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COMPLICATIONS WITH PERCUTANEOUS

NEPHROLITHOTOMY1. Incidence

2. Non-hemorrhagic Complications

Manoj Monga MD

The Cleveland Clinic

THE CLINICAL RESEARCH OFFICE OF THE ENDOUROLOGICAL SOCIETY (CROES)

PERCUTANEOUS NEPHROLITHOTOMY (PCNL) GLOBAL STUDY:INDICATIONS, COMPLICATIONS AND OUTCOMES IN 5803

PATIENTSDe la rosette and CROES

• 96 centres worldwide.

• Complications

– significant bleeding (8%)

– renal pelvis perforation (3%)

– Hydrothorax (2%)

– Blood transfusion (6%)

– fever >38.5 °C (11%)

Risks of PCNL• Chicago• 11,721 patients • National Inpatient Sample for 2002-2008• Mortality rate 0.3% - Stable• Transfusion rate – 5% - Increasing

– Higher – small hospitals, elderly

• Chest tube - 1% – Higher – teaching hospitals, young (<30)

• Need for a chest tube or blood transfusion – 3-fold increase in length of stay and hospital

charge. AUA 2011(Abstract 1686)

Prevention: Pick the right patient

STONE SIZE>15MM

Y N

AnticoagulationPleura on CT

PCNL URS SWL

AnticoagulationHU >1200STSD >12 CMLP 10-15mm

N Y Y N

PD23‐01: The effect of continued aspirin therapy in patients undergoing PCNL

Brandon Otto, Forat Lutfi, Russell Terry, Mohit Gupta, Vincent G Bird, Gainesville, FL

• 77/285 (27%) PCNL’s ‐ on aspirin therapy (86% on 81mg daily)

• Compared aspirin (n= 77) to NO aspirin (n= 208)• NO SIGNIFICANT DIFFERENCES

• Residual fragments• Periop change in Hgb/Hct, creatinine• 30‐day complication rate – bleeding or thrombotic events

• PCNL appears both effective and safe in patients continuing ASA perioperatively

READMISSION AND COMPLICATION RATES IN PATIENTS UNDERGOING PCNL,

STRATIFIED BY CO-MORBID FACTORSN. Ginzburg, D. Hoenig, A.A. Hakimi, A. Ovadia, D. Faleck

Albert Einstein / Montefiore – Bronx USA

• Diabetics– higher readmission rates (p<0.001)

– more emergency room visits (p=0.017)

• BMI– Higher readmission rates (p=0.039).

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Percutaneous Nephrolithotomy (PCNL)

4 of 1000 patients DIE from PCNL

WHY?Sepsis

J Urol 2013 Aug;190(2):558-64.

SEPSIS after PCNL and URS

• LIJ

• Preoperative predictors of sepsis after PCNL and URS– bladder outlet obstruction (OR 6.4)

– positive pre-operative urine culture (OR 6.7)

– indwelling nephrostomy tube (OR 6.4).

• Treatment of a positive preoperative urine culture did not reduce the risk of sepsis, and cannot be considered a reliable preventative measure.

(Abstract 1548)

Stone / Pelvis Culture

• 37% of pts – SIRS after PCNL– 4x higher risk if positive stone culture or positive

pelvis aspirate– Bladder culture not predictive

– J Urol. 2005 May;173(5):1610-4.

MP20-14 ANTIMICROBIAL UTILIZATION PRIOR TO ENDOUROLOGICAL SURGERY FOR UROLITHIASIS: ENDOUROLOGICAL SOCIETY SURVEY RESULTS

Adam Kaplan

The Journal of UrologyVolume 193, Issue 4, (April 2015)

DOI: 10.1016/j.juro.2015.02.986

Copyright © 2015 American Urological Association Education and Research, Inc. Terms and Conditions

MP38-05 THE MODERN ERA STRUVITE STONE: PATTERNS OF URINARY INFECTION AND COLONIZATION

Adam De Fazio, Haresh Thummar, Michael Rothberg, Piruz Motamedinia, Gina Badalato, Mantu Gupta

STRUVITE STONES:Positive Urine Culture for Urea-splitting organism

Preop 31%12 months 58%

Positive stone culture 69%Urea-splitting organism 29%

Non-RCT – Ciprofloxacin 250 BID x 7 days

BJU Int. 2006 Nov;98(5):1075-9.

% Of Pts

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RCT – Macrodantin 100mg BID x 7 days

UROLOGY 77: 45–49, 2011. © 2011

% Of Pts

Antibiotic Options• Follow the guidelines• Individualize approach

– 1 week for:• Recurrent UTIs• Indwelling catheters• Neurogenic Bladders• Pyuria• Struvite

• Treat everyone with 1 week of antibiotics

Porcine Model of PCNLE Coli Infusion

“Mini” arm10F sheath (ID)

7.5F scope

“Standard” arm30F sheath (ID)

24F scopep=

Mean intra-pelvic pressure (mmHg)

18.76 mmHg + 5.82 13.56 mmHg + 5.82 p<0.0001

Median time spent above 30mmHg (sec)

116.99 sec [98.02-165.53]

66.07 sec [33.44-109.08]

p=0.0452

Positive cultures:

- Kidney10/10 10/10

- Spleen 10/10 6/10 p=0.0253

- Liver 9/10 3/10 p=0.0062

- Blood culture 3/10 0/10 p=0.0603

Positioning for PCNL?

DOES IT SAVE TIME?IS THERE LESS RISK OF COMPRESSION, LESS NEED FOR PADDING?IF THE PATIENT NEEDS REINTUBATION OR CPR……?

no

Prone Split-Leg Position

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The Effect of Prone‐Flexed Positioning (PFP) on Airway Pressures During Percutaneous Nephrolithotomy (PCNL) 

K Foell, M Ordon, T Alzahrani, AG Lantz, KT Pace, RJD’A Honey Division of Urology, St. Michael’s Hospital, University of Toronto, Canada

• 63 patients

• All PAP < 40 cmH2O• No patients required repositioning for anesthetic or other reasons

Me

an

PA

P (

cmH

2O

)

MP22‐09

Access

• Align with the pathology– Avoids the need for

aggressive torquing

• Anterior calyx may be more difficult to establish control

• Use stiff working wire

• Always use a safety wire

CourtesyMitchell Humphreys

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Endoscopic vs. Fluoroscopic PCNL

0

2

4

6

8

Abort due to bleeding (%)

Endoscopic Fluoroscopic

160 patientsCourtesyMitchell Humphreys

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CourtesyMitchell Humphreys

What now?

At the end of PCNL – embedded stones….what now?

Upper pole access• Access below the 12 rib

rarely results in plural injury (<5%)

• CT study of pts:1

– Supra-11th rib• Right 86%; Left 79%

– Surpa-12th rib• Right 29%; Left 14%

• Clinical series for supracostal approaches 3.3-15.3%2,3 1. Hopper et al. AJR Am J Roentgenol; 1990.

2. Yadav et al. Int J Urol; 2006.3. Lojanapiwat et al. J Endourol 2006.Courtesy Mitchell Humphreys

Injury to Pleural cavity• Pneumothorax, hemothorax, urothorax,

hydrothorax.– Distal ureteral obstruction

• Tubeless for high puncture

• Routine use of fluoro of chest

• Chest x-ray more sensitive

• Most conservatively managed

• Aspirate at end of case

• Rarely requires chest tube

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Special considerations

• Hemothorax – has HB dropped?

• Infected urine – progress to empyema

• Delay in drainage may lead to need for a Video-assisted thoracoscopic surgery (VATS)

PCNL Case Presentation

32 year old female POD#1 from left PCNL for staghorn calculus

Left upper pole percutaneous access supra 12

Feels well other than some pleuritic chest pain with inspiration, no SOB

Hct 37 from preop 41

Routine non-contrast CT scan ordered to evaluate for residual stone

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No perinephric hematoma. No residual stone.

What do you do now?

a. Remove nephrostomy tube and send patient home

b. Send patient to Interventional radiology for embolization

c. Consult General Surgery for urgent splenectomy

d. Bed rest, serial Hct, leave nephrostomy tube in place for 2 weeks

Misplaced nephrostomy tubeCause•Transhepatic

– Upper pole or supra-11th rib punctures

– Hepatomegaly

•Transplenic– Upper pole or supra-11th rib punctures

– Splenomegaly

•Transcolonic– Retrorenal colon (0.6% pts)

– Congenital renal anomalies: horseshoe, ectopia, fusion anomalies

– Prior gastrointestinal surgery

– Chronic constipation, neurogenic bowel

– Musculoskeletal anomalies

– Anterior calyceal access

PREVENTIONTUBELESS!!

Splenic injuryTreatment•Hemodynamic instability/massive bleeding

– Surgical exploration and splenectomy

•Stable, minor bleeding

– Prolonged immobilization

– Have IR and/or vascular on stand by at time of nephrostomy tube removal

Carey et al. JSLS 2006Shah et al. J Endourol 2007

Hepatic injury

• Usually diagnosed on postoperative CT imaging

• Most hepatic injuries can be managed conservatively

• Transhepatic PCNL has even been reported to be safe when necessary

Lee et al. Korean J Urol 2003Matlaga et al. Urology 2006

El‐Nahas et al. J Endourol 2008

Colon Injury• Colon <1%

– Retrorenal 0.6%1

• Left 2X more common than right

• More common with lower pole access

• Most extraperitoneal

1. Hadar et al. AJR Am Roentgenol; 1984.

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Colonic injuryConservative management if no signs of peritonitis

– Place double J stent

– Pull nephrostomy tube back into colon

– Foley in bladder

– Broad spectrum antibiotic

– Low residue diet

– After 7 days, retrograde pyelogram or CTU and/or BE to rule out persistent fistula

Peritonitis, sepsis, failed conservative management

– Open surgical exploration and repair

Leroy et al. Radiology 1985El‐Nahas et al. Urology 2006Kachrilas et al. Urol Res 2012

Misplaced nephrostomy tube

• Prevention

– Cross sectional imaging with CT scan prior to PCNL

– Ultrasound and/or CT guidance for percutaneous access may be necessary in some cases

– Postoperative CT imaging should be considered

– Fluoroscopy over the chest or CXR in cases of upper pole/supracostal percutaneous access

Retrorenal colon

Ogan et al. Urology 2003Semins et al. Urology 2011

Gnessin et al. J Endourol 2012

Courtesy Mitchell Humphreys

Air embolism• Extremely rare

– Vascular injury is a precondition

– Associated with air pyelography

• Results in hypoxia, hypercapnia, depressed cardiac output, mill-wheel cardiac murmur, widened QRS complex

• Rapid ventilation with 100% O2• Left lateral decubitus position

– Head down, right side up• Central venous line to aspirate the air

Courtesy Mitchell Humphreys

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Obstruction

• Infundibular stenosis <2%– Risks: prolonged op time, large stone burden,

multiple procedures, extended drainage• Stricture <1%

– Proximal ureter and UPJ– Inflammation 2° to impacted stone– Lithotripsy trauma (thermal injury)

• Usually occur first year after treatment, can present asymptomatically

Conclusion• Preparation to avoid complications• High index of suspicion for prompt

identification• Immediate management to avoid

morbidity• Avoid excessive torque

– Use flexible instruments• Most can be conservatively managed