Reviews in Endourology

JOURNAL OF ENDOUROLOGY Volume 28, Number 11, November 2014 ª Mary Ann Liebert, Inc. Pp. 1256–1267 DOI: 10.1089/end.2014.0344

Gastrointestinal System Complications in Percutaneous Nephrolithotomy: A Systematic Review ¨ ztu¨rk, MD Hakan O

Abstract

Purpose: To evaluate gastrointestinal tract complications of percutaneous nephrolithotomy (PCNL), to determine risk factors, and to develop strategies for diagnosis and treatment. Material and Methods: A literature review was conducted for the studies published in the English language in the databases of PubMed and Scopus between July 1985 and June 2013. The key words for digital literature search were limited to the following: ‘‘percutaneous nephrolithotomy complications, ([splenic injury, liver injury, gallbladder injury and biliary peritonitis, colonic injury] during/after [percutaneous nephrolithotomy]), complication, Clavien, Clavien-Dindo classification, management, review, PNL, PCNL.’’ Results: A total of 16 articles on splenic injury were reviewed. There was no consensus in the literature regarding the management of splenic injuries. A conservative approach with new treatment modalities is the most widely accepted method in the literature. A total of seven articles on gallbladder injury were reviewed. All gallbladder injuries resulted in cholecystectomy. The time of diagnosis is the most significant parameter determining choice between laparoscopy and laparotomy. A total of seven articles on liver injury were reviewed. The liver injury generally provides the best response to a conservative approach among other solid organ injuries. A total of 11 articles on bowel injury were reviewed. Bowel injury mostly results in exploratory laparotomy. Unlike colon injuries, bowel injuries are more complex to manage with conservative measures because of the challenges in diagnosis and the fact that the injury is located in the intraperitoneal area. A total of 28 articles, which comprised a large case series with colon injuries, consisted of collaborative reviews and meta-analyses were reviewed. In total, 51 colon injuries (0.5%) were evaluated occurring in 13,424 patients in supine and prone PCNL series. Conservative approaches have proven to be effective in colon injuries in the absence of large perforations and intraperitoneal involvement. Conclusion: There is a downward trend in gastrointestinal complications from PCNL because of the technologic advances that guide the diagnosis and treatment. Paradoxically, the rate of complications is higher in complex kidney stones such as those in a horseshoe kidney and pelvic and malrotated kidney that represent anatomic challenges for intervention. The most important point is to determine the risk factors for preoperative planning of the procedure and to diagnose the complications for proper management early. Introduction

P

ercutaneous nephrolithotomy (PCNL) is a standard, safe, and effective method used in the management of large kidney stones. PCNL was first described by Fernstro¨m and Johansson B in 1976.1 Currently, PCNL offers a 78% to 95% success rate in the management of kidney stones. The rate of major and minor complications related to the procedure, however, is as high as 83%.2 The major complication rate for PCNL varies between 1.1% to 7%.3 The complications of PCNL maintain their importance despite the

improvements in endourologic equipment. The complications continue to be a challenge, despite the development of new treatment modalities such as mini-micro PCNL, supine PCNL, and laparoscopically assisted PCNL. The complications of PCNL occur in a wide spectrum, from those necessitating simple medical therapies and followup to more severe conditions resulting in death. The complications of PCNL have been classified according to the Clavien and Clavien-Dindo classification systems. The most common complication is hemorrhage, accounting for 1% to 12% of the cases. The rate of hemorrhages necessitating

Department of Urology, School of Medicine, Sifa University, Izmir, Turkey.

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GI SYSTEM COMPLICATIONS IN PCNL

blood transfusion, however, is less than 2.5% in the latest series reported in the literature.4 The rate of mortality, which is defined as Grade V, is less than 0.1%. Colon injuries related to PCNL are extremely rare and account for 0.2% to 0.8% of the cases, and the rate of other gastrointestinal complications is less than 0.1%. They are of great importance, however, because of the diagnostic challenges, as well as severe and fatal complications.2 Colon injuries are the most common complications among other gastrointestinal complications; however, fatal but rare incidents of gallbladder rupture have been reported in the literature. Methods Evidence acquisition

MEDLINE was searched from July 1985 until June 2013, restricted to human species, adults, and the English language, using PubMed and Scopus. The MEDLINE search was limited to case reports, journal articles, reviews, and systematic reviews using the filter function. The researchers also performed manual searches of references identified in electronically abstracted articles. Search strategy

The literature search for manuscripts containing the following key words returned 69 results: PCNL complications ([splenic injury, liver injury, gallbladder injury and biliary peritonitis, colonic injury] during/after [percutaneous nephrolithotomy]), complication, Clavien, Clavien-Dindo classification, management, review, PNL, and PCNL (Fig. 1). All gastrointestinal complications related to PCNL were evaluated in the present study. Case reports and available case series were included in the study for splenic injuries. Case reports of liver and gallbladder injuries were included in the study. Case reports, case series, and reviews were included in the study for small bowel injuries. Case reports of colon injuries were excluded from the study. Only large series and collaborative reviews for the colon were included in the study.

FIG. 1.

Literature search database flowchart.

1257 Evidence Synthesis Splenic injury during PCNL

Introduction: Splenic injury related to PCNL is a rare but fatal complication that necessitates early diagnosis. The choice of treatment is as important as early diagnosis in patients with splenic injury. The reason is that most patients can be treated with conservative methods. Other treatment options include exploratory laparotomy and, less commonly, splenectomy. Close hemodynamic monitoring is of particular importance in the management of splenic injuries. Results: The number of PCNL-related splenic injury cases has been recorded as 11. Of these patients, three underwent exploratory laparotomy, two underwent splenectomy, and eight were treated with conservative methods (Table 1). Discussion: The close anatomic proximity of the left kidney to the spleen increases the risk of splenic injury during interventions to the left kidney, particularly during intercostal or upper pole interventions. Splenic injury must be suspected in the presence of excessive hemorrhage in the perioperative period, hemodynamic instability, and abdominal pain. While splenic injuries may present acutely with hemodynamic instability, clinical signs and symptoms vary widely. CT is the recommended diagnostic workup in patients with excessive hemorrhage. CT offers high sensitivity and specificity in detecting splenic injuries. The risk of splenic injury during PCNL has been estimated by Hopper and Yakes,5 who used CT to analyze the relationship of the kidney, spleen, and lower ribs. Their analysis noted that splenic injury is highly unlikely if an 11th or 12th rib supracostal approach is made during expiration. The risk increases to 13% if this approach is taken on inspiration and may be as high as 33% if the access is performed in the 10th to 11th intercostal space. Preoperative diagnostic workup of patients should include CT scans, and the spatial relationship between the kidneys, spleen, colon, and pleura must be delineated, particularly in patients in whom an intervention to the upper pole stones of the left kidney is considered. The use of ultrasonography (US) and CT scans instead of the fluoroscopic method is particularly recommended in the presence of complex anatomic structures.6 Robert and associates7 studied 25 patients using MRI and reported a high risk of splenic injury in percutaneous interventions above the level of the 11th rib. Some authors advocate that splenic injuries should be treated with exploratory laparotomy and splenectomy because of fatal consequences of intraperitoneal hemorrhage.2 Kondas and colleagues8 performed a blood transfusion because of deterioration in the hemodynamic condition caused by splenic trauma occurring after PCNL for a staghorn kidney stone and detected subcapsular splenic injury on US and CT, performed because of failure in conservative treatment. This patient did not have bleeding into the intra-abdominal cavity. The injury, however, resulted in exploratory laparotomy and splenectomy. On the other hand, patients with stable hemodynamic conditions can be treated with conservative methods. Bed rest, close hemodynamic monitoring, insertion of a large nephrostomy tube or tamponade tube, and administration of hemostatic medications are recommended.9,10 The elective embolization of the splenic artery has been defined as an alternative method to surgery in the literature.11 The early diagnosis and treatment of splenic injuries can prevent associated

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Table 1. Literature Review of Splenic Injuries During Percutaneous Nephrolithotomy Author Konda´s et al.

n 8

Management

Outcome

1

Exploratory laparotomy/splenectomy

Carey et al.13

1

Shah et al.14

2

Bed rest, delayed nephrostomy catheter removal after 2 weeks 1. Exploratory laparotomy/splenectomy

Schaeffer et al.15

3

Thomas et al.6

1

Desai et al.16

1

Gnessin et al.17

2

2. Exploratory laparotomy and hemostasis with fibrin glue 1. Direct pressure over nephrostomy tract followed by serial monitoring for 3 days 2. Discharge home with delayed nephrostomy tube removal on postoperative day 15 3. Delayed nephrostomy tube removal on postoperative day 12 Bed rest, delayed nephrostomy catheter removal after 4 days with injection of a collagen-thrombin hemostatic sealant into the nephrostomy tracts With injection of a collagen-thrombin hemostatic sealant into the nephrostomy tracts (Gelfoam pledgets) Delayed nephrostomy catheter removal after 1–2 weeks

Transfused 3 units PRBCs Uneventful recovery Uneventful recovery 1. Transfused 4 units PRBCs. Uneventful recovery 2. EBL 2000 mL Transfused 3 units PRBCs. Uneventful recovery 1. Perisplenic hematoma without further active bleeding. 2. Uneventful recovery 3. Uneventful recovery EBL 750 mL. Transfused 6 units PRBCs. Uneventful recovery Uneventful recovery Transfused PRBC Uneventful recovery

PRBCs = packed red blood cells; EBL = estimated blood loss.

morbidity and mortality, because missed splenic injuries are potentially fatal.12 A heightened suspicion for vascular injuries or splenic trauma in the perioperative period should be considered in patients undergoing PCNL with excessive blood loss, hemodynamic instability, or severe abdominal pain.6 In a case report by Carey and coworkers,13 a percutaneous surgical procedure was reported to be performed by the transsplenic approach. The upper pole kidney stone was only accessible between the 10th and 11th ribs because of a narrow infundibulum of the upper pole of the kidney. An intervention performed through this space also brings high rates of pleural complications, which, however, was not the case in the reported patient. CT scans obtained on Day 5 because of lumbar pain and bleeding revealed transsplenic PCNL. The hemodynamic condition of the patient was managed using conservative methods and was protected from exploratory intervention and splenectomy. The nephrostomy catheter was left in the patient for 2 weeks. During the first year checkup, there were no late complications. Hemodynamic findings are the most important parameters that lead to the decision of a surgical procedure after splenic injury. This parameter, however, may not be decisive alone; bleeding from splenic injury occurs into the intraperitoneal space, and the difficulties in diagnosing this condition may bring the risk of mortality.13 Shah and colleagues14 reported two cases of splenic injury after renal access in the 10th to 11th intercostal space. Both patients needed urgent laparotomy because of hypotension and hemorrhage. One of the patients underwent splenectomy but for the other patient, splenectomy was not used because hemostasis was achieved with the application of fibrin glue. A study by Schaeffer and associates15 evaluated three pa-

tients who underwent transsplenic PCNL. In all cases, supracostal access was performed because of a left kidney stone in the upper pole. The nephrostomy catheter was withdrawn at Days 3, 12, and 15, respectively. All patients were treated by conservative therapy methods without need for splenectomy. This study is the most important report in the literature demonstrating the success of conservative therapy methods and altering the approach toward splenic injuries. In the study by Thomas and coworkers,6 a patient with morbid obesity underwent transsplenic PCNL in the 10th to 11th intercostal space. CT scans performed because of diffuse flank pain and hemorrhage revealed a nephrostomy tube located in the transsplenic tract. Hemostasis was achieved by administering collagen-thrombin hemostatic sealant through the nephrostomy tube without performing exploratory intervention, and the nephrostomy catheter was removed on the fourth day. This report indicated that conservative therapy could be performed to achieve hemostasis by administering coagulant substances via a nephrostomy tube. In a transsplenic PCNL procedure performed by Desai and colleagues,16 this rare complication was managed by the depositing of Gelfoam pledgets along the transsplenic nephrostomy tract and the placement of a ureteral stent. They described a novel conservative treatment method using Gelfoam pledgets in splenic injury without any requirement for exploratory intervention. In their retrospective study, Gnessin and associates17 reported two cases of splenic injury. These conditions were diagnosed with CT and managed with conservative methods. This study indicated that CT scans are essential for early diagnosis and treatment of fatal complications of PCNL. CT is particularly recommended in the early postoperative period, particularly 24 hours after intervention to a kidney with anatomic abnormality, interventions to the upper

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Table 2. Literature Review of Liver Injuries During Percutaneous Nephrolithotomy Author

n

Management

Outcome

El Nahas et al.

1

Delayed nephrostomy catheter removal after 5 days with injection of a collagen-thrombin hemostatic sealant into the nephrostomy tracts.

Nephrostomy tube was clamped; patient received intravenous hemostatic drugs (ethamsylate 250 mg and tranexamic acid). Transfused 1 unit PRBCs. Uneventful recovery.

PRBCs = packed red blood cells.

pole of the kidney that carry high risk for liver and splenic injury, in cases with retrorenal colon diagnosed preoperatively, and in multiple percutaneous interventions that have high risk of perinephritic hematoma risk and necessitate transfusion. Conclusion: The key points in the management of splenic injury are early diagnosis and determination of the most appropriate treatment strategy that will result in lower morbidity and mortality. The patients may need urgent laparotomy and splenectomy. Conservative methods, however, including close monitoring, use of coagulant agents, and delaying the withdrawal of the nephrostomy catheter, can be used in hemodynamically stable patients. The preparation of the patient for urgent splenectomy is of vital importance if conservative methods fail. Liver injury during PCNL

Introduction: Liver injury occurring during PCNL is a rare complication, which mostly remains unnoticed. There have been limited case reports in the literature because of the difficulties in diagnosis. Most kidney stones are accessible through a subcostal percutaneous intervention. Staghorn stones and complex upper pole stones are only accessible by supracostal intervention. This method is advantageous because of flexibility in motion and visibility. This flexibility, however, proportionately increases the rate of complications.18 Supracostal percutaneous renal access (above the 11th rib) increases the risk of gastrointestinal as well as intrathoracic complications.18 Results: In the literature, there is only one case report of liver injury caused by PCNL (Table 2). This patient had multiple complex upper pole stones and underwent supracostal percutaneous renal access (above the 11th rib) under general anesthesia and fluoroscopic guidance. Severe abdominal pain and gross bleeding developed from the nephrostomy tube, and US revealed hypoechoic fluid collection between the upper pole of the right kidney and liver and intraperitoneal fluid collection. CT scans performed after stabilizing the hemodynamic condition of the patient revealed a 5 · 6 cm intrahepatic hematoma, and a nephrostomy tube was seen traversing the lower edge of the right hepatic lobe. After administering parenteral supportive care for 2 days, intravenous hemostatic drugs (ethamsylate 250 mg every 6 hours and tranexamic acid 500 mg every 12 hours), and transfusing one unit of blood, the nephrostomy tube was withdrawn under fluoroscopic guidance, and the tract between the liver and kidney was closed with a fibrin sealant. The nephrostomy tube was withdrawn at Day 5 and control CT confirmed the disappearance of the hepatic hematoma. Discussion: The risks of injuring organs adjacent to the kidney during supracostal PCNL were evaluated using dif-

ferent imaging modalities to gain insight into the reasons for liver injuries during supracostal percutaneous renal access (above the 11th rib).19 In a series of 43 randomly selected patients, Hopper and Yakes5 performed sagittal CT reconstructions in maximum inspiration and expiration and found that percutaneous access above the 11th rib was associated with a 14% risk of liver injury. In accordance with this literature data, Robert and colleagues7 studied 25 patients using MRI and reported a high risk of liver injury in percutaneous interventions above the level of the 11th rib. If percutaneous renal access must be performed above the level of the 11th rib, the spatial relation between the kidney and liver and spleen using CT scans should be performed in the preoperative period.19 The presence of hepatomegaly is another risk factor, even if the tract is to be made through the 11th intercostal space. Therefore, US- or CT-guided percutaneous renal access is advised in these cases to ensure a correct and uneventful percutaneous puncture.20 Unlike splenic injuries that necessitate immediate diagnosis and treatment, liver injuries do not result in serious or fatal consequences. Percutaneous liver injury is often successfully managed with conservative methods. Only patients with an unstable hemodynamic condition should undergo exploratory intervention. A close follow-up with US and CT is essential in liver injuries.21,22 Conclusion: In liver injuries that have occurred during percutaneous access, hemostasis and vascular sealing can be achieved using fibrin products if the patient is hemodynamically stable. Stepwise withdrawal of the nephrostomy tube is particularly important. Exploratory intervention is needed in rare circumstances, and the urologists should adopt a conservative approach.19 Gallbladder injury and biliary peritonitis during PCNL

Introduction: Gallbladder injury related to PCNL is a rare but fatal complication necessitating early diagnosis. As a result of challenges in diagnosis, gallbladder injury is often detected after the development of biliary peritonitis. The first and the earliest symptoms include dyspeptic complaints, nausea, vomiting, and localized or diffuse abdominal pain. New onset dyspeptic complaints and abdominal pain after PCNL should prompt the diagnosis of gallbladder injury. If biliary peritonitis develops because of bile acids, cholecystectomy would be inevitable using either a laparoscopic procedure or laparotomy. Results: In the literature, there are eight case reports regarding gallbladder injury that occurred during PCNL. Of these patients, seven underwent PCNL because of kidney stones and one patient underwent a percutaneous nephrostomy procedure because of hydronephrosis. These

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Table 3. Literature Review of Gallbladder Injuries During Percutaneous Nephrolithotomy Author Martin et al.

n 28

1

Saxby23 Kontothanassis and Bissas24

1 2

Turner et al.26

1

Ricciardi et al.29

1

Patel and Nakada25

2

Management

Outcomes

Time to diagnosis

Exploratory laparotomy and cholecystectomy Nephrostomy( + ) Laparoscopy and cholecystectomy  Exploratory laparotomy and cholecystectomy T-tube in the common biliary duct Nephrostomy( + )  *Exploratory laparotomy and cholecystectomy Laparoscopy and cholecystectomy Nephrostomy(-) incomplete operation Exploratory laparotomy and cholecystectomy

Successful

48 hours

Successful Successful

48 hours 48 hours

Successful Successful

12 hours Intraoperative

Unsuccessful

 Laparoscopy and cholecystectomy Nephrostomy( + )  Laparoscopy and cholecystectomy Nephrostomy( + )

Successful

 Right nephrectomy after 24 hours  Cholecystectomy after 1 week  Roux-en-Y after 5 months 48 hours

Successful 48 hours

*This is the patient who was injured during percutaneous nephrostomy because of hydronephrosis.

cases are presented in Table 3. All patients needed cholecystectomy. Discussion: Although gallbladder injury rarely occurs during PCNL, patients cannot be treated with conservative methods in light of the current literature data. The clinical findings of the patients include abdominal pain, rebound tenderness and guarding, and other findings of generalized peritonitis. The diagnosis can be established intraoperatively or in the postoperative period. Whether gallbladder injury is diagnosed during the intervention or in the postoperative period after the development of biliary peritonitis, all cases necessitate cholecystectomy with exploratory laparoscopy or laparotomy. Secondary complications of biliary peritonitis, however, including intra-abdominal abscess formation and late term adhesions, are less commonly observed if the condition is diagnosed in the early periods. Early diagnosis, termination of PCNL, and laparoscopic cholecystectomy are particularly recommended. Minimally invasive surgical procedures result in lower morbidity and mortality. In the study by Saxby and coworkers23 in 1996, gallbladder injury and biliary peritonitis that were diagnosed 48 hours after the operation were successfully managed with the laparoscopic procedure and cholecystectomy. In the study by Kontothanassis and associates,24 involving two patients, the first patient underwent exploratory laparotomy and cholecystectomy 48 hours after standard PCNL and the development of biliary peritonitis and insertion of a T-tube drain into the common bile duct. The other patient had gallbladder injury that occurred during percutaneous nephrostomy performed because of hydronephrosis. This patient underwent exploratory laparotomy and cholecystectomy because of acute abdominal findings 12 hours after the injury, although this patient had a microscopic injury in the gallbladder, and the resulting clinical picture was biliary peritonitis. During

percutaneous interventions in the right side, gallbladder injury should be considered if a greenish and foamy discharge is observed from the guide wire. If possible, the catheter should be left in place for the maintenance of the discharge, and PCNL must be terminated. All gallbladder injuries reported in the literature resulted in cholecystectomy, regardless of the size of the injury and the timing of the diagnosis.25 In the study by Turner and colleagues,26 the diagnosis was made during the procedure because of opacification of the gallbladder perioperatively with a radiocontrast agent. This is the only reported case in the literature of diagnosis during the procedure. Peritonitis was diagnosed at 36 hours and treated with laparoscopic cholecystectomy. The distance between the calices of the right kidney and the gallbladder can be as close as 2 cm, and this feature is thought to be particularly important in slim patients. The combination of radiography and US access is recommended during the PCNL procedure.27 In their report, Martin and coworkers28 performed cholecystectomy during diagnostic exploratory laparotomy in a patient with peritonitis that developed after PCNL. Ricciardi and colleagues29 described the first case of duodenal injury with biliary peritonitis caused by choledoch necrosis and bile leakage after PCNL. Although extremely rare during PCNL, choledoch necrosis and bile leakage can result in biliary peritonitis. The risk of injury can be higher during a percutaneous intervention to the right kidney that has dense adhesions with the deep structures.29 It is considered that unidentified anatomic variations in the gallbladder and vascular structures of the gallbladder might lead to necrosis. This necrosis should occur in the bilioduodenal junction. Ricciardi and colleagues29 reported that the delay in diagnosis might lead to the development of ARDS and septic

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Table 4. Literature Review of Small Intestine Injuries During Percutaneous Nephrolithotomy Author

n

Operation type

Viville et al.32 Santiago et al.31 Begliomini et al.33 Al-Assiri et al.38

1 1 1 1

Prone Prone Prone Prone

Winer et al.34 Culcin et al.35 Ahmed and Reeve36 Kumar et al.37 Marquesine et al.39

1 1 1 1 1

Prone nephrostomy Prone PCNL Prone PCNL Prone PCNL Prone PCNL Two punctures (low and upper calix)

PCNL PCNL PCNL PCNL

Injured bowel section

Time to diagnosis

Jejunum Jejunum Jejunum Jejunum

48 hours 36 hours 24 hours Intraoperative

Jejunum Duodenum Duodenum Duodenum Jejunum

120 hours 1 week 1 week 24 hours 48 hours

Management

Outcomes

Exploratory laparotomy Successful Exploratory laparotomy Successful Exploratory laparotomy Successful Successful  Conservative  Total parenteral nutrition  Malecot repositioning the intestinal lumen Exploratory laparotomy Successful Exploratory laparotomy Successful Exploratory laparotomy Successful Exploratory laparotomy Successful  Conservative Successful  Total parenteral nutrition  Antibotic

PCNL = percutaneous nephrolithotomy.

shock and even more severe clinical pictures that necessitate the use of inotropic agents. This case report clearly indicates that clinicians should pay particular attention to recognizing the cases in the early period.29 Conclusion: Regardless of the size of the gallbladder injury, the treatment would be cholecystectomy because of the development of biliary peritonitis. Cholecystectomy is mandatory during a laparoscopic procedure or exploratory laparotomy. The condition is a life- threatening complication if there is a failure to diagnose. Small intestine injury during PCNL

Introduction: Small intestinal injuries occurring during the PCNL procedure can be managed with conservative methods if no change occurs in the general condition and clinical status of the patients. Urologists are recommended to obtain intraoperative nephrostography because of the difficulties in diagnosis. The nephrostography data may need to be supported by retrograde urography because CT and other conventional investigations in the postoperative period may reveal normal findings. If the diagnosis can be made intraoperatively, abdominal exploration can be avoided by replacement of the nephrostomy catheter, stopping oral intake, and administration of parenteral supportive therapy. Results: In the literature, there are reports of nine cases with small intestinal injury related to PCNL. Of these patients, eight sustained injury during the PCNL procedure and one during percutaneous nephrostomy; six of these patients had jejunum injury and three had duodenum injury. These cases are presented in Table 4. Of the patients, seven needed exploratory laparotomy, and two were treated with conservative methods. Discussion: The second and third portions of the duodenum can be injured during percutaneous intervention to the kidney because of their close proximity to the right kidney.30 The duodenum lying anteromedially to the right kidney can be injured during right-sided percutaneous procedures if a needle or an instrument is advanced too deeply. In addition, the duodenum can be perforated if the back, stiff part of the

guidewire is erroneously used for dilation of the nephrostomy tract. Such a complication is, however, less commonly observed than colonic perforations. The diagnosis can be made if intestinal mucosa or contents are visualized or if a communication with the small bowel is demonstrated on nephrostogram or the formation of a nephroduodenal fistula is observed on postoperative nephrostography.30 This can occur when the renal pelvis is perforated during dilation or placement of the working sheath, or stone removal. This complication can be prevented by careful fluoroscopic observation during introduction, dilation of the tract, insertion of the working sheath, and performing appropriate endoscopic manipulations.30 In a report in 1998, Santiago and associates31 performed primary small intestinal repair and simultaneous splenectomy in a patient who underwent exploratory laparotomy because of jejunum injury. The splenic injury that manifested with hemodynamic deterioration 36 hours after the injury allowed early repair of the small intestinal injury. In the report by Viville and colleagues,32 jejunum injury that occurred after the prone PCNL procedure was managed with exploration and primary repair. In the study by Begliomini and coworkers,33 conventional CT scans performed because of diffuse abdominal pain guarding that developed within 24 hours after prone PCNL revealed normal findings. Exploratory laparotomy performed because of continuing acute abdominal findings revealed serosal injury in the colon and jejunum perforation that was managed with primary repair. In this case, descendent urography at the end of the surgery did not diagnose the lesion in the small intestine, likely because of the loop transfixation, and the fact that the balloon of the Foley catheter was located in the renal pelvis. Conventional investigations such as US and CT may fail to diagnose small intestinal injuries; nephrostography is particularly recommended.33 In the study by Winer and colleagues,34 intestinal obstruction was detected 5 days after the insertion of a bilateral nephrostomy catheter in a patient who had bilateral hydronephrosis from ovarian cancer. It was found that the right nephrostomy catheter resulted in intestinal obstruction because of jejunum injury, which was treated with primary

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repair during exploration. In a case report by Culcin and associates,35 nephroduodenal fistula formation was detected in one patient 1 week after the PCNL procedure, and the patient was treated with exploratory laparotomy and Roux-en-Y procedure. The delay in diagnosis is associated with the use of a more complicated surgical procedure. Early diagnosis avoids complex surgical procedures.35 In the report by Ahmed and coworkers,36 a nephroduodenal fistula was managed with exploratory laparotomy and primary fistula repair because of a 1 week delay in the diagnosis. The third case of duodenal injury in the literature was reported by Kumar and associates.37 The diagnosis was made within 24 hours after the operation, and the injury was managed with exploration and primary repair. The review of the literature reveals two cases of small intestinal injury that were managed with conservative methods. In the report by Al-Assiri and associates,38 jejunum injury was managed with conservative methods. After the third attempt to the lower calices of the left kidney with the patient in the prone position, the stone was fragmented using an ultrasonic lithotripter after balloon dilation. After visualizing the relation between the renal pelvis and bowel lumen on nephrostography, the Malecot catheter was moved to the bowel lumen and a J-stent was inserted. Oral intake was terminated, and broad-spectrum antibiotics were initiated. The presence of jejunocutaneous fistula was confirmed by tubogram that was performed on postoperative Day 7. The fistula tract between the renal pelvis and the jejunum was closed during this period. After 3 weeks of total parenteral nutrition (TPN), the Malecot catheter and J-stent were removed, and jejunal injury was therefore managed with conservative methods and exploration was avoided. Posterolateral positioning of the colon may predispose to colonic injury, as well. The small bowel, however, is packed by the peritoneum, which lies anterior to the kidneys away from the trajectory path of PCNL; therefore, the chance of bowel injury during PCNL is very low.38 In a study by Marquesine Paul and colleagues,39 enterocutaneous fistula occurred after right-sided PCNL in a patient who underwent a duodenal switch operation because of morbid obesity and who lost 55 kg with this therapy. Two interventions were performed on the upper and lower calices of the kidney. After the observation of intestinal content discharging from the nephrostomy tube in the early postoperative period, fistula drainage was performed, broad-spectrum antibiotics were initiated, oral intake was terminated, TPN was initiated, and the patient was treated with conservative methods by finally withdrawing the nephrostomy catheter at postoperative Day 10. It is said that higher complication rates are observed in patients who undergo obesity surgery or jejunoileal bypass because of a decrease in supportive tissues.39 Among small intestine injuries reported in the literature, only one case was associated with left-sided PCNL. Small intestine injuries mostly occur as the complication of a right-sided PCNL procedure.38 Conclusion: There are sporadic and limited reports in the literature regarding the management of duodenal or jejunal injury. All portions of the small intestine but the second portion of duodenum are intraperitoneal. An exploration is needed in almost all patients who sustain intraperitoneal bowel injury. Only a minority of such injuries can be managed with conservative therapies. Conservative therapies can be considered if the diagnosis has been made in the perioperative period and the nephrostomy tube has been moved

into the bowel lumen, and if clinical, radiologic, and laboratory findings show stability. In the report by Al-Assiri and coworkers,38 after removal of the Malecot catheter into the bowel lumen and insertion of the J-stent into the renal pelvis, the enterourinary fistula was repaired between the renal pelvis and the bowel. This may eliminate the need for laparotomy. Otherwise, all small intestine injuries that remain undiagnosed in the perioperative period will necessitate exploration. Furthermore, exploration would be a must regardless of the site if there is a large injury. Nephrostography and upper gastrointestinal radiography are recommended 10 to 15 days after injury to assess for closure of the fistula.38,40 Colon injury during PCNL

Introduction: Colonic perforation is a rare complication of percutaneous kidney surgery, and it is reported in fewer than 1% of the cases. This rate is even less than 0.5% according to the recent data in the literature. Colon injury mostly occurs during left-sided PCNL. Hadar and Gadoth41 and Sherman and associates42 reported retrorenal position of the colon in 0.6% of the general population. Hopper and colleagues43 examined 500 CT scans of the abdomen and reported that the overall prevalence of the retrorenal colon was 1.9% in the supine position. A puncture placed too laterally may injure the colon. The position of the colon is usually anterior or anterolateral to the lateral renal border. Therefore, the risk of colon injury usually exists only with a very lateral (lateral to the posterior axillary line) puncture.30 Results: Case reports of colonic injuries in the literature related to PCNL were excluded from the current review, and only large case series and the data of meta-analyses were included. Colon injury occurred in 36 of 9996 (0.36%) patients who underwent the PCNL procedure in the prone position. Colon injury occurred in 14 of 3428 (0.40%) patients who underwent the PCNL procedure in the supine position. In large series, colon injuries have other risk factors independent from the position. Table 5 indicates 51 patients (36 prone and 14 supine) who sustained colon injury during the PCNL procedure. Discussion: Elderly patients with chronic constipation or patients with other causes of colonic distention, patients who previously underwent major abdominal surgery (jejunoileal bypass, partial jejunoileal bypass), or those with neurologic impairment and institutional bowel resulting in an enlarged colon exhibit displacement of the colon posterior to the kidney and increased risk of colon perforation. Other factors that increase the risk of colon injury include thin female patients with very little retroperitoneal fat, patients with mobile kidneys, anterior caliceal puncture, previous extensive renal surgery, horseshoe kidney, and other forms of renal fusion or ectopia, and patients with kyphoscoliosis.30 US-guided renal percutaneous intervention can be performed in patients who possess a high risk of retrorenal colon. Preoperative CT evaluation in the prone position is strongly recommended in patients suspected to have a risk for colon injury. In some patients, CT-guided intervention is recommended if the window of entry into the collecting system would be quite small.20 Prompt recognition of a colonic perforation is critical to limit serious infectious sequelae. Colon perforation should be suspected if unexplained fever develops or the patient has intraoperative or immediate

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Table 5. Literature Review of Colon Injuries During Percutaneous Nephrolithotomy Author

Total patients (n) 49

Colonic injury (n,%)

Operation type

Management

Outcomes

NA Conservative NA NA NA Colostomy Colostomy Colostomy Colostomy (n = 2) Conservative (n = 13) Conservative Colostomy NA NA Conservative

NA Successful NA NA NA Successful Successful Successful Successful Successful Successful Successful NA NA Successful

Holman et al. Tefekli et al.50 El-Assmy et al.51 Wezel et al.52 Semins et al.53 Segura et al.45 Lee et al.54 Rodrigues et al.48 El-Nahas et al.62

300 811 661 200 197 1000 582 285 5039

5 3 2 2 1 2 1 1 15

(1.7%) (0.3%) (0.3%) (1%) (0.5%) (0.2%) (0.2%) (0.3%) (0.3%)

Prone Prone Prone Prone Prone Prone Prone Prone Prone

Mousavi-Bahar et al.55 Vallancien et al.56 Wu et al.59 Liu et al.60 Kachrilas et al.58 Overall Overall

671 250 1469 389 1620 9996 3428

2 2 7 2 5 36 14

(0.3%) (0.8%) (0.5%) (0.5%) (0.3%) (0.36%) (0.40%)

Prone Prone Supine Supine Supine Prone PCNL Supine PCNL

NA = not available; PCNL = percutaneous nephrolithotomy.

postoperative diarrhea or hematochezia, signs of peritonitis, or passage of gas or feces through the nephrostomy tract.44 It is of particular importance to diagnose the condition before the removal of the nephrostomy catheter, and this would also avoid major surgical intervention. At this step, nephrostography and retrograde urography must be obtained. Furthermore, it has been reported that sepsis developed in 0.6% to 1.5% of the patients who underwent percutaneous stone surgery.45 Colon perforation should be considered as the source of sepsis in patients who remain unresponsive to the administered therapy because of fever, and CT scans are particularly recommended at this stage. Antegrade urography is another diagnostic tool in patients with unexplained fever and colon injury after the PCNL procedure. Abdominal CT, however, appears to be the best diagnostic tool to detect perforation of the colon by the nephrostomy tube. Unrecognized colonic injury can result in abscess formation, nephrocolic or colocutaneous fistula formation, peritonitis, or sepsis.46 According to the 1985 report in the literature, LeRoy and associates47 successfully treated two patients with colon injury that occurred after a PCNL procedure using conservative methods while avoiding colostomy. In a series of five patients with extraperitoneal colon injury reported by Gerspach and colleagues,46 all patients were treated with conservative methods. In their study, Rodrigues Netto and coworkers48 detected one colon injury in 285 patients who was later treated with colostomy. In the study by Holman and colleagues,49 no colon injury occurred in 150 patients who underwent bilateral simultaneous PCNL procedure; however, they reported five cases of colon injury in a series of 300 patients. In the study by Tefekli and associates,50 all patients with colon injuries (n = 3) were treated with conservative methods. El-Assmy and coworkers51 studied 661 patients and reported colon injury in two cases. In the same series of patients, the rate of colon injury was reported to increase by

50% if the procedure was performed by a radiologist. This study specifically suggests that the access should be performed by an urologist during PCNL procedure. The prevalences of colon injury in the studies by Wezel and associates52 and Semins and colleagues53 were reported to be 0.5% and 1%, respectively. In the studies by Segura and coworkers45 and Lee and colleagues,54 a total of three patients with colon injury were treated with colostomy.45 In the study by Lee and colleagues,54 the rate of colon injury (n = 582) was quite low at 0.2%, and this case necessitated colostomy. In the study by Mousavi-Bahar and coworkers,55 two patients with colon injury were treated with conservative methods. In a series of 250 patients reported by Vallancien and associates,56 two patients with colon injury were treated with colostomy. In one of these patients, colon injury was suspected only with rectal bleeding. In this series, colostomy was inevitable in one patient because of the presence of intraperitoneal injury. The other patient, however, had retroperitoneal colon injury. This patient was also treated with colostomy. This patient might have been treated with colostomy because of limited availability of PCNL equipment and diagnostic tools in 1985 and lack of consensus in the literature regarding conservative management of colon injury. In the study by Ba’adani and colleagues,57 hemicolectomy was needed in a patient with delayed diagnosis of fecal fistula that developed after the PCNL procedure. Although conservative methods proved effective in the majority of colon injuries, hemicolectomy may be rarely needed in large colon injuries. Kachrilas and coworkers58 reported five colon injuries in a series of 1620 patients. The most striking feature of this series is that all colon injuries occurred in the supine PCNL procedure. The five patients with colon injuries in the series underwent other procedures in addition to PCNL. Two patients underwent supine PCNL plus antegrade endopyelotomy because of a right kidney stone and right

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ureteropelvic junction stenosis. Fever that occurred in postoperative Days 1 and 3 and discharge of colonic content from the Malecot catheter were the common clinical features of these patients. Both patients had ascending colon injury. The patients were treated with conservative methods including TPN, terminating oral intake, leaving the endopyelotomy catheter in place for a long time, repositioning of the nephrostomy catheter within the colon lumen, and the administration of broad-spectrum antibiotics ([ampicillin, metronidazole, gentamicin] or [imipenem, vancomycin, metronidazole]). The nephrostomy tube was withdrawn after 10 to 14 days, and the endopyelotomy catheter was withdrawn after 6 weeks. Abdominal CT scans obtained at 3 months did not reveal any pathology between the kidney and colon. The other patient underwent left supine PCNL and simultaneous flexible ureteroscopy because of a staghorn kidney stone, and descending colon injury developed. The patient did not have intra-abdominal fluid collection, and the patient was treated with conservative methods including the repositioning of the nephrostomy tube in the colon and the administration of broad-spectrum antibiotics. The other patient sustained injury to the colonic diverticula. Diverticular colon disease may pose a risk for intervention to the lower pole of the kidney. This patient was also successfully treated with conservative methods.58 As an alternative to supine PCNL, standard prone PCNL was not shown to have increased the complication rates. Supine PCNL can be preferred because of disadvantages related to the anesthesia, neurosurgical and orthopedic pathologies, circulation problems in obese patients, and hemodynamic and ventilation problems. Supine PCNL does not increase the rate of complication compared with standard PCNL. The most important and debated point is the concern of higher rates of colon injuries with supine PCNL procedure. In meta-analyses by Wu and associates59 and Liu and colleagues,60 the complication rates were not different between supine PCNL and standard PCNL. Supine PCNL was found to be as effective and safe as prone PCNL. The rate of colon injury was 0.5%, similar to that reported in the literature. After the diagnosis of colonic perforation was made, the first step of treatment involved the separation of the ne-

phrocolic communication.61 After establishing the diagnosis of colon injury, a permanent J-stent must be inserted and under fluoroscopic observation, the nephrostomy tube must be repositioned and left in the colon. In addition, a Foley catheter must be inserted to relieve the pressure in the urinary system. The patient must have broad-spectrum antibiotics covering anaerobic colon bacteria or triple antibiotic therapy administered. The patient should receive a low-residue diet or TPN by stopping oral intake for bowel rest. Intrarectal and intracolonic pressure should be decreased by anal dilation. This will allow the recovery of the renal collecting system and closure of the medial colonic wall. If a colostogram or retrograde urogram performed after 5 to 7 days does not exhibit extravasation or communication between the colon and collecting system, the Foley catheter is removed and the colostomy tube is withdrawn, but left in place as a drainage site other than the colon. The tube is completely removed after 2 to 3 days (7–10 days in total) if the lateral wall of the colon is assumed to be closed and if there is no sign of persistent nephrocolic fistula. In case of intraperitoneal colonic perforation, peritonitis, sepsis, or failure of conservative management, open surgical exploration should be performed, and a colostomy is usually necessary.30,61 It is recommended that the tube should be removed after complete healing of the colon is confirmed by barium enema at Day 8 or complete separation is confirmed on J-stent retrograde urography 4 to 6 weeks later. A temporary colostomy for 3 months is essential in patients with colocutaneous fistula, despite the use of conservative therapy. The most important point in colon injury is the timing of the diagnosis. The success rate of conservative therapy would be 86% (13/15) if the diagnosis has been made perioperatively or postoperatively before the removal of the nephrostomy tube. The rate of success, however, decreases by half down to 40% if the diagnosis was delayed and the nephrostomy tube was removed before recognizing colon injury. Four of 10 patients need colostomy.61 Therefore, preoperative risk assessment should include the evaluation of the projection of access in CT, spatial relation between the colon and the kidney, and the presence of retrorenal colon. The operation should be terminated by performing nephrostography, the nephrostomy tube should be repositioned,

Table 6. Risk Factors of Gastrointestinal Complications During Percutaneous Nephrolithotomy Colonic injury         

Small intestine injury

 Jejunoileal bypass Elderly  Horseshoe kidney Jejunoileal bypass Retrorenal colon Institutional bowel resulting Decreased retroperitoneal fat tissue, underweight female patients Mobile kidney Anterior calix access, lateral to the posterior axillary line access Horseshoe kidney Kyphoscoliosis

Splenic injury

Liver injury

 Supra-12th supracostal  Supracostal percutaneous access renal access  Direct upper pole  Hepatomegaly access  Splenomegaly  Fluoroscopic guided access

Gallbladder injury  Midpolar right kidney access  Underweight patient  Hydrops gallbladder  Adherent to the surrounding tissues of the right kidney  The distance between the calix gallbladder < 2 cm

GI SYSTEM COMPLICATIONS IN PCNL

and supportive therapy should be initiated in case of any complication. In their study, El Nahas and coworkers62 detected colon injury in 15 of 5039 patients (0.29%). In 12 procedures (80%), colonic perforation complicated lower caliceal puncture and in those with horseshoe kidneys or chronic colonic distension, complicated upper caliceal punctures. Of these 15 patients, there were 5 with a perioperative diagnosis and 10 with a postoperative diagnosis. Of the colon injuries, 66% occurred during a left-sided PCNL procedure and 34% occurred in a right-sided PCNL procedure. In right-sided injuries, all patients had horseshoe kidney or previous history of renal surgery. The most important independent risk factors determined in this study were advanced patient age and the presence of horseshoe kidney. Of the patients, 13 were treated with conservative methods and 2 patients needed a colostomy. All injuries were retroperitoneal. Early diagnosis and proper treatment represent the key to minimizing patient morbidity and avoiding serious complications. Some authors suggest, however, that repositioning of the nephrostomy tube into the colon would be sufficient in colon injury, and internal urinary drainage had no benefit. Nouira and colleagues63 demonstrated conservative management of colon injury without performing internal drainage. In their study, Eduardo and associates64 inserted a flexible fibrin glue applicator into the nephrostomy tract and injected approximately 5 mL of fibrin glue to manage colon injury. The closure of the fistula tract was then confirmed by radiologic investigation. In this study, the application of fibrin glue appears as an alternative to the supportive therapy in colon injuries. This method may decrease the number of patients who need colostomy in circumstances in which the drainage from colocutaneous fistula was decreased but not completely ceased. This method, however, has some potential complications including allergic reaction, immunologically induced coagulopathy, thromboembolic complications, and the theoretical risk of viral transmission. Conclusion: Some factors may increase colonic injury during PCNL, such as previous intestinal bypass surgery, female sex, old age, low body weight, horseshoe kidney, and previous renal surgery. The incidence is greater on the left side, with lower caliceal puncture and lateral origin of the puncture. The most important etiology for this complication is retrorenal or posterolateral position of the colon. Early diagnosis and management is the best way to avoid complications from colonic perforation.65 Risk factors for gastrointestinal complications during PCNL

The advanced age and horseshoe kidney are independent risk factors for the development of colon injury during PCNL. Interestingly, the presence of retrorenal colon or very lateral intervention are not regarded as independent risk factors. Horseshoe kidney is also a risk factor for small intestinal injuries. Supracostal intervention and organomegaly, however, represent the most significant risk factors for solid organ injuries such as injuries to the liver and spleen. The risk factors for gastrointestinal complications of PCNL are summarized in Table 6.

1265 Disclosure Statement

No competing financial interests exist. References

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Address correspondence to: ¨ ztu¨rk, MD Hakan O Basmane Hospital of Sifa University Fevzipasa Boulevard No: 172/2 Basmane-Konak 35240 Izmir Turkey E- mail: [email protected]

Abbreviations Used CT ¼ computed tomography MRI ¼ magnetic resonance imaging PCNL ¼ percutaneous nephrolithotomy PNL ¼ percutaneous nephrolithotomy TPN ¼ total parenteral nutrition US ¼ ultrasonography