pcnl and urology

1. COMPLICATIONS OF PCNL
Presented by : VAMSHI CHANDRA B
URO RESIDENT
CHALMEDA ANAND RAO INSTITUTE OF MEDICAL SCIENCES,
KARIMNAGAR , TELANGANA.
Guide : DR KRISHNA MURTHY S SIR
DR SAMRAT SIR
Reference : SMITH ENDOUROLOGY

2. The Access‐related Complications of Percutaneous
Nephrolithotomy
• Prevention of complications is a complex issue.
• The surgeon should take the following steps prior to every surgery.
Ensure that anticoagulants are held for the appropriate interval prior to surgery.
Ensure that the patient has adequate imaging for selection of the best access to
maximize intraoperative stone removal.
Ensure that the patient has sterile urine prior the procedure. If the patient has
colonized urine, use a percutaneous nephrostomy tube to maximally drain the
kidney and continue antibiotics. The patient can then proceed with a staged
percutaneous nephrolithotomy.
Ensure that backup equipment is available. This will prevent intraoperative delays.

3. Problems with initial puncture of the kidney
• Selection of calyx
• Hemorrhage
• Guide wire insertion
• Arterial puncture
• Venous puncture
• Issue with full staghorn calculus
• Injury to the adjacent structures
Nervous injury
Intrathoracic injury
Bowel injury
Liver and spleen injury

4. Selection of calyx
• When selecting a calyx for puncture, focus should be placed on obtaining access
through a calyceal fornix rather than the calyceal infundibulum. This will minimize the
risk of hemorrhage intraoperatively and postoperatively.
• Further, access should be attempted laterally as opposed to medially with respect to
the kidney. The avoidance of medial access is necessary, as the renal artery and vein
and renal pelvis are more easily injured when medial access is attempted.
• With the patient in the prone position, a retrograde pyelogram is performed. When
inspecting the selected calyx to ensure that the puncture was obtained in the desired
location, or if one wishes to delineate a posterior calyx, inject CO2, not air, as the use
of air increases the risk of air embolism in the event of inadvertent arteriovenous
puncture.
• Care must be taken not to overfill the system, as this may cause extravasation,
resulting in a poorly visualized collecting system. If this occur, the surgeon might
need to select a different calyx or merely wait until the contrast is absorbed.

5. Hemorrhage
• The overall rate of hemorrhage requiring blood transfusion
during PCNL is estimated to be around 2–11%.
• Some important risk factors for intraoperative haemorrhage
during PCNL include
diabetes mellitus leading to arteriosclerosis,
hypertension,
stone size greater than 1250 mm2,
presence of staghorn calculi,
number of accesses,
and operative time greater than 58 minutes.

6. • In most cases, bleeding during PCNL access can be attributed to
laceration of subsegmental veins, and use of the Amplatz sheath
to apply occlusive pressure will control the bleeding.
• To avoid tearing the renal parenchyma, once percutaneous
access is obtained, the surgeon should avoid excessive up and
down movement of the needle.
• In addition, medial insertion of the needle, which can lead to
injury to the renal artery or vein or interlobar vessels, can incur
further risk of bleeding.

7. • If bleeding is excessive and the Amplatz sheath does not suffice, a
large‐caliber nephrostomy tube can be inserted or capped .
• If that fails, insertion of a Kaye tamponade balloon catheter is advised.
This approach allows for drainage of the renal pelvis while
tamponading the nephrostomy tract .
• Once again, if this fails, the patient should be sent to interventional
radiology for angiography. In cases in which conservative measures are
unsuccessful, the use of super‐selective angioembolization will help
control the bleeding.

8. Guide wire insertion
• Appropriate guidewire insertion is crucial to the success of the
procedure.
• Kinking occurs when the tract from the skin to the kidney is not in a
straight line.
• This is commonly related to timing of puncture: while initial puncture
occurring during inspiration may lead to caudal displacement of the
kidney, tract dilation occurring during expiration will lead to cranial
displacement of the kidney, changing the tract trajectory and leading
to guidewire kinking.
• Alternatively, guidewire kinking may result from an angled puncture.

9. • It is essential to monitor the dilation of the tract fluoroscopically
to ensure smooth passage over the wire, Otherwise kinking of
the guidewire is inevitable.
• When kinking of the guidewire is noted upon introduction, the
surgeon should attempt to reposition the wire prior to
re‐attempting puncture.
• Never attempt nephrostomy tract dilation
over a kinked guidewire, as this will likely
lead to dilation tangential to the desired
tract and increases the
risk of injury to adjacent organs .

10. • Initially, the guidewire can be pulled back so that the kink is outside
the nephrostomy tract. This is only possible if there is sufficient
guidewire within the kidney to the ureter.
• Another option is to advance a 6 Fr dilator over the wire through
the nephrostomy tract. The 6 Fr dilator is more flexible and can
often be advanced over a moderate kink. The existing wire can be
removed and exchanged for a new, unkinked super‐stiff wire,
which will allow for tract dilation.
• If all of the above techniques fail, removal of the guidewire and
repeat puncture should be attempted.

11. Arterial puncture
• Cases of arterial puncture are confirmed with pulsatile bleeding noted
from the lumen of the needle; this occurs with a medial puncture or if
the needle is advanced too far medially.
• This can be checked in the 90° position under fluoroscopic guidance.

12. • A puncture of a vessel by an 18 Fr needle seldom poses a
problem. One should merely withdraw the needle approximately
1cm and attempt to insert it into the appropriate calyx.

13. Venous puncture
• Occasionally, introduction of the guidewire leads to insertion into the
renal vein. This is not all that uncommon.
• Fluoroscopic advancement of the wire will show the wire advancing
into the inferior vena cava.
• Once again, withdrawal of the needle and repositioning is all that is
required.

14. • If dilation over the wire into the tract is attempted, the renal vein is
accessed and can appear to look like the renal pelvis without the
calyces in the expected anatomic position.
• When this occurs, remove the nephroscope, gain access to the
Collecting system, dilate the tract, and insert a Councill catheter, with
the balloon of the Councill catheter occluding the laceration in the
renal vein.
• The balloon can be deflated after 48–72 hours.

15. Issues encountered with a full staghorn calculus
• The patient with a full staghorn calculus remains a persistent challenge at
the time of needle placement.
• If the stone fully occludes the calyx, the needle will meet resistance at the
level of the stone. When the needle is removed, the trocar portion of the
needle may not be in the calyx and the guidewire cannot be advanced.
• To counteract this, the trocar (or the sheath of the needle) may be
advanced onto the stone and the needle withdrawn.

16. • Another alternative is to dilate the tract up to the calyx and then
displace the tissue overlying the stone with a grasping forceps.
The Amplatz working sheath is then gently rotated until its edges
are within the Collecting system, and subsequently against the
stone itself.
• Another option is to employ the technique originally described by
Clayman et al.. In this technique, ureteroscopic lithotripsy and
stone extraction is performed to create space within the renal
pelvis and create an appropriate calyx and an unobstructed route
to the calyx to facilitate passage of the wire and subsequent
percutaneous access.

17. Nervous injury
• The intercostal nerve and artery are at high risk for injury when
supracostal access is attempted. For this reason, supracostal
access has been reported to have an increased risk of pain and
bleeding.
• Attempting to access the kidney lateral to the paraspinous muscles
within the lower half of the 11th intercostal space may minimize this
risk.
• Occasionally, a bulge in the skin overlying the area of
percutaneous access is seen and this is associated with nervous
injury.

18. Hemorrhagic Complications Associated with
PCNL
Hemorrhage results from either damage to the
1) kidney parenchyma,
2) disruption of the peri‐ or intrarenal vessels,
3) or injury to adjacent structures.
 Renal parenchymal bleeding, believed to stem most commonly
from the interlobular vessels, is often mild, apparent during
surgery, and frequently can be controlled with intraoperative
tamponade from the access sheath, and with larger bore
nephrostomy or nephroureteral catheters postoperatively.

19. For vessels in spasm, bleeding may be minor during surgery, but once
the spasm abates, bleeding and its effects often become apparent within
the first 24–48 hours postoperatively.
Injury to these larger vessels is also believed to be the cause of delayed
bleeding. Such delayed bleeding often takes one of two forms:
arteriovenous fistulas and pseudoaneurysms.
In both of these cases, significant renal bleeding can present in the early
postoperative course or in delayed fashion as late as a number of weeks
postoperatively

20. Risk factors associated with hemorrhage during
PCNL
• Patient‐related factors:
 Obesity
 hypertension,
 arteriosclerosis and diabetes,
 older
 age,
 renal insufficiency,
 lack of preoperative hydronephrosis,
 history of prior renal surgery, (open vs pcnl vs eswl)
 renal anomalies,
 underlying or prior urinary tract infections
 and the use of anticoagulants

21. • Operative‐related factors:
Operative and technical factors that have been shown to
influence and increase bleeding risk include
longer operative duration, (110 – 120 min)
longer intraoperative time to successful renal puncture
larger access tract size, (18f– 24f 3 fold – 27f 5 fold)
larger bore nephroscopes
less surgeon experience,
use of multiple access tracts, (3 or more)
upper pole calyceal access.

22. • Stone‐related factors:
stone composition and burden have been correlated with increased
bleeding risks
In particular, staghorn stone configuration appears to be consistently
related to increased risk of perioperative PCNL bleeding

23. Preoperative patient assessment and optimization
 Absolute contraindications to PCNL include uncorrected coagulopathy and active
infection.
blood dyscrasias and Medications history.
Appropriately screened and cross‐matched blood products should be available.
Preoperative negative urine cultures should be the goal.
In the operating room, immediately preceding PCNL, maintaining adequate patient
temperature is imperative as efficient clot formation depends on body temperature,
and lower core body temperatures are associated with inefficient clot formation
During patient positioning alone, core body temperatures can fall by approximately
1°C .

24. Intraoperative hemorrhage: recognition and management
strategies
• Intraoperative hemorrhage is typically not subtle, and can happen at any
step during PCNL, from initial percutaneous access to final urinary
drainage.
• The moments of greatest hazard are:
(i) during initial access and percutaneous tract dilation
(ii) during excessive torqueing of the sheath or nephroscope during the
procedure, which can result in renal parenchymal shearing and tearing.

25. • The first step to minimizing bleeding begins with the initial renal
puncture.
The preferred approach involves an “end‐on” calyceal puncture,
where the access needle asses centrally through the longitudinal
axis of the targeted posterior calyx.
The preferred access should traverse Brodel’s avascular plane
along the shortest and straightest track from the skin to the
collecting system, thereby minimizing the amount of renal
parenchymal disruption.
Excessive medial advancement of renal dilators should be avoided.

26. When significant bleeding is encountered anaesthesia team should be
informed so that preparations can be made for closer hemodynamic
monitoring and possible transfusion of blood products.
Most are self limited and tamponade from the access sheath is sufficient
and procedure can to continued.
During stone manipulation, the access sheath should remain positioned
across the renal parenchyma to avoid repeated shearing and loss of
tamponade, both of which will increased bleeding and obscure vision.
To prevent these issues from arising, excessive force should be
minimized when removing calculi, and attempted removal of stones
that are too large should be avoided

27. • If significant bleeding or the passage of blood clots persists through the
sheath, visualization may be impaired. When visualization is too poor to
continue safely, it is best to place a large‐bore nephrostomy tube and
return at a later date, after bleeding has ceased.
• Use of vasopressors by anaesthesia team indicate large blood loss.
• Note that intraoperative assessment of blood counts may
underestimate the degree of blood loss in acute setting.
• So blood products should be started when clinical signs appear.
Hemodynamic instability often evidenced by tachycardia and
hypotension.

28. • When heavy bleeding is encountered, vision can be improved by
1) moving access sheath closer to the stone or collecting system
wall.
2) irrigation pressure can also be increased
– done with caution- increase risk of infection and sepsis.
• If vision remains limited or bleeding persists, a large diameter catheter
(COUNCILL TIP)CAN BE PLACED OVER THE WIRE AND
THROUGHT THE SHEATH OF THE KIDNEY.– 3 to 5 ml , 5 min ,
reassess , re position.
• Procedure terminated when in doubt and catheter left in place

29. • Another option is to use a large‐bore nephroureteral
catheter or re‐entry tube to provide tract tamponade
and maintain access to the collecting system and
ureter
• A kaye tamponade balloon catheter can be advanced
over a wire into the renal pelvis under fluoroscopic
guidance and provides excellent control of tract
bleeding while maintaining collecting system access.
• 1) Refractory bleeding,
2) significant blood clots emanating from the
nephrostomy catheter,
3) hemodynamic instability after any of the above
maneuvers
suggests ongoing, often arterial, bleeding (Figure
33.2).

30. • Attention should be paid to the patient’s vital signs, and if there is concern
for impending hemorrhagic shock, blood product transfusions should be
initiated, the procedure should be aborted, and a low threshold should
exist to transfer patients directly from the operative suite to angiography
for possible angioembolization.
• If Bleeding is believed to be from an intercostal vessel, a small incision and
cutdown directly onto the caudal aspect of the involved rib, allowing for
vascular control, may be considered.

31. • Strategies to avoid this complication include
ensuring urine return through the puncture needle prior to tract dilation,
withdrawing the needle and choosing a different puncture if blood is aspirated during
initial needle puncture,
and directing a stiff guidewire down the ureter prior to tract dilation.
• Catastrophic bleeding in the setting of severe hemodynamic instability may
preclude safe transit for angioembolization. This can result from injury to the
main renal vessels and usually occurs during overly forceful tract dilation or
too medial placement of initial puncture needle and tract. Very occasionally,
though, this may result from overly aggressive nephroscope and renal
manipulation.
• When this is encountered and the patient cannot be safely transferred for
angioembolization or this resource is not available, then retroperitoneal renal
exploration can be attempted to achieve vascular control; however, this often
results in nephrectomy.

32. Management of postoperative and delayed hemorrhage
• In the postoperative period, patients should be monitored for changes in
vital signs and for hematuria, both from the nephrostomy tube and per
urethra.
• Bleeding originating from the parenchyma usually manifests as hematuria
through the nephrostomy tube and or urethral catheter, while bleeding
from the percutaneous tract can present as bleeding around the
nephrostomy.
• Moderate hematuria can often be managed by clamping the nephrostomy
tube temporarily or elevating the nephrotomy drainage bag above the level
of the ipsilateral kidney, both of which aim to facilitate clot formation within
the kidney and potentiate internal tamponade.

33. • Heavy tract bleeding or hematuria in the immediate postoperative period
can often be managed through a combination of local compression and
nephrostomy tube clamping.
• Local compression – repositioning , 3 lit water bag and hands and fist
compression.
• Following the immediate postoperative period, persistent or worsening
hematuria should raise suspicion for hemorrhage that may require
intervention.
• Clamping nephrostomy tube and releasing it after hours and showing
clear or light pink urine indicates cessation of bleeding.

34. • Occasionally, heavy bleeding arises with nephrostomy catheter removal.
This often stems from an open arterial branch that was occluded by the
nephrostomy catheter or by a vessel that was in spasm but opens with
catheter removal.
• Rapid catheter reinsertion and external tract compression are
recommended in this scenario, with consideration for subsequent renal
angiography and possible embolization, especially when accompanied
by signs of hypovolemia and hemorrhagic shock.
• When the above‐described measures are unsuccessful in controlling
bleeding or when the severity and acuity of bleeding are more drastic,
renal angiography with the option of selective or superselective
embolization is recommended.

35. • In general, indications for renal angioembolization include
the need for repeated transfusions,
ongoing hemoglobin decrease,
hemodynamic instability,
repeated bladder clot evacuations,
and imaging suggestive of vascular lesions (AVF and ANEURYSMS) – present
as delayed bleeding – 1 to 2 weeks after surgery.
• When analyzing risk factors for failed initial angioembolization,
multiple bleeding sites and
multiple percutaneous tracts
were found to correlate with angioembolization Failure.

36. • Following renal angioembolization, the vast majority of patients (up
to 90%) can experience some combination of
flank pain,
nausea and vomiting,
and leukocytosis,
collectively referred to as postembolization syndrome.
• Rarely, lumbar artery injury causes significant bleeding which is controlled
by angioembolisation.

37. • Perinephric and subcapsular hematomas may occur in up to one‐third
of PCNLs, and are usually clinically silent with fewer than 1% requiring
intervention with selective angioembolization.
• Perinephric hematoma should be considered when post‐PCNL
hemoglobin continues to drop despite clear urine drainage.
• In rare instances, a perinephric hematoma may lead to a “Page
kidney,” where incomplete or delayed resorption of the hematoma
causes renal compression and relative hypoperfusion and the
subsequent development of hypertension.
• In these instances, percutaneous drainage of the perinephric
hematoma is suggested.

38. Diagnosis and Management of Thoracic Complications of
Percutaneous Renal Surgery
• The superior pole of the right kidney is
typically located slightly superior to the 12th
rib, while the superior aspect of the left
kidney is often located just beneath the 11th
rib.
• the 11th intercostal space is located between
the 11th and 12th ribs.
• If supracostal access is used, needle access
should be done on the superior aspect of the
rib below to minimize bleeding.

39. • Posteriorly, in the midscapular line, the parietal
pleura attaches to the internal aspect of the 12th
rib.
• At the midaxillary line, the pleural is
approximately at the level of the 10th rib and
anteriorly, the parietal pleura is approximately at
the level of the 8th rib.
• Posteriorly, the 12th rib curves downward, yet the
pleura continues in a relatively horizontal plane,
crossing the 12th rib at the lateral border of the
erector spinae muscles of the back.
• The relative levels of the kidneys and parietal
pleura in relation to the ribs means that in many
patients the superior aspects of the kidneys are

40. Incidence, etiology, and risk factors of thoracic
complications
• Thoracic complications constitute a significant percentage of the overall
complication rate following percutaneous renal surgery with an incidence
of 1.8–3.1%.
• The risk of injury to the pleura increases with higher intercostal space
access to the kidney.
• Clinical Research Office of the Endourological Society (CROES)
published data from 5803 patients across 96 worldwide centers showing
an overall rate of thoracic complications of 1.8%, all of which were
hydrothoraces.
• The upper pole access group had a hydrothorax rate of 5.8% whereas the

41. • When access superior to the 12th rib is preferred, staying lateral to the
midscapular line may reduce the risk of pleural injury.
• Therefore, staying lateral to the paraspinal muscles may allow
supracostal access while decreasing the incidence of pleural injury.
• Another risk factor for the development of a hydrothorax is premature
withdrawal of the percutaneous access sheath.
• The percutaneous renal access sheath offers several advantages, it
diverts urine and irrigation from the renal collecting system through the
center of the sheath and out of the body. This helps to decrease the
intrarenal pressures while operating and helps to minimize extravasation
of fluid out of the kidney into the retroperitoneum.

42. • Therefore, care must be taken to ensure that the sheath is not
displaced during the surgery.
• Occasionally the sheath is withdrawn to allow access to nearby
calyces. It is recommended that this be done near the end of the
procedure to help minimize any extravasation that may occur.
• Patients who have certain anatomic variations such as
horseshoe kidney, pelvic kidney, and malrotation tend to have
lower risks of thoracic complications as the kidney is located
more caudad.

43. • Body mass index (BMI) does not appear to have an impact in thoracic
complications.
• Special consideration should be given to patients that have alteration of
normal anatomical landmarks such as patients with severe scoliosis,
spinal cord injury, and other musculoskeletal deformities.
• Relationship of the pleura to the kidneys is often distorted due to their
physical deformities.
• CT or ultrasound imaging should be considered when obtaining access
in these patients to decrease thoracic complications

44. • Descriptions of thoracic complications
Pneumothorax (tension pneumothorax)
Hydrothorax (irrigation fluid, urine, reactionary– urinoma and nephropleural
fistula)
Hemothorax (intercoastal vessels, kidney parenchyma)
Empyema
• secondary infection of sterile fluid that enters the pleural space or as a result of
infectious fluid that accumulates within the pleural space.
• stones also has a known risk of releasing any bacteria.
• An empyema may also result from a nephropleural fistula if associated with a
urinary tract infection.

45. Intraoperative signs of thoracic complications
• This is particularly problematic when the patient is in the prone position,
as expansion of the thoracic cavity is limited in this position and the
patient’s weight further reduces the expansive capability of the chest wall.
• Furthermore, when the patient is in the prone position, it is difficult to
observe any expansion of the thoracic or abdominal cavity.
• Narrowed pulse‐width pressures.
• If a nephrostomy tube is placed at the end of the procedure, many
urologists inject contrast to ensure proper placement. If contrast is seen
communicating with the pleural space, this indicates that a pleural
violation has occurred.

46. Radiologic diagnoses of thoracic
complications
• Radiologic evaluation of the patient after the procedure is
recommended, especially after upper calyceal access.
• Performing intraoperative radiographs has the advantage that if a
significant intrathoracic air or fluid collection is encountered,
percutaneous aspiration or the placement of a chest tube can be
accomplished while the patient is under anesthesia.
• Symptoms of thoracic complications:
pleuritic chest pain
shortness of breath (SOB)
and may demonstrate hypoxia or decreased breath sounds on the
affected side.

47. • Chest X‐rays can detect as little as 50 ml of fluid in the lateral view,
• Whereas volumes of 200 ml are typically needed to view blunting of the
costophrenic angle on anteroposterior films,
• and the diaphragm becomes obscured at a volume of 500 ml .
• Ultrasound may also be used to evaluate for pleural fluid accumulation and
can visualize as little as 50 ml of fluid .
• CT scan is the most sensitive modality, however this is the most costly of the
imaging techniques

48. Differentiating between thoracic pathologies
• A pneumothorax can be easily differentiated from forms of hydrothoraces
by the presence of air in the pleural space.
• Hydrothoraces will demonstrate a hazy appearance in the dependent
portion of the chest that obscures the costophrenic (CP)angle of the
pleural reflection as it continues from the lateral chest wall onto the
domed shape of the diaphragm.
• Differentiating between types of hydrothorax may require aspiration of the
pleural fluid.

49. • If a urinothorax is diagnosed, one must consider if this was urine that
accumulated during the procedure or if a nephropleural fistula is
present.
• The diagnosis of a nephropleural fistula is more likely when the patient
has a delayed presentation of fluid.
• if a nephrostomy tube is still present, a nephrostogram may
demonstrate extravasation of contrast from the collecting system into
the pleural space.
• A retrograde pyelogram may also be beneficial in the evaluation,
diagnosis, and management of nephropleural fistula, particularly when
there is no nephrostomy tube.

51. Management of thoracic complications
• The management of thoracic complications is largely
determined by the patient’s clinical status.
• Small volume of air and fluid in the pleural space may be
observed when the patient is minimally symptomatic.
• Intervention is therefore indicated if the patient is having
significant symptoms, or when significant volumes of air or
fluid are seen.
• Chest drainage is the treatment for thoracic complications.

52. • The type and size of the chest tube depends on the pathology being
managed.
• Small chest tubes are usually adequate to drain air and simple fluid
collections, whereas larger tubes may be needed to optimally drain
hemothoraces and empyemas.
• Chest tubes are typically placed to continuous suction at about 20 cmH2O
and are flushed with small volumes of saline every 6 hours to minimize the
risk of tube occlusion and ensure drainage.
• If clinical improvement is not seen after about 24 hours of drainage, imaging,
such as CT or ultrasound, should be utilized to ensure appropriate
placement.
• If the tube is in the correct location without improvement in the collection,

54. Hydrothorax management
• Symptomatic or large hydrothoraces typically require chest tube
drainage.
• The size of the chest tube and duration of drainage vary depending on
the type and size of the hydrothorax.
• The viscosity and visual assessment of fluid can be done on the initial
aspiration during placement of the chest tube.
• If simple fluid or urine is detected, this may be adequately drained with
smaller bore chest tubes. However, if pus is returned, a largebore chest
tube may be useful.

55. • If there is clinical concern for infection, antibiotics should be
initiated if they have not been already.
• The patient is followed for resolution of symptoms and serial
chest radiographs are obtained to monitor resolution of the fluid
collection.
• Once resolution has been documented, the chest tube may be
removed

56. Empyema
• Empyemas can be difficult to treat and may not resolve with chest tube
drainage alone as the purulent fluid can be quite thick.
• Surgical drainage is recommended in patients who fail chest tube
drainage or for the primary treatment of patients with loculated or thick
fluid on imaging.
• Surgical drainage can be accomplished via endoscopic approaches
(VATS) or open surgical drainage.
• Early surgical drainage was associated with a higher treatment success
rate, fewer days of chest tube drainage, and shorter hospital stay.

57. • Reactive effusions typically resolve spontaneously with time.
• If a nephrostomy tube has been left in place, this should be
removed to eliminate the diaphragmatic irritation.

58. Nephropleural fistulas
• Nephropleural fistulas typically resolve with placement of chest tube and
urinary drainage with a ureteral stent or a nephrostomy tube.
• If the patient has persistent leak, anticholinergics or foleys catheterisation
done.
• This typically resolves in 12 hours and foleys can be removed if it is
placed for the same reason.

59. • The nephrostomy tube itself can be an exacerbating factor in
hydrothoraces.
• If the nephrostomy tube traverses the pleura, urine can extravasate and
course along the tube into the thoracic cavity.
• In this instance, removing the nephrostomy tube will aid in pleural closure
and healing.
• If there is a concern for pleural violation at the time of surgery, placement
of a lower pole nephrostomy tube can drain the kidney while allowing the
pleural violation to heal.

60. Hemothorax and pnemothorax
• Hemothoraces are treated in a similar manner as other hydrothoraces.
However, like empyemas, the fluid collection is typically quite thick
and may require the use of a larger bore chest tube.
• Pneumothoraces may be observed when small and the patient is
minimally symptomatic.
• If the patient is experiencing significant pleuritic pain, decreased
oxygen saturations, shortness of breath, or has failure of the
pneumothorax to resolve on chest radiography, a chest tube is placed.

61. Prevention of thoracic complications
• The most important aspect of minimizing complications is deciding when
the benefits of upper pole access outweigh the risks associated with this.
• Needle access should be obtained in full expiration in order to decrease
the amount of pleura and diaphragm that lies over the kidney.
• If the 10th or 11th intercostal space is used for access, placement of the
needle lateral to the midscapular line can help to minimize injury.
• Another technique that has been used to is to place a needle or a
small‐caliber sheath into the lower aspect of the kidney in order to displace
it inferiorly.

62. • The use of a percutaneous access sheath throughout the entire procedure is
recommended. This will serve to divert most of the urine and irrigation out of
the body, which will minimize any accumulation in the chest.
• It is also important to ensure that the access sheath remains in the collecting
system throughout the procedure. If the sheath is withdrawn from the collecting
system, this may allow fluid to flow into the retroperitoneum and possibly the
thoracic cavity .
• Furthermore, the percutaneous access sheath serves to maintain a low
intrarenal pressure. If this is not done, the intrarenal pressure can increase,
causing extravasation of fluid which can accumulate in the thoracic cavity.
• Prompt removal of a nephrostomy tube is wise if there is concern about pleural
violation as air and fluid can track along the tube into the pleural space. In
addition, the presence of a tube will discourage the closure of the pleural defect.

63. Bowel and Other Organ Injuries with Percutaneous
Nephrolithotomy
Colon injury
• Colon perforation at the time of PCNL is
uncommon, occurring in less than 1% of
procedures.
• The colon is typically positioned anterior or
anterolateral to the kidney, and in this
orientation risk of injury occurs with extreme
lateral access to the kidney, beyond the
posterior axillary line.
• Thus, with normal anatomy, the risk of injury is
low. However when abnormal anatomy is
present, namely a retrorenal colon, the risk

64. • Risk factors for colonic injury include
retrorenal colon,
renal anomalies (e.g. horseshoe kidney and renal ectopia),
any history of small bowel resection and diversion,
or neurogenic bowel,
previous renal surgeries,
chronic constipation and bowel distention.
• Most injuries that occur result from lower calyceal punctures.
• Preoperative cross‐sectional imaging will help identify high‐risk patients
and will allow the surgeon to plan their access in order to avoid colonic
injury.
• For patients with severely altered anatomy with narrow windows of

65. • Early diagnosis of colonic perforation is key to preventing more serious
infectious complications
• A nephrostogram during the case may demonstrate contrast within the
colon, at which time drainage may be established.
• Postoperatively,
the presence of diarrhea,
hematochezia,
or passage of gas or fecal material
through the nephrostomy may all indicate injury.
• Intraoperative or postoperative imaging with nephrostogram or CT scan
is recommended, at which time perforations may be seen.

66. • Delayed recognition may increase the risk for infection, including
sepsis, and appropriate antibiotic coverage for urinary and
colonic pathogens should be implemented.
• Treatment of colonic perforation is usually conservative in the
absence of peritoneal signs or sepsis.
• Conservative management is accomplished by withdrawing the
nephrostomy into the colon to serve as colostomy drainage and
placing a double‐J stent.

67. • A catheter should be placed into the bladder to create a low‐pressure
system. Patients should be covered with broad‐spectrum antibiotics, and
placed on a low‐residue diet or alternately on total parenteral nutrition.
• After 5–7 days, if a colostogram or retrograde pyelogram fails to
demonstrate communication between the colon and kidney, the
colostomy is withdrawn into the retroperitoneum to serve as a drain.
• If a barium enema 2–3 days later demonstrates closure of the colon, the
retroperitoneal drain can be removed by day 7–10.
• Patients who develop signs of sepsis or persistent nephron– colonic or
colocutaneous fistula should be considered for surgical exploration with
diverting colostomy.

68. Other bowel injury
• Due to the proximity of the second and third portions of the duodenum to
the right kidney, injury may occur at the time of PCNL. (very rare).
• With the duodenum lying anterior and medial to the kidney, retroperitoneal
access should be able to avoid this potentially devastating complication.
• However, the duodenum may be injured during right PCNL if the renal
pelvis is perforated during access or dilation when a needle or instrument
is advanced too far.
• Injury to the small bowel should be suspected if bowel mucosa or bowel
contents are visualized along the guidewire or nephrostomy tract. It may
also be identified on nephrostogram either intraoperatively or

69. • A large injury, signs of sepsis, or peritonitis typically necessitate
surgical exploration with open surgical repair.
• Small perforations in a stable patient without evidence of sepsis or
peritonitis may be observed.
• Conservatively managed patients should have confirmation of a
well‐draining nephrostomy tube and be placed on bowel rest with
nasogastric suction and institution of total parenteral nutrition to allow
closure.

70. • Follow‐up interrogation with nephrostogram and upper
gastrointestinal study may be performed 10–14 days after surgery
to ensure closure.
• In this way, early identification of bowel injury allowed for more
conservative approaches, as prompt drainage and initiation of
bowel rest may minimize damage.
• Delayed recognition or large injuries to the small bowel typically
necessitate surgical exploration and may be associated with more
serious morbidity.

71. GB INJURY
• Gallbladder injury during PCNL is a rare but serious complication, with
eight reported cases in the literature, all requiring surgical exploration and
cholecystectomy.
• Injury to the gallbladder should be suspected if a greenish discharge is
found along the access or if a patient develops signs of peritonitis
following a right sided procedure, in which case a CT scan would be the
imaging of choice.
• Timely diagnosis is important, as biliary leakage may result in profound
peritonitis, infection, and scarring with adhesions. All injuries require
exploration with cholecystectomy to avoid severe ‘sequelae of this rare
complication.

72. Liver and spleen injury
• Because of the close proximity of the right kidney to the liver and the
left kidney to the spleen, a theoretical risk of injury occurs at the time of
PCNL. However such injuries are rare.
• A CT‐based analysis of the risk of organ injury during supracostal
approach found a theoretical risk of splenic injury, which increased the
higher the puncture.
• While there was minimal risk of splenic injury with punctures above the
12th rib done on expiration, this risk rose to 33% for punctures above
the 11th rib on inspiration.

73. • Such access should be avoided whenever possible and
if it is needed, the surgeon should consider CT‐guided
access. Careful inspection of cross‐sectional imaging
should precede PCNL so that the surgeon is aware of
at‐risk structures relevant to their access approach of
choice.
• Splenic injury should be suspected in the setting of
profound hemorrhage, hemodynamic instability or pain
out of proportion to the surgery occurring with a left
sided access.
• CT scan is the imaging of choice, but may not always be
obtained immediately as patients with excessive
bleeding are often sent for angiography in order to
perform selective embolization.

74. • In the truly unstable patient, exploration and splenectomy may
be lifesaving. However, there are multiple reports of successful
conservative management of splenic injuries.
• conservative options in the stable patient may include close
observation, delayed removal of the nephrostomy tube, and
novel coagulants down the tract

75. • Liver injury at the time of PCNL is rare, with only one reported case
in the literature .
• Study of anatomic relationships on CT scan predicted minimal risk
to the liver with access above the 12th rib, but a 14% risk was
found in tracts above the 11th rib.
• Hepatomegaly may place the patient at risk, particularly if the
access takes a more lateral orientation (Figure 35.4), but can
usually be avoided with careful inspection of a preoperative CT
scan.
• Conservative measures may include delayed removal of a
nephrostomy tube, ureteral stenting to avoid fistula, and use of

76. • Thank you

77. • The lungs are enveloped by two layers of a thin, serous,
• membrane called the pleura. The parietal pleura lines the
• internal aspect of the thoracic cavity while the visceral
• pleura directly surrounds each lung. These two layers

78. • Upper pole access is often preferred to treat urinary stones in the
proximal ureter, stones associated with UPJ obstruction, upper
calyceal diverticulum stones, renal anomalies, and complex staghorn
stones.
• Some had advocated for the use of a ureteral access sheath during PCNL.
This can serve to further minimize the intrarenal pressures and minimize
hydrothorax
• This risk may be markedly higher in patients with abnormal anatomy,
such as severe spinal scoliosis, where retrorenal colon was identified
in up to 25% of patients.
• Anatomic studies have found that a retrorenal colon exists in
between 0.6% and 2% of patients, and is more common on the left
side

79. • Most commonly, bleeding is secondary to injury of segmental
arteries.
• If that fails, insertion of a Kaye tamponade balloon catheter
involves insertion of a 36Fr occlusive balloon over a 5 Fr
ureteral stent. This approach allows for drainage of the renal
pelvis while tamponading the nephrostomy tract .