Elsevier

European Urology

Volume 51, Issue 4, April 2007, Pages 899-906
European Urology

Review – Endo-urology
Complications in Percutaneous Nephrolithotomy

https://doi.org/10.1016/j.eururo.2006.10.020Get rights and content

Abstract

Objective

This review focuses on a step-by-step approach to percutaneous nephrolithotomy (PNL) and its complications and management.

Methods

Based on institutional and personal experience with >1000 patients treated by PNL, we reviewed the literature (Pubmed search) focusing on technique, type, and incidence of complications of the procedure.

Results

Complications during or after PNL may be present with an overall complication rate of up to 83%, including extravasation (7.2%), transfusion (11.217.5%), and fever (21.032.1%), whereas major complications, such as septicaemia (0.34.7%) and colonic (0.20.8%) or pleural injury (0.03.1%) are rare. Comorbidity (i.e., renal insufficiency, diabetes, gross obesity, pulmonary disease) increases the risk of complications. Most complications (i.e., bleeding, extravasation, fever) can be managed conservatively or minimally invasively (i.e., pleural drain, superselective renal embolisation) if recognised early.

Conclusions

The most important consideration for achieving consistently successful outcomes in PNL with minimal major complications is the correct selection of patients. A well-standardised technique and postoperative follow-up are mandatory for early detection of complications.

Introduction

Percutaneous nephrolithotomy (PNL) was established as a minimally invasive treatment option for removal of kidney stones in the 1970s and was further developed in the ensuing years [1], [2], [3]. However, PNL frequency diminished with the introduction of extracorporeal shock wave lithotripsy (ESWL) in the early 1980s [4]. In recent years, as clinical experience with ESWL revealed its limitations, the role of PNL for treating urolithiasis was redefined [5], [6], [7]. Today, PNL should be the first-line treatment for large or multiple kidney stones and stones in the inferior calyx [8]. Furthermore, improvements in instruments (i.e., flexible pyeloscopes and ureteroscopes) as well as lithotripsy technology (i.e., ultrasound/pneumatic devices, holmium/yttrium-aluminum-garnet laser) increased the efficacy of percutaneous stone disintegration yielding stone-free rates of >90% [9], [10].

Recently, a survey of urologists in Europe revealed that percutaneous procedures are performed by 69.6% of the respondents with a mean of 16.8 PNL procedures a month, clearly underlining the importance of the procedure [11]. Ultrasound renal scanning and PNL are performed more frequently outside of Europe, possibly because of larger stone burdens of the affected patients.

PNL is generally a safe treatment option and associated with a low but specific complication rate [12]. Many complications develop from the initial puncture with injury of surrounding organs (e.g., colon, spleen, liver, pleura, lung). Other specific complications include postoperative bleeding and fever.

Based on personal experience with >1000 cases [1], [3], [13], [14] and an overview of the literature, we present PNL as a step-by-step approach including the description of possible complications and their origin and management.

Section snippets

Materials and methods

Experience gathered at three German centers (Stuttgart, Mannheim, Heilbronn) since 1984 includes >1000 cases, for which the results have been published previously [3], [13], [14], [15]. In addition, a Medline search was performed reviewing the literature published between 1982 and 2006.

Mannheim experience

Overall, early complications occurred in 50.8% of the primary PNL (160 patients). Most of the early complications resolved without sequelae. Minor complications in our series included transient fever (32.1%), clinically insignificant bleeding (7.6%), or both (3.2%). A total of 3.5% of the patients developed UTI without signs of urosepsis, and 3.2% of patients suffered from renal colic. Major complications included septicaemia in 0.3%, renal haemorrhage requiring angiographic intervention in

Discussion

Significant complications in PNL can be divided into complications related to the access and those related to the stone removal.

The sources of intraoperative complications are generally attributable to:

  • Incorrect patient selection

  • The lack of adequate equipment

  • Technical errors

Conclusions

To avoid the complications associated with percutaneous endourologic procedures and to ensure optimum outcomes for patients, urologists must consider a number of factors when planning or performing PNL (Table 2). Therefore, training and experience of the urologist are critical, as is careful patient selection, accurate positioning, and use of the best available instruments.

Editorial Comment

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David Geffen School of Medicine at UCLA, United States

This is a

Conflicts of interest

In this article there is no funding or any disclosure to companies, except for the fact that the study was sponsored by the EUSP of the EAU.

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