Percutaneous nephrolithotomy (PCNL), as primary treatment of kidney urinary stones, has regained much interest in the last decade thanks to the variations and refinements of the technique. Albeit 54% of complications are negligible, such as fever and small bleeding, for which no invasive intervention are needed (I type according to the Clavien classification), severe complications may occur and a prompt correct management should be established to avoid the worsening of patient clinical state. 1 We report on an unusual PCNL complication and its management.
A male patient, 43 years of age, underwent PCNL for a large left pyelocaliceal stone. Surgery was performed in Valdivia- Galdakao supine position. The percutaneous tract was established by combined radiological and sonographic guidance. The tract was dilated by balloon and a 24 F Amplatz sheath was located. As complete clearance was not achieved because of a residual lower pole calyceal stone, an ureteral double J and a 20 F nephrostomy were located for a second-look PCNL through the same tract after 7 days. After second-look PCNL residual stone was still not cleared because it was unreachable through the tract established and the patient was discharged without Nephrostomy and with the ureteral stent, with the plan of performing Retrograde intrarenal surgery (RIRS) in 3-4 weeks. Haemoglobin, Haematocrit and the renal function were normal. At the 7th day after PCNL no leakage was detected from the percutaneous tract, but the patient started to complain about flank discomfort and fever. Imaging showed a 6 cm lower-pole subcapsular collection. After 3 day of conservative management with antibiotics, the sub capsular collection did not resolve and a percutaneous 6 Fr mono-j drainage in the collection was placed. Drain output was at first purulent and evolved into urine throughout the following days. Drain urine culture was positive for E. Coli infection and Carbapenemic targeted antibiotic was offered to the patient.
Collection drained about 400 cc in 7 days and the drain was removed when the output was less than 10 cc per day. No late complications were reported and RIRS was scheduled in 1 month to clear the residual stone.
Improvement of surgical care demands transparent, consistent, and accurate reporting of surgical outcomes that are evaluated and documented in a standardised manner. 2A Clavien-Dindo Complication classification has recently been adopted and validated in a PCNL surgery. A Categorisation of percutaneous nephrolithotomy-specific complications according to Clavien classification score based on expert opinions collected from 74 urologists via an international survey has mentioned most of the PCNL complication and relative management. 3
To our knowledge the aforementioned complication is quite uncommon and deserves to be reported. In the Clavien-Dindo classification it may be located at 3b category, because its resolution needed a radiological intervention under local anaesthesia. The subcapsular collection did not resolve spontaneously because an internal fistula between the damaged calix and the subcapsular space supplying the collection had been established. The second-look PCNL irrigation without an Amplatz sheath probably plumped the collection through the fistulous small path, although it was carried out one week later when the tract should be mature enough and the calix rupture healed. Usually, the collection should shrink without further management when the collecting system is adequately drained by the stent after nephrostomy removal. That was not the case because the tract sealed quickly and the subcapsular collection continued being supplied by urine extravasation despite the double J placement. After 7 days the patient became symptomatic as the collection augmented and evolved into an abscess. Another interesting aspect we observed was the complete absence of blood clots in the collection as it was not a result of a traumatic hematoma, but rather a urine extravasation supplied by the second-look PCNL irrigation.
To our knowledge and experience the aforementioned complication is very uncommon and dreadful. Prompt detection and minivasive management may be resolutive.
1. References Labate G, Modi P, Timoney A, Cormio L, Zhang X, Louie M, Grabe M, de la Rosette J, on behalf of the CROES PCNL Study Group J. The percutaneous nephrolithotomy global study: classification of complications. J Endourol. 2011 Aug;25(8):1275-80
2. Ibarluzea G, Scoffone CM, Cracco CM, Poggio M, Porpiglia F, Terrone C, Astobieta A, Camargo I, Gamarra M, Tempia A, Valdivia Uria JG, Scarpa RM. Supine Valdivia and modified lithotomy position for simultaneous anterograde and retrograde endourological access. BJU Int. 2007 Jul;100(1):233-6.
3. Krupski TL. Standardization of reporting surgical complication. Are we ready? J Urol 2010;183:1671–2.
4. de la Rosette JJ, Opondo D, Daels FP, Giusti G, Serrano A, Kandasami SV, Wolf JS Jr, Grabe M, Gravas S; CROES PCNL Study Group. Categorisation of complications and validation of the Clavien score for percutaneous nephrolithotomy. Eur Urol. 2012 Aug;62(2):246-55.