Bowel and Other Organ Injuries with Percutaneous Nephrolithotomy

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Bowel and Other Organ Injuries with Percutaneous Nephrolithotomy

John J. Knoedler,¹ Matthew T. Gettman,² & Chad J. Fleming³

¹ Division of Urology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA

² Mayo Clinic, Department of Urology, Rochester, MN, USA

³ Mayo Clinic, Department of Radiology, Rochester, MN, USA

Overall complications

Complications of percutaneous nephrolithotomy (PCNL) are common and may occur in 12.5–20% of patients, but they typically are low grade with less than 4% of patients experiencing a Clavien grade III or higher [1–3]. Although rare, solid organ injuries associated with PCNL are among the most feared. While some may be managed conservatively (Clavien grade II), there is significant risk of subsequent intervention (Clavien III or higher) [1]. Although complications such as extravasation, fever, and transfusion are more common, solid organ injury (including colon, bowel, lung, liver and spleen) are fortunately rare, historically occurring in less than 1% of cases [4]. In a 2012 review, Seitz et al. found the overall incidence of organ injury (including liver, spleen, and bowel) to be 0.4%, while thoracic complications occurred in 1.5% of patients [5]. Although various risk factors for organ injury exist, the most unifying may be access through the 10th intercostal space and/or anterior to the posterior axillary line [5]. In this chapter we review the occurrence of organ injury during PCNL, including discussion of diagnosis and management.

Colon injury

Colon perforation at the time of PCNL is uncommon, occurring in less than 1% of procedures [5–9]. In a review of the literature, Ozturk identified 36 colonic injuries among 9996 cases (0.36%) [7]. The colon is typically positioned anterior or anterolateral to the kidney, and in this orientation risk of injury occurs with extreme lateral access to the kidney, beyond the posterior axillary line. Thus, with normal anatomy, the risk of injury is low. However when abnormal anatomy is present, namely a retrorenal colon, the risk increases.

Anatomic studies have found that a retrorenal colon exists in between 0.6% and 2% of patients, and is more common on the left side (Figure 35.1) [10–14]. This risk may be markedly higher in patients with abnormal anatomy, such as severe spinal scoliosis, where retrorenal colon was identified in up to 25% of patients [15]. Additional risk factors may include chronic constipation and bowel distention, such as in elderly patients, previous surgery or neurologic impairment resulting in neurogenic bowel, prior renal surgery [14, 16], or horseshoe kidney and renal ectopia [9, 17]. Preoperative cross‐sectional imaging will help identify high‐risk patients and will allow the surgeon to plan their access in order to avoid colonic injury. For patients with severely altered anatomy with narrow windows of puncture, consideration should be given to CT‐guided access in order to avoid colon injury.

Image described by caption. — **Figure 35.1** CT scan showing colon injury at the time of left percutaneous nephrolithotomy.

Early diagnosis of colonic perforation is key to preventing more serious infectious complications. A nephrostogram during the case may demonstrate contrast within the colon, at which time drainage may be established. Postoperatively, the presence of diarrhea, hematochezia, or passage of gas or fecal material through the nephrostomy may all indicate injury. Intraoperative or postoperative imaging with nephrostogram or CT scan is recommended, at which time perforations may be seen. Delayed recognition may increase the risk for infection, including sepsis, and appropriate antibiotic coverage for urinary and colonic pathogens should be implemented.

Treatment of colonic perforation is usually conservative in the absence of peritoneal signs or sepsis [7, 8]. In 1985, LeRoy et al. reported their experience with successful conservative management of two patients with colon injury during PCNL [12]. Of the 36 cases identified by Ozturk, a majority were managed conservatively [7]. Conservative management is accomplished by withdrawing the nephrostomy into the colon to serve as colostomy drainage and placing a double‐J stent (Figure 35.2). A catheter should be placed into the bladder to create a low‐pressure system. Patients should be covered with broad‐spectrum antibiotics, and placed on a low‐residue diet or alternately on total parenteral nutrition. After 5–7 days, if a colostogram or retrograde pyelogram fails to demonstrate communication between the colon and kidney, the colostomy is withdrawn into the retroperitoneum to serve as a drain. If a barium enema 2–3 days later demonstrates closure of the colon, the retroperitoneal drain can be removed by day 7–10. Patients who develop signs of sepsis or persistent nephron–colonic or colocutaneous fistula should be considered for surgical exploration with diverting colostomy.

Other bowel injury

Due to the proximity of the second and third portions of the duodenum to the right kidney, injury may occur at the time of PCNL. However such injuries are very rare, with only nine reports of small bowel injury in the literature, including six jejunal and three duodenal injuries [7]. Eight injuries occurred at the time of right‐sided PCNL, and one jejunal injury occurred at the time of left PCNL. With the duodenum lying anterior and medial to the kidney, retroperitoneal access should be able to avoid this potentially devastating complication. However, the duodenum may be injured during right PCNL if the renal pelvis is perforated during access or dilation when a needle or instrument is advanced too far. Jejunal injuries may occur in similar fashion. Careful visualization using fluoroscopy at the time of access and dilation may mitigate this risk.

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