and serious outcome of PCNL, but can be safely managed without
serious consequences. Mostly it is secondary to vascular complication e.g., pseudo aneurysms. Presence of risk
factors increases chance of haematuria. Conservative treatment is effective. In responders angiography; and
embolization can be done, whenever indicated.
Keywords: Delayed haematuria; Percutaneous nehrolithotripsy;
Pseudo aneurysm; vascular injury
Introduction
As the appraisal of open stone surgery began to reach its peak,
advancement continued in the development of less invasive techniques
for accessing renal stones. While the rst PCN was performed by
omas Hillier in 1865, Willard Goodwin in 1955 published his work
on PCN for hydronephrosis, that it gained acceptance. More than 20
years later [1-3] this example led to the recognition that the same
access could also be used as a working channel, resulting in the
percutaneous removal of a kidney stone. Over the past 30 years, PCNL
has largely replaced open renal surgery for the management of large
kidney stone [4].
It has since evolved and been rened with the development of
purposely designed instruments, endoscopes and accessories, and has
remained a standard treatment for dierent varieties of renal stones
since the eighties [5]. Compared to open renal surgery, PCNL is
associated with shorter hospital stays and allows the patient an earlier
return to work and activities of daily living. Furthermore, as PCNL is
both less invasive and less expensive to perform than open procedures,
it has become the treatment method of choice for large renal calculi
[6]. Acute hemorrhage is the most common signicant complication of
percutaneous access into the upper urinary tract collecting system.
PCN alone results in haemorrhage requiring transfusion in 0.5% to 4%
of procedures [7-9] With the addition of percutaneous
nephrolithotripsy, likely owing to the larger caliber of the percutaneous
tract and increased intrarenal manipulation, the incidence of
hemorrhage to the point of transfusion rises to 6% to 20% [10-14].
Postoperative haemorrhage can occur with the nephrostomy tube in
place, at time of tube removal, or aer discharge from the hospital.
About 1% of patients having percutaneous renal surgery are
complicated by delayed haemorrhage requiring treatment [15-17]
Delayed haemorrhage is usually due to vascular complication, e.g.:
arteriovenous stulas or arterial pseudo aneurysms,with the latter
being more common. Arterial pseudoaneurysm arises from a
transected or punctured artery that leaks in to a contained Hematoma
cavity.
is complication is likely to happen because of an artery transected
partially or end on during percutaneous nephrolithotomy puncture,
which could subsequently bleed in to contained space. is transected
arterial branch may be either partially thrombosed or in spasm
initially, leading to its non-recognition in the operating room ,as the
patient increases his /her activity ,the occluding clot may possible get
dislodged, accounting for the delayed occurrence of haematuria [18].
Valecha et al., Med Sur Urol 2017, 6:3
DOI: 10.4172/2168-9857.1000189
Research Article Open Access
Med Sur Urol, an open access journal
ISSN:2168-9857
Volume 6 • Issue 3 • 1000189
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ISSN: 2168-9857
Medical & Surgical Urology

Methods
Data from 75 patients, who underwent PCNL procedures between
January 2013 to June 2017 and developed delayed hematuria, were
retrospectively reviewed and included in our study. Selection criteria
for PCNL was stone size ≥ 2 cm in adult patients. Children, patients
with active infection and bleeding disorders were not included in
study.
Preoperative patient evaluation included history, clinical
examination, serum creatinine level, complete blood count,
coagulation prole. All patients who have urinary tract infections were
treated according to their culture sensitivity. Patients who were taking
aspirin or other anticoagulants were stopped a week before.
All patients were evaluated with contrast enhances computed
tomography (CT) before the procedure. All procedures were
performed in prone position aer insertion of ureteric catheter.
Percutaneous renal access was established under C-arm uoroscopic
guidance through the poster lateral plane of the kidney by Urologist.
Dilatation of tract was performed by serial Aalken dilators
technique. Stones were removed following fragmentation with an
ultrasonic lithotripter and a nephrostomy tube was placed at the end of
the procedure. Aer 48 hours antegrade pyelography was done and
nephrostomy tube removed aer conrming patency and absence of
signicant residual stone.
e patients were discharged next day of nephrostomy removal, if
there were no complications.
Overall, a total of ve patients presented and were admitted in our
department with delayed intermittent haematuria following PCNL
procedures. Initially, patients were managed conservatively by bed rest,
bladder clots removal and irrigation, IV Fluid, antibiotics with
diagnostic imaging ultrasound and non-contrast abdomen CT and
serial follow up with blood tests.
Angiography was performed in selected cases to evaluate and treat
possible AV malformation. All patients characteristics, including age,
sex, stone size, operation time, number of renal accesses, access site
(subcostal or supracostal), calyx punctures, and number of blood
transfusions were recorded.
See Table 1 for patient demographic (Figures 1 and 2).
Figure 1: Sex distribution.
Figure 2: patients with delayed haematuria.
Results
Among all, 53 were male and 22 were female. Five patients (6.6%),
out of 75 patients, had delayed haematuria, and only in two patients
(2.66%) vascular injury was conrmed. All ve patients were male and
one patient had malrotated kidney. All patients, who developed this
complication, had comorbidities. Mean age of patient was 47.8 years.
Average stone size in longest diameter was 2.95(2-5 cm). Out of ve
patients; four were known hypertensive, controlled by medicines.
Average time for onset of hematuria was 13.2 days.
Four patients, those who have angiography, in two patients it was
unremarkable and in one patient it showed pseudo aneurysm,
therefore super selective angio embolization was done. He did well
initially, hematuria was settled but aer two days, gradually it started
again. It leads to clots formation in renal pelvis followed by renal
impairment. His other kidney was also relatively small, therefore we
did ureteroscopic clots removal and stenting, but unfortunately he
developed big renal hematoma and severe sepsis that necessitated
nephrectomy as life saving measure. Another patient, angiography
conrm vascular injury and leak, it was treated by balloon angioplasty.
Another patient that has extensive urolithiasis with CKD and
Hypertension and solitary functioning kidney. His angiography was
normal. We did for him cystoscopy and stenting earlier on admission
due to renal impairment. During course of conservative management
he develops sepsis. We replace stent and continue supportive
treatment, including hemodialysis, so he recovered well and
discharged. One patient who present on 5th post op day, he also bleed
during primary surgery for PCNL, so procedure was abandoned.
Bleeding was controlled by nephrostomy insertion. He didn’t require
transfusion either during or in peri- operative period. His angiography
was also normal. He had Hypertension, hyperuricemeia and .treated
for lymphoma about 10yrs before. One patient was admitted for
delayed hematuria on 8th post op day, He had Diabetes Mellitus,
Hypertension, HBsAG +VE, Glaucoma, and refuse for angiography.
He was managed with conservative treatment. Only two patients
whose angiography was positive needs blood transfusion, rest were
treated conservatively without signicant drop in hemoglobin.
Citation: Valecha NK, Bagheri F, Hassani S, Sadi A, Souliman R (2017) Delayed Haematuria after Percutaneous Nephrolithotripsy and its
Management. Med Sur Urol 6: 189. doi:10.4172/2168-9857.1000189
Page 2 of 5
Med Sur Urol, an open access journal
ISSN:2168-9857
Volume 6 • Issue 3 • 1000189

Discussion
In era of endourology and minimally invasive surgery PCNL is
standard treatment of large renal stones, as it is safe and ecient.
However minor to major complications can occurs during and aer
surgery [19-22].
Bleeding is one of most common complications. Fortunately
majority of these are minor and self-limiting and managed
conservatively but some time it necessitate the intervention.
Haemorrhage related to PCNL has reported incidence varies from
0.8% to 7.6% [23-26]. In our study we observe delayed haematuria in
ve patients that is about 6.6% and only two patients prove vascular
injury that is only 2.66%.
As kidney has got very high blood ow, 25% of cardiac output.
Some bleeding is natural with the procedure. While it requires
transfusion in 3% to 25% of cases PCNL [27-29]. Venous bleeding can
usually be controlled with nephrostomy insertion, while severe arterial
bleeding requires angiography and selective angioembolization.
Reported incidence is 0.3-1.4% [30,31] that is slight higher in our
study, and result may vary in larger scale study with increased number
of patients. Excessive bleeding usually arises from injury of segmental
arteries, which are surrounded by dense renal parenchyma, thus easier
to temponade with nephrostomy sheath or tube [32].
Patients
number
Age
(years)
Sex Stone
burden
Co-morbids Access
site and
number
Urinary
anomaly
Operation
Time
(minutes)
Occurrence of
post op
hematuria
Angiography Management
1. 68 yrs M Right
Staghorn
2.5 -2 cm
1.Hypertension
2.hyperuricemeia
3.treated for
lymphoma 2006
Middle
calyx
nil 95min/
procedure
abandoned
due to
bleeding
5th post op day Normal Conservative
2. 31 yrs M Right
Forgotten
stent +stag
horn stone 5
× 4 cm
1.Hypertensive
2.CKD
3.Bilateral renal
stone, left small
kidney
Lower pole Nil 120 min 01 month
Restart after a
week
Normal Initially
conservative
Cystoscopy
+stenting due to
sepsis and clots
removal
3. 43 M Left renal
stone 2.6 ×
1.4 cm
DM,HTN
HBsAG +VE
Glaucoma
Middle
calyx
Left mal
rotated
kidney
+partial
duplex
system
100 min 08 days Not done
(patient
refuse)
Conservatively
4 27 M Right renal
stone
+forgoten
stent
+ureteric
stones
(multiple
calculi)
Recurrent stone
former, left
kidney relatively
small, CKD
Lower
calyx
Nil 150 min 16 days angiography
reveal lower
pole pseudo
aneurysm so
embolization
performed
Cystoscopy+clots
Evacuation and
stenting due to
elevated critinine.
Blood transfusion.
5 70 M Bilateral
renal stone.
1.2 cm in
right kidney
2.5 cm left
kidney
Hypertensive,IH
D
Middle
calyx
Nil 160min 7 days Angiography
reveal
vascular
injury,treated
by baloom
angioplasty
Conservative /
supportive with
blood transfusion.
Table 1: Patients Demographic.
e Bleeding can occur during renal puncture, tract dilatation, and
manipulation of nephroscope or in post-operative period [33]. Patients
with arteriosclerosis of renal artery branches accelerated by aging,
hypertension, or diabetes mellitus are presumably are at higher risk of
bleeding. Arteriosclerosis may impair the ability of self-healing
properties of arterial wall because of loss of normal muscle and elastic
layers. Bleeding tendency is frequently noted in patients with uremia
and liver cirrhosis and those under anti-coagulant agent treatment.
Kidneys those have had retroperitoneal inammation from renal
infection and xed in the retro peritoneum are specially at higher risks
of parenchymal trauma during percutaneous intrarenal surgery [34].
Published data suggests that patient age, ASA grade, stone burden and
operation duration are associated with increased risk of vascular
complications [35]. Kessarris .et al reported in his study of 2200 PCNL,
that age, gender, medical illness, stone burden, number of renal
punctures, and procedure duration were not risk factors [36]. In our
study, all patients has some risk factors. In one patent hematuria
couldn’t settled with angioembolization, leads to severe sepsis and
nephrectomy.
Citation: Valecha NK, Bagheri F, Hassani S, Sadi A, Souliman R (2017) Delayed Haematuria after Percutaneous Nephrolithotripsy and its
Management. Med Sur Urol 6: 189. doi:10.4172/2168-9857.1000189
Page 3 of 5
Med Sur Urol, an open access journal
ISSN:2168-9857
Volume 6 • Issue 3 • 1000189

Nephrectomy related to PCNL is rare but reported in literature.
Kernohan et al reported a case of complete embolization of renal artery
which resulted in loss of kidney. Selective embolization was not
successful due to abnormal arteries which made it impossible to
embolize the feeding artery selectively [37] Stephen R, et al
[38]reported nephrectomy due to cardiovascular instability secondary
to haemorrhage [35]. Another study from Pakistan reported
nephrectomy due to massive delayed bleeding aer PCNL, due to
unavailability of interventional radiology facilities [38].
Transfusion requirement inuenced by many factors, including
operative techniques, surgeons experience, stone complexity, and
patient status. Lam et al reported that improved skills and the presence
of exible nephroscope decreased rate of blood transfusions.
In some studies it was reported that multiple parenchyma punctures
were associated with vascular injuries and increased blood
transfusions.
El-Nahas et al. [28] observed that stag horn stones and upper calyx
punctures were signicant risk factor for severe bleeding. All patients,
who presented with delayed haematuria have complex stone disease
along with co morbid risk factors. Mean operation time was 116.25
minutes, all patients were approached by lower calyx.
In our study we did angiography in 4 patients, two have normal
angiography and one patient showed Pseudoaneurysm ,therefor
embolization was done ,but that didn’t works, and he start hematuria
in 48hrs in same admission and end up with nephrectomy due sepsis
and hemodynamic instability. El-Nahas et al. [28] reported that success
rate of controlling the bleeding aer PCNL was 92.3% and 72.3% of
patients were successfully treated with single session without any
complication. is study suggest that about 28% failure of
angioembolization, this may be similar to our study ,where one patient
re start bleeding that end up with lifesaving nephrectomy. is is
similar to literature. Limitations of our study were low number of
patients and retrospective study. Probably, a multicentric prospective
study can result in a more precise outcome.
Conclusions
Delayed haematuria is one of rare and serious outcome of PCNL,
mostly It is secondary to vascular complication e.g., pseudo
aneurysms. Presence of risk factors increases chances of haematuria.
Conservative treatment is eective and still the treatment option.
Angiography can be an option for non-responder with possible
embolization if indicated.
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Citation: Valecha NK, Bagheri F, Hassani S, Sadi A, Souliman R (2017) Delayed Haematuria after Percutaneous Nephrolithotripsy and its
Management. Med Sur Urol 6: 189. doi:10.4172/2168-9857.1000189
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ISSN:2168-9857
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Citation: Valecha NK, Bagheri F, Hassani S, Sadi A, Souliman R (2017) Delayed Haematuria after Percutaneous Nephrolithotripsy and its
Management. Med Sur Urol 6: 189. doi:10.4172/2168-9857.1000189
Page 5 of 5
Med Sur Urol, an open access journal
ISSN:2168-9857
Volume 6 • Issue 3 • 1000189