PNL is an effective procedure for treating large or complex kidney stones. Common complications include bleeding, infection, and injury to surrounding organs like the lungs or colon. Management involves conservative measures like nephrostomy tube placement, but sometimes requires angioembolization or open surgery. Most complications can be safely managed with appropriate perioperative care and early recognition. Major complications are rare but can include loss of kidney function or even death in very severe cases.

1. POST PCNL COMPLICATIONS AND
MANAGEMENT
Dr Shambhavi Sharma
MS Resident
PAHS
Moderator :
Ass.prof Dr Samir Shrestha

2. INTRODUCTION
• Percutaneous nephrolithotomy (PNL) is accepted as the
procedure of choice for the treatment of large or complex
renal calculi
AUA guideline on management of staghorn calculi: diagnosis and treatment recommendations.Preminger
Gm et al.J Urol. 2005 Jun; 173(6):1991-2000.

3. OPERATIVE STEPS
• Insertion of ureteric catheter (allowing dilation of the
collecting system with saline and contrast media)
• Positioning of the patient
• Puncture of calyx and access
• Serial Dilatation of access tract
• Amplatz sheath
• Introduction of nephroscope
• Stone fragmentation and retrieval

4. COMPLICATIONS
During Positioning

5. Neuromusculoskeletal Complications
associated with prone positioning
related to the head and neck region
• Ocular injury resulting in visual loss
• Facial nerve injury
• Necrosis over facial bones,tip of the nose,
• Cerebrovascular accident due to carotid or vertebrobasilar
artery dissection

6. • Careful padding of the head, in a neutral and nonextended
position,
• Malpositioning of the extremities -- peripheral nerve injury
• 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

7. COMPLICATIONS
•During access/puncture of calyx

8. 1. Pleural Injury
• Hydrothorax, pneumothorax-when
access made above 11th rib
(1.8-8%)
• Lung injury
• Nephropleural fistula (urinothorax)-
rare
• incidence of pleural complications
with punctures above the 12th rib
considered acceptable risk
• if provides optimal access to
the upper urinary tract

9. Diagnosis :
• Intraoperative:
• Monitoring airway pressure
• ETCO2 and oxygen saturation
• Postoperative :
• Chest fluoroscopy during or at the conclusion of the procedure
• Chest radiography
• If hydrothorax is noted intraoperatively:
• insert a small- caliber (8-Fr to 12-Fr) Cope nephrostomy tube as
the thoracostomy
• Large-bore thoracostomy tube -for lung injury

10. 2. Acute hemorrhage
Most common significant complication(6.5-8.5%)
• Factors associated with hemorrhage
 multiple access
 increasing tract size
 Guys Stone score >3
 Prolonged operative time >83 min
 Renal pelvic perforation
 Previous ipsilateral surgery
Shakhawan H.A. Said,Arab J Urol 2017 Mar; 15(1): 24–29.

11. Hemorrhage can occur during :
• during needle passage
• tract dilatation
• nephrostomy
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
• Misplacement of nephrostomy tube

12. Ideal access:
• one that enters a posterior calyx
at the fornix
• second most inferior calyx seen on
retrograde pyelography is typically
posteriorly oriented
• ideal for initial access for most
patients
• Most straight path to calyx with
highest stone burden
• Dilated calyx

13. To minimize the unfavorable impact of multiple
accesses on bleeding:
• Flexible nephroscopy
• Holmium laser lithotripsy,
• Improved grasping devices and baskets
Akman T.et al. J Endourol. 2011;25:327–333

14. Identification of source of bleeding
• Most hemorrhage occurs from the renal parenchyma, most
cases not significant
• noticeable bleeding from the tract after sheath removal
following an otherwise unremarkable procedure
Management
• Insert and occlude a nephrostomy tube
• Apply pressure to the incision
• Let the collecting system clot off
• Nephrostomy tubes should not be irrigated the day or evening
of the procedure if not draining
• By the next morning, it is safe to gently irrigate the tube
because hemostasis is more certain

15. If severe hemorrhage occurs following
sheath removal refractory to the
hemostatic measure:
Kaye Nephrostomy Tamponade Balloon
considered
• 15-cm long
• 36 F balloon which surrounds the
length of the tube
• Tamponade the nephrostomy
tract
• Simultaneous drainage of tract

16. • Intraoperative hemorrhage from an injured vein or artery
within the collecting system
• mandates cessation of the procedure if vision is lost
• If Venous bleeding :
• Place nephrostomy tube
• let the collecting system clot off
• If small arterial injury
• fulguration under direct vision

17. Significant arterial hemorrhage (drop in Hb by 2gm/dl with 4
or more transfusions)
• If the bleeding from the nephrostomy tube continues or
gross hematuria with acute urine retention occurs
• Blood transfusion plus fluid resuscitation
• Foley catheterization with urinary bladder irrigation
• IV administration of mannitol (hemodynamically stable
patients )
• lead to rapid forced diuresis and swelling of the kidney within the capsule,
which may enhance tract tamponade

18. In case of failure of these
maneuvers:
Color duplex sonography/
CT/ MR angiography or
renal angiography
• Selective renal artery
embolization

19. Misplacement of nephrostomy tube
At the stage of access tract dilation.
Diagnosis:
massive hemorrhage necessitating immediate placement of a
nephrostomy tube and abortion of the procedure
Management:
hemodynamically stable:
• managed conservatively with strict bed rest,
• intravenous antibiotics,
• CT or fluoroscopy-guided nephrostomy tube withdrawal
• (in the operating room with the vascular team ready to intervene if
needed)
• Open surgery can be used as an alternative treatment

20. 3.postoperative Hemorrhage
Can occur during :
 with the nephrostomy tube in place early
 at time of tube removal
 after discharge from the hospital(1-3weeks)
• Delayed hemorrhage due to arteriovenous fistulas or
arterial pseudoaneurysms(more common)
• formed by a high-pressure leak from a lacerated artery
• leak transmitted through the tract into a lower
resistance system, such as a vein or a connective tissue
space

21. • As late as 13 weeks after a percutaneous nephrolihotomy
• Continuous bleeding -arteriovenous fistula
• Intermittent bleeding-arterial pseudoaneurysm
• Selective angio-embolization
Other options :
• endovascular placement of a covered stent to occlude the site
of arterial injury
• USG guided percutaneous puncture of an arterial
pseudoaneurysm
• Injection of thrombin or fibrin tissue adhesive
Anil kumar et al. Ijcmr.2016;3:2454-7379

22. •In case of failure of these maneuvers:
•Partial nephrectomy

23. 3. Collecting System Injury
(7.2%)
• Tears in the infundibulum
• Renal pelvic perforation:
• occur during initial access or during dilation
• Pushing on a renal pelvic stone too hard during lithotripsy
• Collapse of a previously distended renal pelvis is a usual sign
if the perforation is not visualized directly at first
• avoided by using a J guide wire with a soft and curved tip
• Perforation can lead to :
• Retroperitoneal extravasation
• Intraperitoneal extravasation

24. Retroperitoneal extravasation :
• Noted by medial displacement of
the kidney during fluoroscopy
• Direct visualization of perinephric
structures or fat
• abnormal hemodynamic
parameters,
• decrease in irrigation fluid drainage
• Postoperative enhanced CT may
reveal signs of urine leakage

25. • Minor perforations
• No intervention required
• Significant perforations
• Termination of the procedure and nephrostomy and ureteral
drainage
• nephrostography after 2 to 7 days and tube removal,
depending on the severity of the injury

26. •Intraperitoneal extravasation:
• Abdominal distention difficult to recognize due to
prone position
• gradual rise in the patient’s diastolic blood pressure
• Narrowing of the pulse pressure
• Increase in CVP
• In advanced cases of a large-volume extravasation
event:
• Ventilation difficult because of raised IAP

27. Management :
• Early recognition of major extravasation is crucial
• Vigorous diuresis
• Peritoneal drainage
• Laparotomy
Postoperative :
• abdominal distention, ileus, and/or fever
Management :
• placement of a percutaneous drain

28. 4. Visceral Injury
Colon injury:
• left colon injury more
common
• 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
• Horseshoe kidney

29. Preoperative CT IVU
• Identification of structures
• retrorenal colon,
• Liver or spleen
• Patients with ectopic kidneys,
dysmorphic body habitus(eg
spinal dysraphism)
• Intra-abdominal structures,
such as the bowel, may be
located between the skin
and the renal access point

30.  Diagnosis
Postoperatively:
• Unexplained fever
• Prolonged ileus
• Unexplained leukocytosis
• Rectal bleeding
• Evidence of peritoneal inflammation,
• fecaluria
• pneumouria or clinically apparent nephrocolonic fistula
• Postoperative nephrostogram or CT imaging

31. Management :
If extraperitoneal:
• Management may be expectant
• Placement of a ureteral catheter or DJ stent to decompress
the collecting system
• Withdrawal of the nephrostomy tube from an intrarenal
position to an intracolonic position to serve as a colostomy
tube
• Left in place for a minimum of 7 days
• Removed after a nephrostogram or a retrograde
pyelogram shows no communication between the colon
and the kidney

32. Duodenal and jejunal injuries:
• Less common
• If no peritonitis-Conservative management
• If peritonitis-open Surgery

33. Liver injury
Patient at risk :
• Right-sided supracostal (superior to the 11th rib)
• percutaneous renal access anterior to the posterior axillary line.
• Hepatomegaly
Diagnosis :
unusual burning sensation at the right flank
CT scan to reveal the route of injury to the liver

34. Management
Hemodynamically stable:
• close monitoring and coagulant agents as needed
• Prolonged nephrostomy drainage to ensure proper healing of the
injured site
• Foley catheterization for adequate urinary drainage
• Follow-up ultrasound or CT scan recommended if there is a concern
for the formation of a biloma

35. Splenic injury
• 10th intercostal access and/or splenomegaly -higher risk
for injury
• Diagnosis :
• Hemodynamic instability in the absence of
significant intraoperative blood loss
• Abdominal CT scanning can characterize the
injury
• Management
hemodynamically stable:
• strict bed rest is recommended.
• consider leaving the nephrostomy tube in place
to tamponade the bleeding and induce fibrosis

36. Hemodynamically unstable,
• Life-saving splenorraphy
• splenectomy
• hemostatic fibrin glue can be used to increase the chance of
preserving the spleen

37. Complications
due to irrigating fluid
Collecting system perforation

38. 1. Metabolic and Physiologic Complications
During irrigation
• amount of fluid absorption generally clinically insignificant
• volume of fluid absorbed increased with the amount of
irrigating fluid used, pelvicaliceal perforation, bleeding
Intravascular or extravascular extravasation in the setting large
venous injury or collecting system perforation:
• hyponatremia and other electrolyte abnormalities
• renal or hepatic dysfunction
• mental status changes

39. large amount of saline extravasation
• clinically significant respiratory distress
• cardiac failure due to volume overload
Prevention :
• Irrigation fluid used should always be saline(physiologic)
• Using a low-pressure system and staging, the procedure for large renal
stone burdens
• especially in the presence of complications such as perforation of the
pelvicaliceal system
• height of irrigating fluid and total time for irrigation do not affect the
amount of fluid absorption
Dip saxena et al.Urol Ann.2019 Apr-Jun; 11(2): 163–167.

40. Other complications

41. 1. Extrarenal stone migration
Occurs due to:
• the application of excessive pressure of the probe onto
the stone
• existence of a perforation in the collecting system
• or the use of an improper technique of stone extraction
with an Amplatz sheath
Diagnosis:
• Intraoperative pyelography
• Renal ultrasound

42. Management :
• As long as the stone is not infected and fragment-associated
inflammation does not obstruct the urinary tract—t/t not
necessary.
• Endoscopic retrieval of fragments outside of the urinary
tract should not be attempted-- enlarge the perforation
• Intraperitoneal and pleural migration of stone reported
• Laparoscopy and thoracosopy in order to prevent peritoneal
and thoracic complications

43. • Indicated by
• hypoxemia
• 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.
• sudden decrease in capnometry reading of the P(end-tidal) CO2
2. Venous gas embolism (0.4% )

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

45. 2. Postoperative Fever and Sepsis
• Incidence: 10% to 30%
Risk factors for fever
• infectious stones
• preoperative urinary tract infection
• Hydronephrosis
• indwelling ureteral stent or
• nephrostomy tube

46. Management
Prevention :
• Preoperative antibiotics according to C/S
• Intra-operative irrigation pressure < 30 mmHg
• Unobstructed post-operative urinary drainage
Treatement
• Initiation of antimicrobial therapy and other supportive care
• If pus is aspirated upon initial percutaneous to the upper
urinary tract,
• abort the procedure and leave a nephrostomy tube for
drainage

47. 3. Collecting System Obstruction
• Predisposing factors:
• large stone burden requiring multiple or long procedures
• prolonged nephrostomy tube drainage
• previous open stone surgery
• diabetes mellitus
• obesity
• Endoscopic treatment in most cases
• Stenting ,cold knife excision ,laser ablation , balloon dilation or
endoscopic formation of a new infundibulum
• open surgical reconstruction or excision with partial nephrectomy
or total nephrectomy may be required

48. 4. Loss of Renal Function
• owes to disastrous vascular injury or
• the angio-embolization used to treat hemorrhage

49. 5.Postoperative persistent nephrocutaneous
leakage (1.5-4.6%)
• normally closes within 6–12 h of nephrostomy tube removal
• Urinary leakage persisting >24 h after nephrostomy tube removal
called prolonged
• Usually needs treatment
• obtain a low-dose CT scan to evaluate for stone fragments in the
ureter that may be causing obstruction
• Management :
• insertion of a ureteral stent
• Foley catheter may be inserted for 24 h in order to relieve pressure
in the urinary system
• promote anterograde drainage of urine

50. 5.Death (0.3-0.5%)

51. Summary
• PCNL is a safe procedure with a low incidence of major complications
• common complications :
• bleeding, infection, and infundibular stenosis
• Most complications can be managed conservatively
• appropriate perioperative measures should be taken in order to
minimize the risk of preventable complications

52. References
• Campbell Walsh text book of urology 12th edition
• EAU guidelines for management of nephrolithiasis
• Gadzhiev N, Malkhasyan V, Akopyan G, Petrov S, Jefferson F, Okhunov
Z. Percutaneous nephrolithotomy for staghorn calculi:
Troubleshooting and managing complications. Asian J Urol.
2020;7(2):139-148. doi:10.1016/j.ajur.2019.10.004
• Lee KL, Stoller ML. Minimizing and managing bleeding after
percutaneous nephrolithotomy. Curr Opin Urol. 2007;17(2):120-124.
doi:10.1097/MOU.0b013e3Incidence, Prevention, and Management
of Complications Following Percutaneous Nephrolitholapaxy
• Saxena, Dipti et al. “Effects of fluid absorption following
percutaneous nephrolithotomy: Changes in blood cell indices and
electrolytes.” Urology annals vol. 11,2 (2019)

53. •Thank you
•Any queries ?