Review – Endo-urology
Complications in Percutaneous Nephrolithotomy
Maurice Stephan Michela, Lutz Trojana, Jens Jochen Rassweilerb,*
aDepartment of Urology, Medical School Mannheim, University of Heidelberg, Germany
bDepartment of Urology, SLK Kliniken Heilbronn, University of Heidelberg, Germany
Percutaneous nephrolithotomy (PNL) was estab-
lished as a minimally invasive treatment option
for removal of kidney stones in the 1970s and was
further developed in the ensuing years [1–3]. How-
ever, PNL frequency diminished with the introduc-
tion of extracorporeal shock wave lithotripsy (ESWL)
in the early 1980s . In recent years, as clinical
experience with ESWL revealed its limitations, the
role of PNL for treating urolithiasis was redefined
[5–7]. Today, PNL should be the first-line treatment
for large or multiple kidney stones and stones in
the inferior calyx . Furthermore, improvements
in instruments(i.e., flexible
ureteroscopes) as well as lithotripsy technology
european urology 51 (2007) 899–906
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journal homepage: www.europeanurology.com
Accepted October 16, 2006
Published online ahead of
print on October 25, 2006
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Objective: This review focuses on a step-by-step approach to percuta-
neous nephrolithotomy (PNL) and its complications and management.
Methods: 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
Results: 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 compli-
cations, 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.
successful outcomes in PNL with minimal major complications is the
correct selection of patients. A well-standardised technique and post-
operative follow-up are mandatory for early detection of complications.
# 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved.
* Corresponding author. Department of Urology, SLK Kliniken Heilbronn,
Am Gesundbrunnen 20, D-77074 Heilbronn, Germany. Tel. +49 7131 492400;
Fax: +49 7131 492429.
E-mail address: firstname.lastname@example.org (J.J. Rassweiler).
0302-2838/$ – see back matter # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved.doi:10.1016/j.eururo.2006.10.020
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David Geffen School of Medicine at UCLA,
This is a well-written review on the complica-
tions of percutaneous nephrolithotomy (PNL) for
large renal and impacted proximal ureteral stones
and the authors are to be commended for their
accurate andhonest analysis.Theauthors present
their large experience with an overall complica-
tion rate of 50.8%, including a minor complication
rate of 49.6%. This finding corresponds to their
ence, PNL remains a milestone technique in
the urologic field with a very low percentage of
major complications and with a very high success
Of note, the incidence of big staghorn calculi has
drastically decreased, and more stones in the 2-cm
range are seen. The new generation of flexible
ureteroscopes has been significantly improved in
terms of therapeutic and diagnostic efficacy .
Also the advances in lithotripsy, in particular,
the holmium laser, have resulted in increased
treatment success for stones and reduced proce-
dure-related morbidity . The success rate for
intrarenal stones >2 cm after the first or second
95% . The complication rate reported varies from
1.5% to 12% [3–5], including major and minor com-
plications. Of note, the incidence of major compli-
cations suchasureteralavulsion orperforationhas
decreased to the 0% range in the most recently
published data . The disadvantage of uretero-
scopy to PNL is that ureteroscopy may require
multiple procedures to clear a big stone and to
extract the fragments, as opposed to PNL, which
can offer a 95% stone-free rate after the first treat-
ment . The cost to pay for this high success rate
is, indeed, a higher complication rate. Further stu-
procedure versus the other.
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