Current insights on haemorrhagic complications in percutaneous nephrolithotomy

doi:10.1016/j.ajur.2021.05.007

Asian Journal of Urology, 2022, 9 (1): 81-93 doi: 10.1016/j.ajur.2021.05.007

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Current insights on haemorrhagic complications in percutaneous nephrolithotomy

Sujeet Poudyal(

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Department of Urology and Kidney Transplant Surgery, Tribhuvan University Teaching Hospital, Kathmandu, Nepal

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Abstract

Objective: Percutaneous nephrolithotomy (PCNL) is the standard procedure for the management of large and complex renal stones. Blood loss during PCNL may occur during puncture, tract dilatation, and stone fragmentation. Therefore, despite recent advances in PCNL, haemorrhagic complication still occurs. This study aims to enlighten on various aspects of haemorrhagic complication in PCNL, mainly focusing on risk factors and management of this dreadful complication.
Methods: Literature search for the study was carried out using advanced search engines like PubMed, Cochrane, and Google Scholar, combining keyword “percutaneous lithotomy” with other keywords like “bleeding”, “haemorrhage”, “complications”, “stone scoring systems”, “mini-PCNL vs. standard”, “dilatation techniques”, “supine vs. prone”, “USG-guided”, “endoscopic combined intra-renal surgery”, “papillary vs. non-papillary puncture”, “bilateral”, and “angioembolization”. The articles published between January 1995 and September 2020 were included for the review.
Results: A total of 3670 articles published from January 1995 to September 2020 were screened for the review. Although not consistent, multiple studies have described various preoperative and intraoperative risk factors related to significant bleeding in PCNL. Identification of these risk factors help urologists to anticipate and promptly manage haemorrhagic complications associated with the procedure. A conservative approach suffices to control bleeding in most cases; nevertheless, bleeding can be life-threatening and few still need surgical intervention in the form of angiographic embolisation or open surgical exploration.
Conclusion: As hemorrhagic complication in PCNL is associated with considerable morbidity and mortality, prudent intraoperative decision and postoperative care are necessary for its timely prevention, detection, and management.

Key words： Percutaneous nephrolithotomy Bleeding Embolisation Renal stone Puncture

Received: 02 October 2020 Available online: 20 January 2022

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Sujeet Poudyal. Current insights on haemorrhagic complications in percutaneous nephrolithotomy[J]. Asian Journal of Urology, 2022, 9(1): 81-93.

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http://www.ajurology.com/EN/10.1016/j.ajur.2021.05.007 OR http://www.ajurology.com/EN/Y2022/V9/I1/81

Study	Type	Patients, n	Factors affecting bleeding in PCNL	Factors not affecting bleeding in PCNL	Bleeding (%)
Lee et al. [11]	Retrospective study	370	- Staghorn stones, high BMI, large stones, prolonged operation time, and absence of hydronephrosis	- Age, sex, stone position, operative time, underlying disease, history of anticoagulant medication, presence of previous nephrostomy catheter, stone composition, and thickness of the renal cortex	- Blood transfusion (11.6%) - Severe bleeding requiring intervention (2.4%)
Said et al. [10]	Prospective study	200	- Stone complexity (Guy's stone score Grades 3 and 4), history of ipsilateral renal stone surgery, and occurrence of intraoperative pelvicalyceal perforation	- Age, sex, BMI, diabetes mellitus, hypertension, renal failure, absence of hydronephrosis, larger stone size, operative time (>83 min), more than one puncture, and size of the Amplatz sheath (26-30 Fr)	- Blood transfusion (8.5%) - Severe bleeding requiring intervention (0.5%)
Gok and Cift [12]	Retrospective study	341	- HU value, operation time, thickness of renal parenchyma, degree of hydronephrosis, and stone size	- Age, sex, stone side, BMI, diabetes mellitus, hypertension, chronic renal failure, renal abnormality, anticoagulant use, history of urinary tract infection, and previous renal surgery and ESWL	- Blood transfusion (0.5%) - Severe bleeding requiring intervention (1.7%)
Arora et al. [14]	Retrospective study	583	- History of ipsilateral renal surgery, increased stone complexity, multiple access tracts, and injury to the pelvicalyceal system	- Age, sex, diabetes mellitus, hypertension, serum creatinine level, urine culture, degree of pelvicalyceal dilatation, cortical thickness, presence of narrow infundibulum, and injury to pelvicalyceal system	- Severe bleeding requiring intervention (0.51%)
Kukreja et al. [15]	Prospective study	301	- Diabetes, multiple tract procedures, prolonged operative time, occurrence of intraoperative complications, method of access guidance (fluoroscopy vs. ultrasound), method of tract dilatation, size of the tract, and renal parenchymal thickness	- Age, hypertension, renal insufficiency, urinary infection, degree of hydronephrosis, stone bulk, function of the ipsilateral renal unit, past stone intervention, operating surgeon, and calyx of entry	- Blood transfusion (7.9%)
Turna et al. [16]	Retrospective study	193	- Staghorn stones, multiple tracts, diabetes, large stones, and balloon dilatation (decreased bleeding)	- Age, sex, hypertension, preoperative urinary tract infection, serum creatinine level, past ipsilateral stone intervention, stone side, affected kidney function, ipsilateral parenchymal thickness, degree of hydronephrosis, calyx of puncture, tract size, intraoperative complications, and operative time	- Blood transfusion (23.8%) - Severe bleeding requiring intervention (1.5%)
Du et al. [17]	Retrospective study	812	- Diabetes mellitus	- Age, sex, stone side, stone size, stone type, urinary tract infection, puncture site, history of antiplatelet therapy, and anticoagulation therapy	- Severe bleeding requiring intervention (3.9%)
Akman et al. [18]	Retrospective study	649	- Multiple access tracts, staghorn calculi, presence of diabetes, and prolonged operative time	- Age, sex, hypertension, serum creatinine level, history of ipsilateral renal procedures, degree of hydronephrosis, preoperative hemoglobin level, calix of puncture, and pelvicalyceal system perforation	- Blood transfusion (10.8%)
Kumar et al. [20]	Retrospective study	242	- Preoperative positive urine culture, diabetes, and stone burden	- Age, sex, hypertension, renal insufficiency, history of previous renal surgery, and stone side	- Severe bleeding requiring intervention (18.6%)
Jinga et al. [21]	Retrospective study	2095	- Multiple/staghorn calculi, upper calyx puncture, and history of pyelonephritis	- Sex, side, number of tracts, renal failure, site of puncture (subcostal vs. supracostal), and solitary kidney	- Severe bleeding (1.05%)
Zehri et al. [22]	Retrospective study	326	- Chronic renal failure, female gender, presence of staghorn calculi, and stone fragmentation using ultrasonic device	- Age, hypertension, presence of urinary infection, diabetes mellitus, calyx of puncture, tract size, size of Amplatz, multiple puncture, serum creatinine, ischemic heart disease, experience of the operating endourologist, calyx of access, and number of attempts for a successful puncture return of haemorrhagic urine	- Blood transfusion (14.2%)
Srivastava et al. [27]	Retrospective study	1854	- Stone size	- Number of punctures, bilateral PCNL, chronic renal failure, and intraoperative pelvic perforation	- Blood transfusion (12.23%) - Severe bleeding requiring intervention (1.45%)
Senocak et al. [23]	Retrospective study	105	- Degree of hydronephrosis, number of tracts, and operative time	- Age, sex, stone side, BMI, stone surgery, stone burden and number, calyx entry, renal anomaly, and surgeon experience	- Blood transfusion (5.7%)
El-Nahas et al. [26]	Retrospective study	2909	- Upper calyceal puncture, solitary kidney, staghorn stone, multiple punctures, and inexperienced surgeon	- Sex, side, renal morphology (degree of hydronephrosis), congenital anomalies, and site of puncture (subcostal vs. supracostal)	- Blood transfusion (5.5%) - Severe bleeding requiring intervention (1.0%)
Tan et al. [46]	Retrospective study	982	- Inferior calyx puncture, multiple renal stones, and solitary kidney stones	- Multiple tracts and punctures, prior ESWL, operative time, and chronic renal failure	- Severe bleeding requiring intervention (1.01%)
Kim et al. [48]	Retrospective study	1554	- Correct puncture through fornix of posterior calyx	- Age, sex, stone laterality, stone location, stone size, presence of staghorn stone, Guy's stone score, HU, degree of hydronephrosis, preoperative PCN, BMI or ASA classification, operation time, location of access, number of tracts, and stone free rate	- Blood transfusion (3.4%) - Severe bleeding requiring intervention (1.4%)
Stoller and Wolf [87]	Retrospective study	127	-Multiple punctures and renal pelvic perforation	- Calculus morphology, location, composition, and length	- Blood transfusion (23%)
Syahputra et al. [94]	Prospective study	85	-Stone burden	- Age, BMI, stone number, preoperative hemoglobin, and creatinine	- Blood transfusion (13.5%)

Studies showing factors affecting haemorrhagic complications in PCNL.

Studies comparing blood loss in standard PCNL vs. mini-PCNL.

Algorithm for the management of significant haemorrhage in PCNL. CT, computerised tomogram; DSA, digital subtraction angiography; PCNL, percutaneous nephrolithotomy;

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