Elsevier

European Urology

Volume 61, Issue 1, January 2012, Pages 146-158
European Urology

Collaborative Review – Stone Disease
Incidence, Prevention, and Management of Complications Following Percutaneous Nephrolitholapaxy

https://doi.org/10.1016/j.eururo.2011.09.016Get rights and content

Abstract

Context

Incidence, prevention, and management of complications of percutaneous nephrolitholapaxy (PNL) still lack consensus.

Objective

To review the epidemiology of complications and their prevention and management.

Evidence acquisition

A literature review was performed using the PubMed database between 2001 and May 1, 2011, restricted to human species, adults, and the English language. The Medline search used a strategy including medical subject headings (MeSH) and free-text protocols with the keywords percutaneous, nephrolithotomy, PCNL, PNL, urolithiasis, complications, and Clavien, and the MeSH terms nephrostomy, percutaneous/adverse effects, and intraoperative complications or postoperative complications.

Evidence synthesis

Assessing the epidemiology of complications is difficult because definitions of complications and their management still lack consensus. For a reproducible quality assessment, data should be obtained in a standardized manner, allowing for comparison. An approach is the validated Dindo-modified Clavien system, which was originally reported by seven studies. No deviation from the normal postoperative course (Clavien 0) was observed in 76.7% of PNL procedures. Including deviations from the normal postoperative course without the need for pharmacologic treatment or interventions (Clavien 1) would add up to 88.1%. Clavien 2 complications including blood transfusion and parenteral nutrition occurred in 7%; Clavien 3 complications requiring intervention in 4.1.%; Clavien 4, life-threatening complications, in 0.6%; and Clavien 5, mortality, in 0.04%. High-quality data on complication management of rare but potentially debilitating complications are scarce and consist mainly of case reports.

Conclusions

Complications after PNL can be kept to a minimum in experienced hands with the development of new techniques and improved technology. A modified procedure-specific Clavien classification should be established that would need to be validated in prospective trials.

Introduction

Percutaneous nephrolitholapaxy (PNL) has been an essential technique for 35 yr for kidney stone removal, avoiding complications of open surgery [1]. PNL is the first-line approach for large, multiple, or inferior calyx renal stones according to the European Association of Urology (EAU) guidelines [2]. PNL generally is safe and effective and associated with a few but specific complications. However, definitions of complications of PNL and their management still lack consensus. The literature was systematically reviewed for the incidence, prevention, and management of complications following PNL.

The terms minor and major complications for percutaneous procedures are not standardized, and therefore comparison is difficult. For a reproducible quality assessment, relevant data on complication rates should be obtained in a standardized manner, allowing for comparison. A rational approach is to stratify complications by timing (intraoperative or postoperative). A useful tool is the Dindo-modified Clavien system, which was validated in 6336 patients for quality assessment in surgery worldwide [3].

While using standardized complication reporting to compare techniques and results, it must be understood that there are definite limitations of this approach with PNL where there are manifold technical differences in surgical technique, often based on different surgical traditions in different countries. For access, fluoroscopy is used in countries with Anglo-Saxon surgical traditions and ultrasound in others, puncture may be done by a radiologist or by the urologist, a mono-J or an occlusion ureteral catheter may be placed, an Amplatz sheath with low intrarenal fluid pressure or direct nephroscope insertion after Alken telescope tract dilatation may be used. In addition, the size of the tract and the scope and size of the nephrostomy tube inserted afterward add further variables that make direct comparisons difficult if not impossible. With an awareness of these differences, the literature search was evaluated as follows.

Section snippets

Material and methods

Medline was searched from 2001 until May 1, 2011, restricted to human species, adults, and the English language. The Medline search used a strategy including medical subject headings (MeSH) and free-text protocols.

Search strategy

A literature review using the keywords percutaneous, nephrolithotomy, PCNL, PNL, urolithiasis, complications, Clavien, and the MeSH terms nephrostomy, percutaneous/adverse effects, and intraoperative complications or postoperative complications resulted in 635 records (Fig. 1).

Studies

Grading system for complications

Standardizing complications is necessary to allow comparison among different centers and within a center over time. The Dindo-modified Clavien system was proposed as a grading system for perioperative complications in general surgery [3]. According to this classification system, perioperative complications were stratified into five grades (Table 1).

In PNL there are some limitations in classifying complications because auxiliary treatments (eg, second-look PNL, ureterorenoscopy, and

Conclusions

Ensuring that PNL is performed for the appropriate indications, together with careful selection and preparation of patients, significantly lowers complication rates. Reduction of the risk of UTI by preoperative urine culture and appropriate antibiotic therapy and prophylaxis in patients with sterile urine together with a meticulous technique for access tract establishment are key preventive measures for complications. Stone burden, the number and size of access tracts, duration of the

References (115)

  • S. Bag et al.

    One week of nitrofurantoin before percutaneous nephrolithotomy significantly reduces upper tract infection and urosepsis: a prospective controlled study

    Urology

    (2011)
  • A.M. El-Assmy et al.

    Outcome of percutaneous nephrolithotomy: effect of body mass index

    Eur Urol

    (2007)
  • A.M. El-Assmy et al.

    Renal access by urologist or radiologist for percutaneous nephrolithotomy—is it still an issue?

    J Urol

    (2007)
  • M. De Sio et al.

    Modified supine versus prone position in percutaneous nephrolithotomy for renal stones treatable with a single percutaneous access: a prospective randomized trial

    Eur Urol

    (2008)
  • A.M. Shoma et al.

    Percutaneous nephrolithotomy in the supine position: technical aspects and functional outcome compared with the prone technique

    Urology

    (2002)
  • J.G. Mancini et al.

    Factors affecting patient radiation exposure during percutaneous nephrolithotomy

    J Urol

    (2010)
  • M.H. Lu et al.

    A comparative study of clinical value of single B-mode ultrasound guidance and B-mode combined with color Doppler ultrasound guidance in mini-invasive percutaneous nephrolithotomy to decrease hemorrhagic complications

    Urology

    (2010)
  • B.C. Tzeng et al.

    Doppler ultrasound-guided percutaneous nephrolithotomy: a prospective randomized study

    Urology

    (2011)
  • N.R. Netto et al.

    Comparative study of percutaneous access for staghorn calculi

    Urology

    (2005)
  • G.V. Raj et al.

    Percutaneous management of calculi within horseshoe kidneys

    J Urol

    (2003)
  • A. Srivastava et al.

    Vascular complications after percutaneous nephrolithotomy: are there any predictive factors?

    Urology

    (2005)
  • A.R. El-Nahas et al.

    Colonic perforation during percutaneous nephrolithotomy: study of risk factors

    Urology

    (2006)
  • R. Munver et al.

    Critical analysis of supracostal access for percutaneous renal surgery

    J Urol

    (2001)
  • B.R. Matlaga et al.

    Computerized tomography guided access for percutaneous nephrostolithotomy

    J Urol

    (2003)
  • A.A. Shokeir et al.

    Percutaneous nephrolithotomy in treatment of large stones within horseshoe kidneys

    Urology

    (2004)
  • A.E. Krambeck et al.

    Percutaneous nephrolithotomy success in the transplant kidney

    J Urol

    (2008)
  • D. Canes et al.

    Functional outcomes following percutaneous surgery in the solitary kidney

    J Urol

    (2009)
  • T. Akman et al.

    Tubeless procedure is most important factor in reducing length of hospitalization after percutaneous nephrolithotomy: results of univariable and multivariable models

    Urology

    (2011)
  • A. Nouralizadeh et al.

    Experience of percutaneous nephrolithotomy using adult-size instruments in children less than 5 years old

    J Pediatr Urol

    (2009)
  • M.R. Desai et al.

    A prospective randomized comparison of type of nephrostomy drainage following percutaneous nephrostolithotomy: large bore versus small bore versus tubeless

    J Urol

    (2004)
  • E. Shleyfer et al.

    Urinothorax: an unexpected cause of pleural effusion

    Eur J Intern Med

    (2006)
  • E.N. Liatsikos et al.

    “Angular percutaneous renal access”. Multiple tracts through a single incision for staghorn calculous treatment in a single session

    Eur Urol

    (2005)
  • D.E. Zilberman et al.

    Tubeless percutaneous nephrolithotomy—the new standard of care?

    J Urol

    (2010)
  • Türk C, Knoll T, Petrik A, et al. Guidelines on urolithiasis. Chapter 6.4: selection of procedure for active removal of...
  • D. Dindo et al.

    Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey

    Ann Surg

    (2004)
  • J. de la Rosette et al.

    The Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study: indications, complications, and outcomes in 5803 patients

    J Endourol

    (2011)
  • M. Duvdevani et al.

    Third prize: contemporary percutaneous nephrolithotripsy: 1585 procedures in 1338 consecutive patients

    J Endourol

    (2007)
  • D. Allen et al.

    Defining the learning curve for percutaneous nephrolithotomy

    J Endourol

    (2005)
  • S.A. Ziaee et al.

    Evaluation of the learning curve for percutaneous nephrolithotomy

    Urol J

    (2010)
  • Schilling D, Gakis G, Walcher U, Stenzl A, Nagele U. The learning curve in minimally invasive percutaneous...
  • A. Häcker et al.

    A biological model to teach percutaneous nephrolithotomy technique with ultrasound- and fluoroscopy-guided access

    J Endourol

    (2007)
  • S. Mishra et al.

    Percutaneous renal access training: content validation comparison between a live porcine and a virtual reality (VR) simulation model

    BJU Int

    (2010)
  • K.L. Lee et al.

    Minimizing and managing bleeding after percutaneous nephrolithotomy

    Curr Opin Urol

    (2007)
  • A. Tefekli et al.

    Does the metabolic syndrome or its components affect the outcome of percutaneous nephrolithotomy?

    J Endourol

    (2008)
  • M. Osman et al.

    Percutaneous nephrolithotomy with ultrasonography-guided renal access: experience from over 300 cases

    BJU Int

    (2005)
  • P. Mariappan et al.

    One week of ciprofloxacin before percutaneous nephrolithotomy significantly reduces upper tract infection and urosepsis: a prospective controlled study

    BJU Int

    (2006)
  • B. Lojanapiwat et al.

    Role of preoperative and intraoperative factors in mediating infection complication following percutaneous nephrolithotomy

    Urol Int

    (2011)
  • G. Ibarluzea et al.

    Supine Valdivia and modified lithotomy position for simultaneous anterograde and retrograde endourological access

    BJU Int

    (2007)
  • G. Ibarluzea González et al.

    Percutaneous kidney lithotripsy. Clinical course, indications, and current methodology in our lithotripsy unit [in Spanish]

    Arch Esp Urol

    (2001)
  • P. Wu et al.

    Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis

    Int Urol Nephrol

    (2011)
  • View full text