COMPLICATIONS OF PCNL

Dr.Sanjay S Deshpande
Sidheshwar Urological Society
Solapur

07/28/2020 Complications of PCNL 1

 Importance
• Procedure has steep learning Curve
• Complications can lead to prolonged
morbidity and if not recognised and treated
properly can lead to death
• How they can be prevented?
• If they happen how to deal with them?

07/28/2020 Complications of PCNL 2

 General Complications
• Cardiac or respiratory diseases leading to
death
• DM patient going to hypoglycaemia during
surgery when under GA
• Abdominal distension due to poor bowel
preparation
• Fluid and Electrolyte imbalance during
prolonged surgery or fluid under pressure

07/28/2020 Complications of PCNL 3

 General Complications
• SEPSIS
• Anaesthesia related problems
• High spinal
• GA in prone position Tube dislodgement
• Injury to dependent parts like eyes, patella or
ankle joint

07/28/2020 Complications of PCNL 4

 Specific Complications
• Related to Access
• Related to dilatation
• Haemorrhage
• Pleural injury
• Bowel injury

07/28/2020 Complications of PCNL 5

 Access and Dilatation
• Failure to obtain access coule be due to
• Impacted stone, very little space between calyx
and stone
• Guide wire not passing beyond the stone
• Dilatation either UNDER OR OVER DILATATION
and difficult to assess under fluoroscopy
• Loss of track, guide wire during dilatation
• Buckling, Guide wire getting stuck in the needle

07/28/2020 Complications of PCNL 6

 Haemorrhage
• Anticogulants
• Guidelines are
• Asprin and Clopidrogel 10days prior to
surgery
• Warfarin 5 days
• Heparin 6hrs
• Low molecular weight heparin 24hrs

07/28/2020 Complications of PCNL 7

 Haemorrhge
Surgeon dependant factors
Primary or Secondary
• Single puncture blood in the urosac bag
similar to that some time happens during
renal biopsy
• Dilatation between stone and cortex instead
of up to the stone, wrong axis and depth
• When the amplatz sheath is in the cortical
tissue i.e. underdilatation

07/28/2020 Complications of PCNL 8

 Specific : Haemorrhge Contd
• Infundibular tear due to dilatation more than
the size of the infundibulum
• Overdilatation going to the opposite side
leading to perforation
• Inflamed PCS
• Improper fitting Amplatz sheath, cut ends,
bent tip etc

07/28/2020 Complications of PCNL 9

 Haemorrhage
• Venous : Placement of Amplatz sheath in the
cortical tissue into the calyx
• No overdilatation of the infundibulum which
will tear it and cause bleeding
• If more put a nephrostomy tube and come out
keep it for 3-4 days and then do secondary
PCNL
• Kaye balloon dilator can be used

07/28/2020 Complications of PCNL 10

 Haemorrhage
• Arterial : Brisk bright red usually secondary
• False aneurysm or A-V fistula
• Needs embolisation
• Rarely Nephrectomy

07/28/2020 Complications of PCNL 11

 Thoracic Complications
• Hydrothorax
• Hydro-pneumothorax
• Haemothorax
• Lung injury
• Nephro-pleural fistula
• Can happen during PCNL or while removing
the nephrostomy tube

07/28/2020 Complications of PCNL 12

 Diagnosis
• Clinical
• Fluoroscopy
• CXR
• USG
• Chest CT Scan

07/28/2020 Complications of PCNL 13

 Pleural injury
• Supracostal puncture Upper calyceal puncture
• More medial puncture
• In patients with kyphoscoliosis
• COPD
• Diagnosis: Breathlessness, Chest pain
• CXR, USG, C-Arm screening on table
• Chest drain, aspiration

07/28/2020 Complications of PCNL 14

 Prevention
• More lateral punctures
• Along the upper border of the rib to prevent
intercostal vessel bleed
• Puncture in expiration
• RENAL DISPLACEMENT technique
• Nephropleural fistula : RGP & D-J stenting
and rule out distal obstruction

07/28/2020 Complications of PCNL 15

 Bowel and Visceral Injuries
• Colon, Duodenum,
• Retrorenal colon, Pts with previous
laparotomy or renal surgery
• More lateral punctures
• Role of CT Scan or USG
• USG guided puncture
• How to recognise during surgery or post-op?
• How to treat it?
07/28/2020 Complications of PCNL 16
 Bowel injury Colonic
• During puncture see whether kidney or bowel
moves
• Per-Op : Air and faecal matter through the
nephrostomy
• Diorrhea, abd pain, distension, leading to sepsis
• If extraperitoneal : Conservative : Pigtail
catheter to the kidney and drainage of the colon
• If intraperitoneal: Laparotomy SOS Colostomy

07/28/2020 Complications of PCNL 17

 Bowel injury Colonic
• Extrperitoneal Conservative
• Pigtail to colon D-J Stenting
• After one week to do colostogram and RGP if
no leak to remove the drain
• Intraperitoneal injury: Laparotomy and
Colostomy

07/28/2020 Complications of PCNL 18

 Injury to renal pelvis and ureter
• Happens due to aggressive tract dilatation or
during the ICPL process
• Antegrade D-J Stenting and nephrostomy is
the treatment

07/28/2020 Complications of PCNL 19

 SEPSIS
• Operating on pyonephrosos
• Operating on a Large staghorn calculus

07/28/2020 Complications of PCNL 20