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.
    Full-text · Article · Jul 2015 · SpringerPlus
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    • "In the literature, blood loss requiring transfusion is reported in 0.4–23% of cases and is associated with stone burden, sheath size, number of tracts, and operative time [2,56789 . However, previous studies with regards to risk factors have not achieved consistent conclusions [2,56789. The purpose of this study was to detect the potential risk factors for severe postoperative bleeding in 982 patients with kidney stones undergoing PCNL. "
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    ABSTRACT: Hemorrhage is a major complication after percutaneous nephrolithotomy (PCNL). In the current study, we analyzed the risk factors for severe bleeding after PCNL. Medical records of 982 consecutive patients undergoing PCNL at the Department of Urology, the Third Xiangya Hospital, were reviewed. The type of stone included: solitary (n = 471), multiple (n = 192) and staghorn (n = 319). 139 patients had renal stones of solitary kidney or functional solitary kidney. The puncture site was the inferior calyx in 246 cases, the middle calyx in 651 cases, and the upper calyx in the remaining 85 cases. The success rate (complete removal of the stone) was 92.8%, 73.4%, and 80.9% for solitary, multiple and staghorn stones, respectively. Severe bleeding occurred in 3.25% (8/246) of the cases with inferior calyx access, and 0.3% (2/651) in cases with middle calyx access. No severe bleeding occurred in patients with upper calyx access. The bleeding was controlled successfully with focal embolization under angiography in all 10 cases. Severe postoperative bleeding after PCNL is associated with renal puncture via the inferior calyx, multiple renal stones and solitary kidney stones.
    Full-text · Article · Apr 2015 · Archives of Medical Science
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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.
    Full-text · Article · Sep 2014 · Scandinavian Journal of Urology
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