Current insights on haemorrhagic complications in percutaneous nephrolithotomy

Severe bleeding in patients following "tubeless" percutaneous nephrolithotomy: Predictors of angioembolization

INTRODUCTION

Percutaneous nephrolithotomy (PCNL) is a widely used procedure for treating renal calculi. Advanced techniques have improved outcomes, but hemorrhage remains a significant complication. While most cases of hemorrhagic complications are typically managed conservatively, few cases necessitate interventions like angioembolization (AE). The purpose of this study is to identify risk factors closely associated with severe bleeding post-PCNL requiring AE and to assess if these factors can independently predict the type of lesion [arteriovenous fistula (AVF) vs pseudoaneurysm (PA)].

MATERIALS AND METHOD

A retrospective analysis was conducted on 119 patients who underwent "tubeless" PCNL and experienced severe bleeding between January 2018 and December 2023. The study reviewed demographic characteristics, stone characteristics, perioperative factors, and adverse events. The chi-square test and Fisher's exact test were used for univariate analysis. Logistic regression analysis was used in binomial analysis with a value of p < 0.05 considered statistically significant.

RESULTS

Out of 119 patients, 51 required AE. Elevated preoperative serum creatinine levels (>1.5 mg/dl) [p = 0.01], upper pole access [p = 0.008], and a larger access sheath size (standard PCNL vs mini-PCNL) [p ⩽ 0.001] were found to be significantly associated with AE. Logistic regression analysis revealed standard PCNL was significantly associated with post-PCNL bleeding requiring AE (odds ratio [OR]: 50, 95% confidence interval [CI]: 6.529-382.90, p ⩽ 0.001). Stone size and co-morbidities showed no significant association with AE. The average duration of presentation of symptoms post PCNL was 13.6 days. Most patients underwent coiling for AE, with a clinical success rate of 94%.

CONCLUSION

Elevated serum creatinine levels, upper pole access, and tract size >24 Fr are more prone to post-tubeless PCNL severe bleeding, which requires renal AE. The findings suggest that early angiography and possible AE should be considered for at-risk patients. In the future, these predictors may be integrated into predictive models to improve patient risk stratification.

A case report of sepsis associated coagulopathy after percutaneous nephrostomy

BACKGROUND

Hemorrhage is a common complication of nephrostomy and percutaneous nephrolithotripsy, and it is caused by surgical factors. Here we report a rare case of hemorrhage caused by sepsis-related coagulation dysfunction.

CASE PRESENTATION

A 72-years-old male patient with bilateral ureteral calculi accompanied by hydronephrosis and renal insufficiency developed sepsis and hemorrhage on the third day after bilateral nephrostomy. After vascular injury was excluded by DSA, the hemorrhage was considered to be sepsis-associated coagulopathy(SAC/SIC), finally the patient recovered well after active symptomatic treatment.

CONCLUSIONS

In patients with sepsis and hemorrhage, SAC/SIC cannot be excluded even if coagulation function is slightly abnormal after surgical factors are excluded. For urologists who may encounter similar cases in their general urology practice, it is important to be aware of these unusual causes of hemorrhage.

Analysis of factors affecting intraoperative hemorrhage during percutaneous nephrolithotomy and establishment of nomogram model

Intraoperative hemorrhage is an important factor affecting intraoperative safety and postoperative patient recovery in percutaneous nephrolithotomy (PCNL). This study aimed to identify the factors that influence intraoperative hemorrhage during PCNL and develop a predictive nomogram model based on these factors.A total of 118 patients who underwent PCNL at the Department of Urology, The Affiliated Huai'an No.1 People's Hospital of Nanjing Medical University from January 2021 to September 2023 was included in this study. The patients were divided into a hemorrhage group (58 cases) and a control group (60 cases) based on the decrease in hemoglobin levels after surgery. The clinical data of all patients were collected, and both univariate analysis and multivariate logistic regression analysis were conducted to identify the independent risk factors for intraoperative hemorrhage during PCNL. The independent risk factors were used to construct a nomogram model using R software. Additionally, receiver operating characteristic (ROC) curves, calibration curves and decision curve analysis (DCA) were utilized to evaluate the model.Multivariate logistic regression analysis revealed that diabetes, long operation time and low psoas muscle mass index (PMI) were independent risk factors for intraoperative hemorrhage during PCNL (P < 0.05). A nomogram model was developed incorporating these factors, and the areas under the ROC curve (AUCs) in the training set and validation set were 0.740 (95% CI: 0.637-0.843) and 0.742 (95% CI: 0.554-0.931), respectively. The calibration curve and Hosmer-Lemeshow test (P = 0.719) of the model proved that the model was well fitted and calibrated. The results of the DCA showed that the model had high value for clinical application.Diabetes, long operation time and low PMI were found to be independent risk factors for intraoperative hemorrhage during PCNL. The nomogram model based on these factors can be used to predict the risk of intraoperative hemorrhage, which is beneficial for perioperative intervention in high-risk groups to improve the safety of surgery and reduce the incidence of postoperative complications.

Prevention of complications in endourological management of stones: What are the basic measures needed before, during, and after interventions?

Objective

This narrative review aims to describe measures to minimise the risk of complications during percutaneous nephrolithotomy (PCNL), ureteroscopy, and retrograde intrarenal surgery.

Methods

A literature search was conducted from the PubMed/PMC database for papers published within the last 10 years (January 2012 to December 2022). Search terms included "ureteroscopy", "retrograde intrarenal surgery", "PCNL", "percutaneous nephrolithotomy", "complications", "sepsis", "infection", "bleed", "haemorrhage", and "hemorrhage". Key papers were identified and included meta-analyses, systematic reviews, guidelines, and primary research. The references of these papers were searched to identify any further relevant papers not included above.

Results

The evidence is assimilated with the opinions of the authors to provide recommendations. Best practice pathways for patient care in the pre-operative, intra-operative, and post-operative periods are described, including the identification and management of residual stones. Key complications (sepsis and stent issues) that are relevant for any endourological procedure are then be discussed. Operation-specific considerations are then explored. Key measures for PCNL include optimising access to minimise the chance of bleeding or visceral injury. The role of endoscopic combined intrarenal surgery in this regard is discussed. Key measures for ureteroscopy and retrograde intrarenal surgery include planning and technique to minimise the risk of ureteric injury. The role of anaesthetic assessment is discussed. The importance of specific comorbidities on each step of the pathway is highlighted as examples.

Conclusion

This review demonstrates that the principles of meticulous planning, interdisciplinary teamworking, and good operative technique can minimise the risk of complications in endourology.

Acute liver injury and contralateral pleural effusion as two rare complications following percutaneous nephrolithotomy: a case report

INTRODUCTION

Percutaneous Nephrolithotomy (PCNL) is a widely used surgical intervention for removing large and complex renal calculi. While considered a safe and effective procedure, it can still lead to severe and rare complications, including bleeding, pulmonary complications, and liver dysfunction.

CASE PRESENTATION

This case report presents a case who underwent PCNL for a kidney stone and subsequently developed a series of rare and severe complications. Following the PCNL procedure, the patient experienced significant bleeding, a known but uncommon complication of PCNL, pulmonary complications, a common complication that may carry a risk of death, and acute liver failure, an exceedingly rare consequence of PCNL.

CONCLUSION

In summary, while PCNL is a valuable technique for treating kidney stones, it is not without risk. This case underscores the importance of recognizing and managing rare complications following PCNL surgery, highlighting the need for vigilance, multidisciplinary care, and timely interventions to ensure favorable patient outcomes.

A rare case report of renal vein embolization after failed selective angioembolization to treat delayed complication of percutaneous nephrolithotomy

INTRODUCTION

Percutaneous nephrolithotomy (PCNL) has been considered the standard procedure for renal caliculi for its safety, shorter operative time, and cost-effectivity. Despite being minimally invasive, rare complications may still occur. This case presented a rare case of renal venous pseudoaneurysm after PCNL.

PRESENTATION OF CASE

A 34-year-old male was diagnosed with left lower calyx renal stone sized 14x13x8 mm with 388-571 Hounsfield Unit (HU). He underwent left mini PCNL with standard protocol. However, on two-weeks follow-up, gross haematuria was presented on emergency department admission. Patient underwent two times cystoscopy and blood clot evacuation. Postoperative contrast-enhanced CT showed saccular lesion sized 6.7 mm × 4.8 mm in the interlobar vein of left kidneys' lower pole. Patient was then consulted to Cardiothoracic-Vascular division, and undergone selective angiography and left renal artery embolization-coiling (VortX Diamond-18). Complaints and haemoglobin decline persists; thus, another attempt of embolization was performed with a different approach. Follow-up arteriography and venography showed complete obliteration of the aneurysm sac, followed by cessation of symptoms. This study is reported in line with SCARE criteria.

DISCUSSION

This is a rare case where a second embolization attempt (specifically via vein) was needed to overcome PCNL postoperative complication. Reviewing vascular complications risk factors after PCNL is crucial. This case report suggests complication management could be handled appropriately through procedures of selective angiography and embolization.

CONCLUSION

Coil embolization targeting the vein is a potentially effective and safe for selective cases of renal vein pseudoaneurysm. This case shows the importance of multidisciplinary approach and collaboration for better patient management.

Predictive factors of delayed bleeding after percutaneous nephrolithotomy requiring angioembolization

Objectives

To investigate the predictive factors of delayed post-percutaneous nephrolithotomy (PCNL) haemorrhage because of arteriovenous fistula (AVF) or pseudoaneurysm (PA) and compare the factors between AVF and PA.

Patients and methods

This is a case-control study with a case-to-control ratio of 1:3. Out of 5077 patients who underwent PCNL from April 2015 to April 2018 in three different teaching hospitals, 113 had post-PCNL haemorrhages because of AVF and/or PA. Seventy-two patients met the inclusion criteria and entered the study as cases, while 216 patients without any postoperative complications were selected as controls.

Results

Of all 72 studied patients with complications after PCNL, 35 (48.6%) had AVF, and the rest had PA. The regression model revealed that a history of diabetes (odds ratio [OR]: 2.799, 95% confidence interval [CI]: 1.392-5.630, p-value = 0.004) and renal anomalies (OR: 2.929, 95% CI: 1.108-7.744, p-value = 0.03) were associated with developing delayed post-PCNL haemorrhage. However, no differences were seen between AVF and PA regarding selected variables (p-value > 0.05).

Conclusion

History of diabetes and renal anomalies were predictive factors for delayed post-PCNL haemorrhage, but no predictive factors were found to differentiate PA and AVF from one another.

A case of bleeding shock induced by injury of the intercostal artery following percutaneous nephrolithotripsy

Introduction

The risk of postoperative bleeding complications should be concerned to perform percutaneous nephrolithotripsy. Most of the vascular injuries occurred at the peripheral renal artery in the previous reports. We experienced a case of bleeding shock induced by the injury of the intercostal artery in the abdominal wall following percutaneous nephrolithotripsy.

Case presentation

A 56-year-old woman had been in the bleeding shock status on the 2nd day after percutaneous nephrolithotoripsy. Emergently, contrast-enhanced computed tomography was performed and extravasation of contrast agents was seen in the abdominal wall. Injuries of the intercostal artery were identified in the angiography and controlled by transcatheter arterial embolization.

Conclusion

The intercostal arteries could be injured in the anterolateral zone of the abdominal wall over the end of the ribs. Contrast-enhanced computed tomography was useful to detect the bleeding point. Transcatheter arterial embolization was an effective and safe method to control bleedings from them.

Retrograde ureteral catheterization under local anesthesia for emergency drainage in patients with infection and hydronephrosis secondary to ureteral calculi: Experience from a tertiary care hospital

Objectives

The aim is to evaluate the safety and efficacy of retrograde ureteral catheterization under local anesthesia in patients with urinary tract infections complicated by hydronephrosis caused by ureteral stone obstruction.

Materials and Methods

From October 2020 to September 2021, a retrospective analysis of patients' medical records was performed. Records of past history, physical examination, laboratory tests, and imaging investigations were reviewed. Retrograde ureteric stent (RUS) was performed under local anesthesia using cystoscopes and guided by portable fluoroscopy. Real-time fluoroscopy was used to verify the double-J stent position and confirm a smooth process. The postoperative recovery and length of admission were also recorded.

Results

A total of 14 patients with ureteral stone obstruction with infective hydronephrosis received 15 total emergency RUS procedures (one bilateral). Intraoperative findings, operation times, and infection signs were recorded and analyzed. All patients met systemic infection criteria, with a mean body temperature of 38.7°C ± 1.7°C. Leukocytosis was noted in 8 (57.1%) patients. Elevated C-reactive protein (8.5 ± 6.3 mg/L) and procalcitonin (24.1 ± 22.0 ng/mL) were found in 13 (92.9%) and 9 (64.3%) patients, respectively. Mean stone size was 8.5 ± 6.3 mm, mostly localized to the upper ureter (upper: 12; middle: 0; lower: 3). Mean operation time was 14.1 ± 4.3 min. After emergency drainage, all patients improved and were discharged after infection was controlled. The average length of admission was 6.2 ± 2.2 days.

Conclusion

RUS under local anesthesia is safe and effective for treating infective hydronephrosis due to ureteral stone obstruction. A randomized controlled trial with a large sample remains necessary to validate these findings.

Percutaneous nephroscopy combined with the laser used for right kidney bullet extraction: A case report

RATIONALE

Wounds caused by firearms are intractable problems in treating war traumas and clinical management. Conventional open surgery inflicts large injury and leads to slow recovery. At the same time, most patients suffer from compound injuries with the critical condition and poor operation tolerance. Thus, it is crucial to probe into the minimally invasive surgical removal of residual kidney bullets.

PATIENT CONCERNS

We report a case where a bullet remained in the right renal parenchyma on the patient, with penetrating injury in his liver.

DIAGNOSIS

Obviously the patient has suffered gunshot wound with a bullet stuck in his kidney, while his liver function was impacted.

INTERVENTIONS

Six months after the injury, we performed the minimally-invasive procedures on the patient with percutaneous nephroscope technology and laser technology under the guidance of ultrasound localization. The bullet and ammunition granulation and scar surrounding tissue were fully removed. Intraoperative bleeding was little, while the incision was small. The patient could leave the bed and walk on the 1st postoperative day. The drainage tube was removed on the 3rd postoperative day, after which the patient was discharged on the 4th postoperative day.

OUTCOMES

The patient recovered well after surgery and was followed up for 5 years. The latest examination of his liver and kidney function was as follows: alanine aminotransferase 61IU/L, aspartate aminotransferase 33 IU/L, albumin/globulin 46.6/26.0, total bilirubin 19.1μmol/L, direct bilirubin 4.9μmol/L, indirect bilirubin 14.2μmol/L, alkaline phosphatase 111 IU/L, creatinine 57μmol/L, urea 5.16mmol/L, cystatin 0.73mg/L. The plain computed tomography scan showed a few calcifications in the liver and a patchy low-density shadow in the right kidney. It was proved that the liver and kidney function of the patient recovered well, and his living qualify has come back to the track, with no postoperative complications.

LESSONS

Innovative integration of percutaneous nephroscopy technology and laser was used to remove kidney foreign bodies and developed the optimal surgical plan, small trauma, fast recovery, and the treatment of kidney foreign bodies was newly explored.

Retroperitoneal laparoscopic renorrhaphy for post-percutaneous nephrolithotomy hemorrhage: a case report

Percutaneous nephrolithotomy is the preferred treatment for large renal calculi; however, postoperative hemorrhage is a dangerous complication. The three main causes of hemorrhage after percutaneous nephrolithotomy are pseudoaneurysms, arteriovenous fistulas, and arterial lacerations. The preferred treatment for acute hemorrhage is superselective angioembolization. However, in a few cases, angiography reveals no abnormal findings pertaining to hemorrhage. We herein present a clinical case of a 48-year-old man who presented with multiple complex right renal calculi and was managed with percutaneous nephrolithotomy in the prone position. Massive hemorrhage occurred 6 days postoperatively, and renal angiography was immediately performed. However, while the bleeding was still occurring, no extravasation was observed on renal angiography. We performed retroperitoneal laparoscopic renorrhaphy, which successfully stopped the bleeding and consequently preserved the kidney. We suggest that retroperitoneal laparoscopic renorrhaphy can be effective in patients who have undergone failed renal arterial embolization or are reluctant to undergo renal arterial embolization.

Endoscopic Combined Intrarenal Surgery vs Percutaneous Nephrolithotomy for Large and Complex Renal Stone: A Systematic Review and Meta-Analysis

Background: Managing complex and large renal stones with percutaneous nephrolithotomy (PCNL) is difficult because of the likelihood of residual stones and multiple access. Endoscopic combined intrarenal surgery (ECIRS) is introduced as an improvement to the procedure to manage stones in one session. The objective of this systematic review and meta-analysis is to compare the efficacy and safety between ECIRS and PCNL for treating large and complex renal stones. Materials and Methods: We conducted a systematic review in the Embase, Scopus, and MEDLINE databases based on the 2020 Preferred Reporting Items for Systematic Review and Meta-Analyses guideline. Eligible studies comprised both randomized and nonrandomized studies comparing ECIRS and PCNL. Results: A total of five nonrandomized studies and one randomized controlled trial were included. The analysis was divided into two subgroups based on the PCNL type, a conventional PCNL (cPCNL) and a mini-PCNL (mPCNL). The one-step stone-free rate (SFR) of ECIRS were significantly higher compared with both the cPCNL (odds ratio [OR] 5.14, 95% confidence interval [CI] 2.54 to 10.4, p < 0.001) and mPCNL (OR 4.27, 95% CI 2.57-7.1, p < 0.001). There were no significant differences in mean operative time and hemoglobin drop between both groups (p > 0.05). The use of auxiliary procedures was significantly higher in both PCNL groups compared with the ECIRS group (OR 0.19, 95% CI 0.13-0.30, p < 0.001). The overall complication rate of ECIRS was lower compared with PCNL (OR 0.43, 95% CI 0.21-0.85, p = 0.02), especially urosepsis, in which the incidence was lower compared with cPCNL (OR 0.14, 95% CI 0.02-0.78, p = 0.02), but not mPCNL (p > 0.05). Conclusion: ECIRS is an effective and safe treatment particularly for large and complex nephrolithiasis, with significantly higher one-step SFR, a lower necessity for auxiliary procedures, and a lower complication rate compared with PCNL.

Renal vein injury during percutaneous nephrolithotomy: A surgical catastrophe - Management and lessons learned

Percutaneous nephrolithotomy (PCNL) is the treatment of choice for large and complex renal calculi. We encountered a patient who was planned for PCNL in a peripheral hospital, without a preoperative computed tomography scan but was abandoned during tract dilatation due to intractable bleeding and was referred to our institute with nephrostomy in situ in a clamped state. After evaluation, the tip of the nephrostomy tube was found to be in the left renal vein causing secondary thrombosis. Due to the nonfunctional status of the kidney in the dynamic scan, the patient underwent laparoscopic left simple nephrectomy with thrombectomy without any major intraoperative complication and was discharged in stable condition.