Percutaneous nephrolithotomy for staghorn calculi: Troubleshooting and managing complications

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Abstract

Staghorn calculi comprise a unique subset of complex kidney stone disease. Percutaneous nephrolithotomy (PCNL) is the gold standard treatment for staghorn stones. Despite continuous refinements to the technique and instrumentation of PCNL, these stones remain a troublesome challenge for endourologists and are associated with a higher rate of perioperative complications than that for non-staghorn stones. Common and notable intraoperative complications include bleeding, renal collecting system injury, injury of visceral organs, pulmonary complications, thromboembolic complications, extrarenal stone migration, and misplacement of the nephrostomy tube. Postoperative complications include infection and urosepsis, bleeding, persistent nephrocutaneous urine leakage, infundibular stenosis, and death. In this review, we report recommendations regarding troubleshooting measures that can be used to identify and characterize these complications. Additionally, we include information regarding management strategies for complications associated with PCNL for staghorn calculi.

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Complications in percutaneous nephrolithotomy.

Maurice Stephan Michel, Lutz Trojan, Jens Jochen Rassweiler (2007)

This review focuses on a step-by-step approach to percutaneous nephrolithotomy (PNL) and its complications and management. Based on institutional and personal experience with >1000 patients treated by PNL, we reviewed the literature (Pubmed search) focusing on technique, type, and incidence of complications of the procedure. Complications during or after PNL may be present with an overall complication rate of up to 83%, including extravasation (7.2%), transfusion (11.2-17.5%), and fever (21.0-32.1%), whereas major complications, such as septicaemia (0.3-4.7%) and colonic (0.2-0.8%) or pleural injury (0.0-3.1%) are rare. Comorbidity (i.e., renal insufficiency, diabetes, gross obesity, pulmonary disease) increases the risk of complications. Most complications (i.e., bleeding, extravasation, fever) can be managed conservatively or minimally invasively (i.e., pleural drain, superselective renal embolisation) if recognised early. The most important consideration for achieving consistently successful outcomes in PNL with minimal major complications is the correct selection of patients. A well-standardised technique and postoperative follow-up are mandatory for early detection of complications.

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The Guy's stone score--grading the complexity of percutaneous nephrolithotomy procedures.

Kay Thomas, Naomi Smith, Nicholas Hegarty … (2011)

To report the development and validation of a scoring system, the Guy's stone score, to grade the complexity of percutaneous nephrolithotomy (PCNL). Currently, no standardized method is available to predict the stone-free rate after PCNL. The Guy's stone score was developed through a combination of expert opinion, published data review, and iterative testing. It comprises 4 grades: grade I, solitary stone in mid/lower pole or solitary stone in the pelvis with simple anatomy; grade II, solitary stone in upper pole or multiple stones in a patient with simple anatomy or a solitary stone in a patient with abnormal anatomy; grade III, multiple stones in a patient with abnormal anatomy or stones in a caliceal diverticulum or partial staghorn calculus; grade IV, staghorn calculus or any stone in a patient with spina bifida or spinal injury. It was assessed for reproducibility using the kappa coefficient and validated on a prospective database of 100 PCNL procedures performed in a tertiary stone center. The complications were graded using the modified Clavien score. The clinical outcomes were recorded prospectively and assessed with multivariate analysis. The Guy's stone score was the only factor that significantly and independently predicted the stone-free rate (P = .01). It was found to be reproducible, with good inter-rater agreement (P = .81). None of the other factors tested, including stone burden, operating surgeon, patient weight, age, and comorbidity, correlated with the stone-free rate. The Guy's stone score accurately predicted the stone-free rate after PCNL. It was easy to use and reproducible. Copyright © 2011 Elsevier Inc. All rights reserved.

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Incidence, prevention, and management of complications following percutaneous nephrolitholapaxy.

Christian Seitz, Mahesh Desai, Axel Häcker … (2012)

Incidence, prevention, and management of complications of percutaneous nephrolitholapaxy (PNL) still lack consensus. To review the epidemiology of complications and their prevention and management. 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. 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. 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. Copyright © 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.

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Author and article information

Contributors

Nariman Gadzhiev

Journal

Journal ID (nlm-ta): Asian J Urol

Journal ID (iso-abbrev): Asian J Urol

Title: Asian Journal of Urology

Publisher: Second Military Medical University

ISSN (Print): 2214-3882

ISSN (Electronic): 2214-3890

Publication date PMC-release: 19 October 2019

Publication date (Print): April 2020

Publication date (Electronic): 19 October 2019

Volume: 7

Issue: 2

Pages: 139-148

Affiliations

[a ]Department of Urology, Pavlov First Saint Petersburg State Medical University, Russia

[b ]Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia

[c ]Department of Urology, Sechenov First Moscow State Medical University, Russia

[d ]Department of Urology, University of California, Oakland, CA, USA

Author notes

[∗ ]Corresponding author. nariman.gadjiev@ 123456gmail.com

Article

Publisher ID: S2214-3882(19)30103-1

DOI: 10.1016/j.ajur.2019.10.004

PMC ID: 7096695

PubMed ID: 32257807

SO-VID: b360fc36-5df2-439c-87e4-f5271ae7bbac

License:

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

History

Date received : 19 February 2019

Date revision received : 6 May 2019

Date accepted : 17 July 2019

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Percutaneous nephrolithotomy for staghorn calculi: Troubleshooting and managing complications

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Most cited references 96

Complications in percutaneous nephrolithotomy.

The Guy's stone score--grading the complexity of percutaneous nephrolithotomy procedures.

Incidence, prevention, and management of complications following percutaneous nephrolitholapaxy.

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