Endourology and Stones Vascular Complications After Percutaneous Nephrolithotomy: 10 Years of Experience Marawan M. El Tayeb, John J. Knoedler, Amy E. Krambeck, Jessica E. Paonessa, Matthew J. Mellon, and James E. Lingeman OBJECTIVE METHODS
RESULTS
CONCLUSION
To provide a contemporary look at vascular complications after percutaneous nephrolithotomy (PNL) with access performed solely by a urologist using fluoroscopic guidance. A retrospective review of 2792 patients who had 3338 PNLs at Indiana University Health Methodist Hospital and Mayo Clinic Rochester was performed. Patients who experienced significant bleeding requiring diagnostic renal angiography and superselective embolization (SSE) were reviewed and compared with the overall database. There were 15 patients (16 renal units) requiring renal angiography and SSE (0.48%). Mean time from PNL to bleeding was 7 days (range, 1-15 days) and to SSE was 9.6 days (range, 2-18 days). Mean drop in hemoglobin was 5.3 g/dL (range, 2-9 g/dL). Transfusion was needed in 9 patients (60%). There were no differences between the vascular complications group and the uneventful PNL group in mean age (55.06 vs 52.2 years; P ¼ .519), UTI history (40% vs 38%; P ¼ .92), mean operative time (125.8 vs 102.47 minutes; P ¼ .192), the need for multiple access (18.75% vs 18%; P ¼ .939), and access location. The vascular complications group had a lower stone burden than the uneventful PNL group (stones > 2 cm; 43.7% vs 74.03%; P ¼ .014). The incidence of vascular complications in this contemporary series is one of the lowest reported to date. At our centers, vascular bleeding complications appear to be a random and rare event after PNL as we were unable to identify any specific risk factors. Early SSE avoided the need for blood transfusion in many patients. UROLOGY -: -e-, 2015. 2015 Elsevier Inc.
P
ercutaneous nephrolithotomy (PNL) is the preferred approach for managing large and/or complex kidney stones. Although PNL is less invasive than open pyelolithotomy or nephrolithotomy, complications still occur.1 Bleeding is the most common significant complication with potential for major morbidity. The incidence of bleeding requiring transfusion after PNL is reported to be 1%-11%.2-6 Most bleeding is self-limiting and resolves with conservative measures.1-6 However, angiographic embolization is sometimes warranted.3-7 The reported incidence of angiographic embolization after PNL is 1%-2.6%.7-10 Our aim is to provide a contemporary look at vascular complications after PNL with access performed solely by a urologist using fluoroscopic guidance and to examine potential risk factors for post-PNL severe hemorrhage. Financial Disclosure: James E. Lingeman is a consultant, advisor, meeting participant, and lecturer, is associated with scientific studies or trials, and has investment interests with Boston Scientific Corporation. Amy E. Krambeck is consultant and advisor to Histonic. The other authors declare that they have no relevant financial interests. From the Department of Urology, Indiana University School of Medicine, Indianapolis, IN; and the Department of Urology, Mayo Clinic, Rochester, MN Address correspondence to: James E. Lingeman, M.D., Department of Urology, Indiana University School of Medicine, 1801 Senate Boulevard., Suite 220, Indianapolis, IN 46202. E-mail: [email protected] Submitted: October 15, 2014, accepted (with revisions): December 30, 2014
ª 2015 Elsevier Inc. All Rights Reserved
METHODS After institutional review board approval, a retrospective review of databases at Indiana University Health Methodist Hospital and Mayo Clinic Rochester identified 2792 patients who had undergone 3338 PNLs between January 2003 and September 2013. Patients who experienced significant bleeding requiring diagnostic renal angiography (RA) and subsequent superselective embolization (SSE) were reviewed and compared to the overall database. Preoperative patient evaluation included history, physical examination, medications, and standard laboratory investigations, as well as noncontrast computed tomography (CT). The basic technique of PNL at these institutions is as follows. After inserting a ureteral catheter in the lithotomy position, the patient is positioned in the prone position for the percutaneous procedure. The posterior calyceal group is usually entered. Biplanar fluoroscopy and an 18-gauge diamond-tip needle are used for the puncture, and care is taken during the puncture to limit the manipulation of the needle while acquiring the access. Respiration is suspended during needle alignment with the targeted calyx as the renal capsule is traversed, and no major adjustments to the needle path are made once the needle is within the renal parenchyma to minimize the risk of laceration of renal tissue. If a major adjustment to the direction of the access is required, the needle is withdrawn from the kidney, and the puncture is appropriately adjusted before traversing the renal capsule.11 http://dx.doi.org/10.1016/j.urology.2014.12.044 0090-4295/15
1
Table 1. PNL preoperative characteristics Characteristic N Male, n (%) Female Stones greater or equal than 2 cm Stones
RESULTS
CONCLUSION
To provide a contemporary look at vascular complications after percutaneous nephrolithotomy (PNL) with access performed solely by a urologist using fluoroscopic guidance. A retrospective review of 2792 patients who had 3338 PNLs at Indiana University Health Methodist Hospital and Mayo Clinic Rochester was performed. Patients who experienced significant bleeding requiring diagnostic renal angiography and superselective embolization (SSE) were reviewed and compared with the overall database. There were 15 patients (16 renal units) requiring renal angiography and SSE (0.48%). Mean time from PNL to bleeding was 7 days (range, 1-15 days) and to SSE was 9.6 days (range, 2-18 days). Mean drop in hemoglobin was 5.3 g/dL (range, 2-9 g/dL). Transfusion was needed in 9 patients (60%). There were no differences between the vascular complications group and the uneventful PNL group in mean age (55.06 vs 52.2 years; P ¼ .519), UTI history (40% vs 38%; P ¼ .92), mean operative time (125.8 vs 102.47 minutes; P ¼ .192), the need for multiple access (18.75% vs 18%; P ¼ .939), and access location. The vascular complications group had a lower stone burden than the uneventful PNL group (stones > 2 cm; 43.7% vs 74.03%; P ¼ .014). The incidence of vascular complications in this contemporary series is one of the lowest reported to date. At our centers, vascular bleeding complications appear to be a random and rare event after PNL as we were unable to identify any specific risk factors. Early SSE avoided the need for blood transfusion in many patients. UROLOGY -: -e-, 2015. 2015 Elsevier Inc.
P
ercutaneous nephrolithotomy (PNL) is the preferred approach for managing large and/or complex kidney stones. Although PNL is less invasive than open pyelolithotomy or nephrolithotomy, complications still occur.1 Bleeding is the most common significant complication with potential for major morbidity. The incidence of bleeding requiring transfusion after PNL is reported to be 1%-11%.2-6 Most bleeding is self-limiting and resolves with conservative measures.1-6 However, angiographic embolization is sometimes warranted.3-7 The reported incidence of angiographic embolization after PNL is 1%-2.6%.7-10 Our aim is to provide a contemporary look at vascular complications after PNL with access performed solely by a urologist using fluoroscopic guidance and to examine potential risk factors for post-PNL severe hemorrhage. Financial Disclosure: James E. Lingeman is a consultant, advisor, meeting participant, and lecturer, is associated with scientific studies or trials, and has investment interests with Boston Scientific Corporation. Amy E. Krambeck is consultant and advisor to Histonic. The other authors declare that they have no relevant financial interests. From the Department of Urology, Indiana University School of Medicine, Indianapolis, IN; and the Department of Urology, Mayo Clinic, Rochester, MN Address correspondence to: James E. Lingeman, M.D., Department of Urology, Indiana University School of Medicine, 1801 Senate Boulevard., Suite 220, Indianapolis, IN 46202. E-mail: [email protected] Submitted: October 15, 2014, accepted (with revisions): December 30, 2014
ª 2015 Elsevier Inc. All Rights Reserved
METHODS After institutional review board approval, a retrospective review of databases at Indiana University Health Methodist Hospital and Mayo Clinic Rochester identified 2792 patients who had undergone 3338 PNLs between January 2003 and September 2013. Patients who experienced significant bleeding requiring diagnostic renal angiography (RA) and subsequent superselective embolization (SSE) were reviewed and compared to the overall database. Preoperative patient evaluation included history, physical examination, medications, and standard laboratory investigations, as well as noncontrast computed tomography (CT). The basic technique of PNL at these institutions is as follows. After inserting a ureteral catheter in the lithotomy position, the patient is positioned in the prone position for the percutaneous procedure. The posterior calyceal group is usually entered. Biplanar fluoroscopy and an 18-gauge diamond-tip needle are used for the puncture, and care is taken during the puncture to limit the manipulation of the needle while acquiring the access. Respiration is suspended during needle alignment with the targeted calyx as the renal capsule is traversed, and no major adjustments to the needle path are made once the needle is within the renal parenchyma to minimize the risk of laceration of renal tissue. If a major adjustment to the direction of the access is required, the needle is withdrawn from the kidney, and the puncture is appropriately adjusted before traversing the renal capsule.11 http://dx.doi.org/10.1016/j.urology.2014.12.044 0090-4295/15
1
Table 1. PNL preoperative characteristics Characteristic N Male, n (%) Female Stones greater or equal than 2 cm Stones
