post pcnl complications.pptx

Pcnl complications

1. POST PCNL COMPLICATIONS AND MANAGEMENT Dr S hambhavi Sharma MS Resident PAHS Moderator : Ass.prof Dr Samir Shrestha

2. INTRODUCTION Percutaneous nephrolithotomy (PNL) is accepted as the procedure of choice for the treatment of large or complex renal calculi AUA guideline on management of staghorn calculi: diagnosis and treatment recommendations. Preminger Gm et al.J Urol. 2005 Jun; 173(6):1991-2000.

3. OPERATIVE STEPS Insertion of ureteric catheter (allowing dilation of the collecting system with saline and contrast media) Positioning of the patient Puncture of calyx and access Serial Dilatation of access tract Amplatz sheath Introduction of nephroscope Stone fragmentation and retrieval

4. COMPLICATIONS During Positioning

5. Neuromusculoskeletal Complications associated with prone positioning related to the head and neck region Ocular injury resulting in visual loss Facial nerve injury Necrosis over facial bones, tip of the nose, Cerebrovascular accident due to carotid or vertebrobasilar artery dissection

6. Careful padding of the head, in a neutral and nonextended position, Malpositioning of the extremities -- peripheral nerve injury Shoulder and elbow should not be abducted more than 90 degrees, so as to prevent brachial plexopathy Generous padding at the elbow and forearm reduces the risk of nerve compression

7. COMPLICATIONS During access/puncture of calyx

8. 1. Pleural Injury Hydrothorax , pneumothorax-when acc ess made above 11 th rib (1.8-8%) Lung injury Nephropleural fistula ( urinothorax )- rare incidence of pleural complications with punctures above the 12th ri b considered acceptable risk if provides optimal access to the upper urinary trac t

9. Diagnosis : Intraoperative: Monitoring airway pressure ETCO2 and oxygen saturation Postoperative : C hest fluoroscopy during or at the conclusion of the procedure C hest radiography If hydrothorax is noted intraoperatively : insert a small- caliber (8-Fr to 12-Fr) Cope nephrostomy tube as the thoracostomy L arge-bore thoracostomy tube -for lung injury

10. 2. Acut e hemorrhage M ost common significant complication (6.5-8.5%) Factors asso ciated with hemorrhage multiple access increasing tract size Guys Stone score >3 Prolonged operative time >83 min Renal pelvic perforation Previous ipsilateral surgery Shakhawan H.A. Said, Arab J Urol 2017 Mar; 15(1): 24–29 .

11. Hemorrhage can occur during : during needle passage tract dilatation nephrostomy Technical errors predisposing to hemorrhage : Infundibular entry risks injury to interlobar (infundibular) arteries Entry into wrong calyx resulting into overly aggressive torquing of the sheath and rigid endoscope Misplacement of nephrostomy tube

12. Ideal access: one that enters a posterior calyx at the fornix second most inferior calyx seen on retrograde pyelography is typically posteriorly oriented ideal for initial access for most patients Most straight path to calyx with highest stone burden Dilated calyx

13. To minimize the unfavorable impact of multiple accesses on bleeding: Flexible nephroscopy Holmium laser lithotripsy, Improved grasping devices and baskets Akman T.et al. J Endourol . 2011;25:327–333

14. Identification of source of bleeding Most hemorrhage occurs from the renal parenchyma , most cases not significant noticeable bleeding from the tract after sheath removal following an otherwise unremarkable procedure Management Insert and occlude a nephrostomy tube Apply pressure to the incision Let the collecting system clot off Nephrostomy tubes should not be irrigated the day or evening of the procedure if not draining By the next morning, it is safe to gently irrigate the tube because hemostasis is more certain

15. If severe hemorrhage occurs following sheath remova l refractory to the hemostatic measure : Kaye Nephrostomy Tamponade Balloon considered 15-cm long 36 F balloon which surrounds the length of the tube T amponade the nephrostomy tract Simultaneous drainage of tract

16. Intraoperative hemorrhage from an injured vein or artery within the collecting system mandates cessation of the procedure if vision is lost If Venous bleeding : Place nephrostomy tube let the collecting system clot off If small arterial injury fulguration under direct vision

17. Significant arterial hemorrhage ( drop in Hb by 2gm/dl with 4 or more transfusions) If the bleeding from the nephrostomy tube continues or gross hematuria with acute urine retention occurs Blood transfusion plus fluid resuscitation F oley catheterization with urinary bladder irrigation IV administration of mannitol ( hemodynamically stable patients ) lead to rapid forced diuresis and swelling of the kidney within the capsule, which may enhance tract tamponade

18. In case of failure of these maneuvers: C olor duplex sonography / CT/ MR angiography or renal angiography Selective renal artery embolization

19. Misplacement of nephrostomy tube At the stage of access tract dilation. Diagnosis : massive hemorrhage necessitating immediate placement of a nephrostomy tube and abortion of the procedure Management: hemodynamically stable: managed conservatively with strict bed rest, intravenous antibiotics, CT or fluoroscopy-guided nephrostomy tube withdrawal (in the operating room with the vascular team ready to intervene if needed) Open surgery can be used as an alternative treatment

20. 3. postoperative Hemorrhage Can occur during : with the nephrostomy tube in place early at time of tube removal after discharge from the hospital (1-3weeks) Delayed hemorrhage due to arteriovenous fistulas or arterial pseudoaneurysms (more common ) formed by a high-pressure leak from a lacerated artery leak transmitted through the tract into a lower resistance system, such as a vein or a connective tissue space

21. As late as 13 weeks after a percutaneous nephrolihotomy Continuous bleeding - arteriovenous fistula Intermittent bleeding-arterial pseudoaneurysm Selective angio -embolization Other options : endovascular placement of a covered stent to occlude the site of arterial injury USG guided percutaneous puncture of an arterial pseudoaneurysm Injection of thrombin or fibrin tissue adhesive Anil kumar et al. Ijcmr.2016;3:2454-7379

22. In case of failure of these maneuvers: Partial nephrectomy

23. 3. Collecting System Injury (7.2%) Tears in the infundibulum Renal pelvic perforation: occur during initial access or during dilation Pushing on a renal pelvic stone too hard during lithotripsy Collapse of a previously distended renal pelvis is a usual sign if the perforation is not visualized directly at first avoided by using a J guide wire with a soft and curved tip Perforation can lead to : Retroperitoneal extravasation Intraperitoneal extravasation

24. Retroperitoneal extravasation : Noted by medial displacement of the kidney during fluoroscopy D irect visualization of perinephric structures or fat abnormal hemodynamic parameters, decrease in irrigation fluid drainage Postoperative enhanced CT may reveal signs of urine leakage

25. Minor perforations No intervention required Significant perforations Termination of the procedure and nephrostomy and ureteral drainage nephrostography after 2 to 7 days and tube removal, depending on the severity of the injury

26. Intraperitoneal extravasation: Abdominal distention difficult to recognize due to prone position gradual rise in the patient’s diastolic blood pressure Narrowing of the pulse pressure Increase in CVP In advanced cases of a large-volume extravasation event: Ventilation difficult because of raised IAP

27. Management : Early recognition of major extravasation is crucial Vigorous diuresis Peritoneal drainage Laparotomy Postoperative : abdominal distention, ileus, and/or fever Management : placement of a percutaneous drain

28. 4. Visceral Injury Colon injury: left colon injury more common majority of colon injuries involve access to the lower pole Additional risk factors: Advanced patient age Dilated colon Prior colon surgery or disease Thin body habitus H orseshoe kidney

29. Preoperative CT IVU Identification of structures retrorenal colon, Liver or spleen Patients with ectopic kidneys, dysmorphic body habitus( eg spinal d ysraphism ) Intra-abdominal structures, such as the bowel, may be located between the skin and the renal access point

30. Diagnosis Postoperatively: Unexplained fever Prolonged ileus Unexplained leukocytosis Rectal bleeding Evidence of peritoneal inflammation, fecaluria pneumouria or clinically apparent nephrocolonic fistula Postoperative nephrostogram or CT imaging

31. Management : If extraperitoneal : Management may be expectant Placement of a ureteral catheter or DJ stent to decompress the collecting system Withdrawal of the nephrostomy tube from an intrarenal position to an intracolonic position to serve as a colostomy tube Left in place for a minimum of 7 days Removed after a nephrostogram or a retrograde pyelogram shows no communication between the colon and the kidney

32. Duodenal and jejunal injuries: Less common If no peritonitis-Conservative management If peritonitis-open Surgery

33. Liver injury Patient at risk : R ight-sided supracostal (superior to the 11th rib) percutaneous renal access anterior to the posterior axillary line. Hepatomegaly Diagnosis : unusual burning sensation at the right flank CT scan to reveal the route of injury to the liver

34. Management Hemodynamically stable: close monitoring and coagulant agents as needed Prolonged nephrostomy drainage to ensure proper healing of the injured site Foley catheterization for adequate urinary drainage Follow-up ultrasound or CT scan recommended if there is a concern for the formation of a biloma

35. Splenic injury 10th intercostal access and/or splenomegaly -higher risk for injury Diagnosis : Hemodynamic instability in the absence of significant intraoperative blood loss Abdominal CT scanning can characterize the injury Management hemodynamically stable: strict bed rest is recommended. consider leaving the nephrostomy tube in place to tamponade the bleeding and induce fibrosis

36. H emodynamically unstable, Life-saving splenorraphy splenectomy hemostatic fibrin glue can be used to increase the chance of preserving the spleen

37. Complications due to irrigating fluid Collecting system perforation

38. 1 . Metabolic and Physiologic Complications During irrigation amount of fluid absorption generally clinically insignificant volume of fluid absorbed increased with the amount of irrigating fluid used, pelvicaliceal perforation, bleeding Intravascular or extravascular extravasation in the setting large venous injury or collecting system perforation: hyponatremia and other electrolyte abnormalities renal or hepatic dysfunction mental status changes

39. large amount of saline extravasation clinically significant respiratory distress cardiac failure due to volume overload Prevention : I rrigation fluid used should always be saline(physiologic) Using a low-pressure system and staging, the procedure for large renal stone burdens especially in the presence of complications such as perforation of the pelvicaliceal system height of irrigating fluid and total time for irrigation do not affect the amount of fluid absorption Dip saxena et al.Urol Ann . 2019 Apr-Jun; 11(2): 163–167.

40. Other complications

41. 1. Extrarenal stone migration Occurs due to: the application of excessive pressure of the probe onto the stone existence of a perforation in the collecting system or the use of an improper technique of stone extraction with an Amplatz sheath Diagnosis: Intraoperative pyelography R enal ultrasound

42. Management : As long as the stone is not infected and fragment-associated inflammation does not obstruct the urinary tract—t/t not necessary. Endoscopic retrieval of fragments outside of the urinary tract should not be attempted-- enlarge the perforation Intraperitoneal and pleural migration of stone reported Laparoscopy and thoracosopy in order to prevent peritoneal and thoracic complications

43. I ndicated by hypoxemia evidence of pulmonary edema increased airway pressure hypotension , jugular venous distention facial plethora dysrhythmias, and auscultation of a mill-wheel cardiac murmur and/ or the appearance of a widened QRS complex with right heart strain patterns on electrocardiography. sudden decrease in capnometry reading of the P(end-tidal) CO2 2. Venous gas embolism (0.4% )

44. Management Swift response is required includes rapid ventilation with 100% oxygen positioning the patient head down with the right side up general resuscitative maneuvers

45. 2 . Postoperative Fever and Sepsis Incidence: 1 % to 30% Risk factors for fever infectious stones preoperative urinary tract infection Hydronephrosis indwelling ureteral stent or nephrostomy tube

46. Management Prevention : Preoperative antibiotics according to C/S  Intra-operative irrigation pressure < 30 mmHg U nobstructed post-operative urinary drainage T reatement Initiation of antimicrobial therapy and other supportive care If pus is aspirated upon initial percutaneous to the upper urinary tract, abort the procedure and leave a nephrostomy tube for drainage

47. 3 . Collecting System Obstruction Predisposing factors: large stone burden requiring multiple or long procedures prolonged nephrostomy tube drainage previous open stone surgery diabetes mellitus obesity E ndoscopic treatment in most cases Stenting ,cold knife excision ,laser ablation , balloon dilation or endoscopic formation of a new infundibulum open surgical reconstruction or excision with partial nephrectomy or total nephrectomy may be required

48. 4 . Loss of Renal Function owes to disastrous vascular injury or the angio-embolization used to treat hemorrhage

49. 5.Postoperative persistent nephrocutaneous leakage (1.5-4.6%) normally closes within 6–12 h of nephrostomy tube removal Urinary leakage persisting >24 h after nephrostomy tube removal called prolonged Usually needs treatment obtain a low-dose CT scan to evaluate for stone fragments in the ureter that may be causing obstruction Management : insertion of a ureteral stent Foley catheter may be inserted for 24 h in order to relieve pressure in the urinary system promote anterograde drainage of urine

50. 5. Death (0.3-0.5%)

51. Summary PCNL is a safe procedure with a low incidence of major complications common complications : bleeding, infection, and infundibular stenosis Most complications can be managed conservatively appropriate perioperative measures should be taken in order to minimize the risk of preventable complications

52. References C ampbell Walsh text book of urology 12 th edition EAU guidelines for management of nephrolithiasis Gadzhiev N, Malkhasyan V, Akopyan G, Petrov S, Jefferson F, Okhunov Z. Percutaneous nephrolithotomy for staghorn calculi: Troubleshooting and managing complications.  Asian J Urol . 2020;7(2):139-148. doi:10.1016/j.ajur.2019.10.004 Lee KL, Stoller ML. Minimizing and managing bleeding after percutaneous nephrolithotomy .  Curr Opin Urol . 2007;17(2):120-124. doi:10.1097/MOU.0b013e3 Incidence, Prevention, and Management of Complications Following Percutaneous Nephrolitholapaxy Saxena , Dipti et al. “Effects of fluid absorption following percutaneous nephrolithotomy : Changes in blood cell indices and electrolytes.”  Urology annals  vol. 11,2 (2019 ) Review  

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