COMPLICATIONS OF PCNL

DR. SWAPNIL TOPLEDNB UROLOGY

YASHODA SUPER SPECIALTY HOSPITAL,HYDERABAD

1. Acute Hemorrhage

• The most common significant complication• Factors associated with hemorrhage during percutaneous

surgery include: patient characteristics multiple access sites supracostal access increasing tract size tract dilation with methods other than balloon dilation

Prolonged operative time renal pelvic perforation• Technical errors predisposing to hemorrhage: Infundibular entry risks injury to interlobar (infundibular)

arteriesEntry into wrong calyx resulting into overly aggressive

torquing of the sheath and rigid endoscopemisuse of any tool—lithotrites, resectoscopes, wires,

sheaths, graspers, baskets, and so on

• Most hemorrhage occurs from the renal parenchyma, and in most cases this hemorrhage is not significant

• The access sheath provides intraoperative tamponade of parenchymal bleeding. Postoperatively, hemostasis is achieved by collapse of the parenchyma onto itself

• There is no difference in measures of postoperative bleeding between small (8- to 18-Fr) and large (20- to 28-Fr) tubes

• Randomized controlled trials suggest that hemorrhage is no greater when the nephrostomy tube is omitted altogether

• If there is noticeable bleeding from the tract after sheath removal following an otherwise unremarkable procedure, this suggests bleeding from intraparenchymal vessels

• The best management is to insert and occlude a nephrostomy tube, apply pressure to the incision, and let the collecting system clot off

• Nephrostomy tubes should not be irrigated the day or evening of the procedure if they are not draining; it is best to let the collecting system remain occluded to tamponade bleeding. By the next morning, it is safe to gently irrigate the tube because hemostasis is more certain.

• If the procedure was not complicated by bleeding, but severe hemorrhage occurs following sheath removal and is refractory to the hemostatic measures described earlier, then use of a Kaye Nephrostomy Tamponade Balloon should be considered. Inflated upto 36F

• Intraoperative hemorrhage from an injured vein or artery within the collecting system mandates cessation of the procedure if vision is lost

• If the injury appears to be venous, then placing a nephrostomy tube and letting the collecting system clot off is effective

• If a small arterial injury-fulguration under direct vision, • If in cases of significant arterial hemorrhage-selective

angioembolization

2. Delayed Hemorrhage

• Postoperative hemorrhage can occur:with the nephrostomy tube in placeat time of tube removalafter discharge from the hospital• Delayed hemorrhage is usually due to arteriovenous

fistulas or arterial pseudoaneurysms(more common)

• Continuous bleeding -arteriovenous fistula• intermittent bleeding-arterial pseudoaneurysm• but the distinction is not critical because treatment is the

same• The standard treatment of renal arteriovenous fistulae and

arterial pseudoaneurysms is selective angio-embolization• Nephrectomy may be required if selective

angioembolization fails, and partial or total renal loss may occur if angio-embolization is not selective enough

• A recently introduced alternative to angio-embolization is endovascular placement of a covered stent to occlude the site of arterial injury

• Another alternative is ultrasonographically guided percutaneous puncture of an arterial pseudoaneurysm, with injection of thrombin or fibrin tissue adhesive

3. Collecting System Injury

• Tears in the infundibulum• Ureteral injuries• Renal pelvic perforation: occur during initial access or during dilation Pushing on a renal pelvic stone too hard during lithotripsy misusing a lithotripter or resectoscope Collapse of a previously distended renal pelvis is a usual

sign if the perforation is not visualized directly at first

A perforation that has not been recognized intraoperatively might be heralded by postoperative abdominal distention, ileus, and/or fever

If noted intraoperatively, abort the procedure unless it is near completion, in which case the task can be completed at lower irrigation pressure if the patient is doing well clinically

insert a nephroureteral stent or a nephrostomy tube plus an internal ureteral stent to optimize drainage and then wait 2 to 7 days before nephrostography and tube removal, depending on the severity of the injury

• If renal pelvic perforation is detected postprocedure, despite adequate drainage of the collecting system, then placement of a percutaneous drain into the urinoma might be required

4. Visceral Injury

• Colon injury: on the basis of the anatomy, with the apposition of the colon to

the kidney being greatest on the left side and at the lower pole the left colon is injured twice as often as the right colon and the

majority of colon injuries involve access to the lower pole Additional risk factors:advanced patient agedilated colonprior colon surgery or disease thin body habitus the presence of a horseshoe kidney

Injury might be less likely with the patient in the supine position than prone position

Injury might be less likely with the patient in the supine position

If not determined intraoperatively, colon injury should be considered postoperatively if a patient develops unexplained fever, prolonged ileus, unexplained leukocytosis, rectal bleeding, evidence of peritoneal inflammation, or fecaluria o pneumouria or clinically apparent nephrocolonic fistula may be the presenting sign

Most colon injuries are extraperitoneal and can be managed conservatively

The main principle of care is prompt and separate drainage of the colon and urinary collecting system

• Duodenal and jejunal injuries: Less common If no peritonitis-Conservative management If peritonitis-open Sx

• Splenic and hepatic injuries unlikely unless the kidney is accessed above the 10th

rib, although access above the 11th or 12th rib might traverse these organs in rare cases

If splenomegaly or hepatomegaly is present, these relationships change and access guided by CT is recommended

5. Pleural Injury

• Hydrothorax, and occasionally pneumothorax-when access was made above 11th rib

• The incidence of pleural complications with punctures above the 12th rib (the 11th intercostal space) is generally considered an acceptable risk if that approach provides optimal access to the upper urinary tract

• Access above the 11th rib or higher carries a much greater risk of pleural injury and even lung injuries

• Nephropleural fistula (urinothorax)-is rare

• Pleural complications of supracostal percutaneous access can often be detected with chest fluoroscopy during or at the conclusion of the procedure

• Nonetheless, formal chest radiography is recommended following all cases of supracostal percutaneous renal access

• If hydrothorax is noted intraoperatively, then insert a small-caliber (8-Fr to 12-Fr) Cope nephrostomy tube as the thoracostomy

• A large-bore thoracostomy tube -for lung injury

6. Metabolic and PhysiologicComplications

• Normal saline should be the irrigant for percutaneous renal surgery

• glycine or similar nonelectrolytic isotonic fluids when monopolar electrocautery is used

• Irrigation with water during percutaneous renal surgery risks intravascular hemolysis, which can be fatal

• Intravascular or extravascular extravasation of nonelectrolytic isotonic fluid from continued irrigation in the setting of a large venous injury or collecting system perforation, respectively, can result in hyponatremia and other electrolyte abnormalities, renal or hepatic dysfunction, and mental status changes

• When normal saline is used in uncomplicated cases, the amount of fluid absorption is generally clinically insignificant

• A large amount of saline extravasation can lead to clinically significant respiratory distress or cardiac failure due to volume overload

• Venous gas embolism: is rare

• Venous gas embolism is indicated bymhypoxemia, evidence of pulmonary edema, increased airway pressure, hypotension, jugular venous distention, facial plethora, dysrhythmias, and auscultation of a mill-wheel cardiac murmur and/ or the appearance of a widened QRS complex with right heart strain patterns on electrocardiography.

• The most sensitive measure-sudden decrease in capnometry reading of the P(end-tidal) CO2

• Swift response is required and includes rapid ventilation with 100% oxygen, positioning the patient head down with the right side up, and general resuscitative maneuvers

7. Postoperative Fever and Sepsis

• Incidence: 15% to 30%• Risk factors for fever infectious stonespreoperative urinary tract infectionHydronephrosis indwelling ureteral stent ornephrostomy tube

• Careful observation, appropriate diagnostic evaluation, and initiation of antimicrobial therapy and other supportive care

• If pus is aspirated upon initial percutaneous to the upper urinary tract, the safest measure is to abort the procedure and leave a nephrostomy tube for drainage

8. Neuromusculoskeletal Complications

• Most reported injuries associated with prone positioning are related to the head and neck region including ocular injury resulting in visual loss, facial nerve injury or necrosis over facial bones or the tip of the nose, and cerebrovascular accident due to carotid or vertebrobasilar artery dissection

• Careful padding of the head, in a neutral and nonextended position, is important

• Malpositioning of the extremities can lead to peripheral nerve injury

• The shoulder and elbow should not be abducted more than 90 degrees, so as to prevent brachial plexopathy,

• Generous padding at the elbow and forearm reduces the risk of nerve compression

9. Venous Thromboembolism

• The AUA Best Practice Statement for the prevention of deep vein thrombosis in patients undergoing urologic surgery does not include percutaneous renal surgery among procedures for which prophylaxis against venous thromboembolism is recommended

• Early ambulation is the best measure to reduce the already low risk of venous thromboembolism.

10. Tube Dislodgement

• all tubes should be secured at the skin to reduce the risk of at least one mechanism of tube removal

• Malecot tubes are the easiest to pull out, and circle nephrostomy tubes are the hardest. The Cope retention mechanism is more secure than Malecot wings but does not retain as well as a balloon

11. Collecting System Obstruction

• Predisposing factors:• large stone burden requiring multiple or long

procedures• prolonged nephrostomy tube drainage• previous open stone surgery• diabetes mellitus• obesity

• Obstruction after percutaneous renal surgery should respond to endoscopic treatment in most cases

• but open surgical reconstruction or excision with partial nephrectomy or total nephrectomy may be required

12. Loss of Renal Function

• Despite the direct puncture of renal parenchyma and enlargement of sometimes multiple tracts to up to 34 Fr, the kidney suffers little permanent damage after uncomplicated percutaneous renal surgery

• When there is renal loss following percutaneous renal surgery, it usually owes to disastrous vascular injury or the angio-embolization used to treat hemorrhage

13. Death

• Death after percutaneous renal surgery is extremely rare, and when it occurs it is usually due to underlying

• cardiovascular conditions• In the current AUA guideline on management of

staghorn calculi, the median death estimate for percutaneous nephrolithotomy was zero, which reflects the paucity of data on the subject

Classification of surgical complications according to the modified clavien grading system

DRANAGE AFTER PCNL

• “Tubeless” with Ureteral Stent• one that omits the postoperative nephrostomy tube—was

initially proposed by Wickham and colleagues (1984)• Although this technique is called “tubeless,” most series employ

a ureteral stent for at least a short period postoperatively• ADVANTAGES: decreased pain and analgesic use avoidance of an external drainage device abbreviated hospital stay decreased health care costs

• DISADVANTAGES: Loss of the percutaneous tract for a secondary procedure and

the cost Inconvenience and discomfort associated with an internal

ureteral stent that requires cystoscopic removal at a later date• In properly selected patients including those who do not for

some other reason need external drainage (e.g., pyonephrosis, significant bleeding, significant collecting system injury) and those who are unlikely to need a secondary procedure, omission of the postoperative nephrostomy tube appears to be safe and effective

• “Totally tubeless”• Omitting both the nephrostomy tube and ureteral

catheter• The procedure is done in selected patients, with low-

volume stones, atraumatic single access, and no hemorrhage, perforation, or obstruction

• The more important comparison would be “totally tubeless” versus internal stent without nephrostomy tube, which to date has not been reported

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