This document discusses complications of percutaneous nephrolithotomy (PCNL). It describes the most common complications as acute hemorrhage from the renal parenchyma or collecting system. Delayed hemorrhage can also occur due to arteriovenous fistulas or pseudoaneurysms. Collecting system injuries like tears or perforations need drainage with stents or nephrostomy tubes. Rare but serious complications include visceral injuries to nearby organs, pleural injuries, metabolic disturbances, and neurological issues from positioning. Management involves drainage, angioembolization, or open surgery depending on the complication. The document also reviews drainage techniques after PCNL including tubeless procedures with just ureteral stents or

1. COMPLICATIONS OF PCNL
DR. SWAPNIL TOPLE
DNB UROLOGY
YASHODA SUPER SPECIALTY HOSPITAL,
HYDERABAD

2. 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

3.  Prolonged operative time
 renal pelvic perforation
• Technical errors predisposing to hemorrhage:
 Infundibular entry risks injury to interlobar (infundibular)
arteries
 Entry into wrong calyx resulting into overly aggressive
torquing of the sheath and rigid endoscope
 misuse of any tool—lithotrites, resectoscopes, wires,
sheaths, graspers, baskets, and so on

4. • 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

5. • 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.

6. • 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

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

8. 2. Delayed Hemorrhage
• Postoperative hemorrhage can occur:
 with the nephrostomy tube in place
 at time of tube removal
 after discharge from the hospital
• Delayed hemorrhage is usually due to arteriovenous
fistulas or arterial pseudoaneurysms(more
common)

9. • 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

10. • 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

11. 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

12.  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

13. • 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

14. 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 age
dilated colon
prior colon surgery or disease
thin body habitus
the presence of a horseshoe kidney

15.  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

16.  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

17. • 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

18. 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

19. • 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

20. 6. Metabolic and Physiologic
Complications
• 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

21. • 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

22. • 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

23. 7. Postoperative Fever and Sepsis
• Incidence: 15% to 30%
• Risk factors for fever
 infectious stones
 preoperative urinary tract infection
 Hydronephrosis
 indwelling ureteral stent or
 nephrostomy tube

24. • 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

25. 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

26. • 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

27. 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.

28. 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

29. 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

30. • 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

31. 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

32. 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

33. Classification of surgical complications according
to the modified clavien grading system

34. 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

35. • 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

36. • “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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