Intraoperative Hemorrhage

Patients undergoing PRS are at risk for significant intraoperative bleeding and subsequent blood transfusion. The transfusion rates from various contemporary series have ranged from 1% to 34%. Several factors have been shown to be associated with an increased risk for transfusion. These include surgical technique, surgeon experience, preoperative anemia, advanced patient age, increased stone surface area, and the need for multiple tracts. Intraoperative complications such as infundibular tear or pelvic wall tear have been shown to significantly increase blood loss. Other factors that have been shown to predict increased blood loss during PRS include diabetes, longer operating time, and increased parenchymal thickness.

Proper preoperative workup of the patient is necessary to decrease risks of intraoperative hemorrhage. Perioperative use of anticoagulation is a controversial topic and should be discontinued in the proper time frame to allow the anticoagulant effect to wear off whenever possible. However, with the increased use of anticoagulants, studies are now being performed to evaluate the safety in performing PRS while on anticoagulation. Current evidence demonstrates that some medications such as aspirin, which were typically stopped in the perioperative period, need not necessarily be witheld. Leavitt and colleagues performed a retrospective review of 321 patients showing that perioperative use of aspirin is not associated with higher rates of bleeding complications. While there is no guideline for management of these medications at this time, proper discontinuation and administration of other anticoagulation therapies allow for successful PRS without an increase in bleeding or thromboembolic complications. Lange and associates evaluated the safety and efficacy of perioperative removable inferior vena cava filter placement in patients who were at significant risk for a venous thromboembolic event, allowing for complete discontinuation of these medications; bleeding and thrombotic complications were absent, although this may not be a satisfactory option in all patients.

Operative technique is a modifiable risk factor, and certain principles, if followed, can help to reduce the risk of significant blood loss. For the prone approach, the collecting system should be accessed through a posterior calyx along the direction of the infundibulum. This technique avoids the blood vessels that course adjacent to the infundibulum. The posterior calyx that provides the most direct access to the targeted stone should be chosen. Once access is established, the tract should be dilated only up to the peripheral aspect of the collecting system. Care should be taken not to dilate the tract too far medially because this increases the risk of pelvic wall tear and injury to the hilar vessels. Stoller and colleagues reported that renal pelvic perforation is a risk factor for excessive blood loss.

The impact on blood loss by the method of tract dilation is controversial. Davidoff and Bellman found that the use of balloon dilators was associated with significantly less blood loss and lower transfusion rates when compared with the Amplatz serial dilators. More recently, the Endourological Society Percutaneous Nephrolithotomy Study Group found that balloon dilation and larger sheath size were associated with bleeding and transfusion risk, although on multivariate analysis only sheath size remained significant. Another series demonstrated that Alken serial dilators were associated with significantly greater blood loss than were either balloon dilators or Amplatz dilators. Turna and colleagues reported that Amplatz serial dilators were associated with significantly greater blood loss compared with balloon dilation. However, Osman and associates reported on 300 patients who had tracts dilated with Alken dilators, none of whom required a transfusion. Other investigators have found no difference in blood loss among methods of dilation, including a one-shot dilation with a 25- or 30Fr Amplatz dilator. Additional experimental techniques for tract creation and dilation are under investigation, including a method utilizing bipolar plasma vaporization of the renal tissue for tract formation, which was noted to be safe and effective in decreasing operative blood loss.

Once access is obtained and the tract is dilated, a working sheath is often placed. Tract and sheath size appear to be one of the strongest risk factors for operative blood loss, but regardless of tract size, care must be taken to keep the working sheath in the collecting system to limit parenchymal bleeding. Excessive torquing of rigid instruments through the working sheath may injure renal parenchyma and vasculature and therefore should be avoided. Flexible nephroscopy or placement of additional nephrostomy tracts should be performed instead, as demonstrated by Lam and colleagues. These investigators reported that the use of multiple tracts and flexible instruments decreased transfusion rates for their patients undergoing percutaneous nephrolithotomy (PCNL) in the treatment of staghorn calculi. Accessing the appropriate calyx, or using multiple access tracts when appropriate, can reduce the amount of blood loss and the number of complications. Care must also be taken when removing stone fragments through an access sheath because sharp fragments can tear the sheath. Further manipulation of the fragments and sheath can lead to significant bleeding.

When access is achieved and the working sheath is in place, it is not unusual for some bleeding to continue. However, if bleeding is such that visibility is compromised, certain measures should be taken. First, the surgeon should assess the position of the working sheath. If the end of the sheath has withdrawn into the parenchyma, simply repositioning the sheath back into the collecting system may correct the problem. If this maneuver does not correct the problem, or if the sheath is not malpositioned to begin with, then other interventions need to be undertaken. Inflation of a 30Fr dilating balloon in the tract for 10 to 20 minutes with subsequent placement of a large nephrostomy tube (24–28Fr) usually controls the bleeding. If bleeding persists, the nephrostomy tube should be clamped for 2 to 3 hours to allow the blood to clot and tamponade the injured vessel(s). Administration of mannitol may hasten this process by causing renal swelling within the capsule that may help tamponade vessels along the nephrostomy tract. The nephrostomy tube is left to straight drainage when unclamped if the patient has no signs of continued bleeding.

If these maneuvers are unsuccessful, a specialized nephrostomy tamponade catheter can be inserted (Kaye, Cook Medical, Spencer, IN). This catheter has a peripherally located balloon that is inflated in the nephrostomy tract while urine drains through the inner core. The catheter is typically left inflated for 2 to 4 days. The aforementioned measures are usually successful in controlling bleeding from peripheral vessels along the nephrostomy tract. Significant bleeding can also arise from injury to the main renal vein, and this bleeding can be controlled using a tamponade approach. Gupta and colleagues reported successful management of this complication in four patients by inflating a Council balloon catheter adjacent to the point of venous injury. Additionally, Millard and associates noted the success of a hemostatic “sandwich” method whereby two nephrostomy tubes are left, one with the balloon inflated within the collecting system and the second inflated just under the skin within the tract; the region between the balloons was injected with hemostatic sealant with excellent hemostasis. When these measures fail, or when significant arterial injury is suspected, then one should proceed expeditiously to renal angiography with selective embolization.

Postoperative Hemorrhage

Patients continue to be at risk for significant bleeding for the first several weeks postoperatively. Most patients who bleed postoperatively can be managed conservatively, but approximately 1% will require invasive treatments. If bleeding occurs with the nephrostomy tube in place, the measures discussed earlier may be employed, although it should be noted that large-bore nephrostomy tubes (>18Fr) are associated with lower bleeding complications than small-bore tubes. If significant bleeding from the tract is encountered after removal of the tube, digital tamponade should be performed with subsequent placement of a tamponade catheter or large nephrostomy tube under fluoroscopic guidance. If a nephrostomy tube is placed, it should be clamped. The patient should then be placed on bed rest and transfused as needed. Renal angiography with selective angioembolization should be performed on patients who continue to require blood transfusions or who become hemodynamically unstable.

Delayed bleeding often occurs approximately 1 to 3 weeks postoperatively. When angiography is performed on these patients, the most common causes of bleeding are laceration of a segmental artery, arteriovenous malformation, pseudoaneurysm, and arteriovenous fistula. Renal angiography with selective embolization is highly effective in treating these lesions ( Fig. 28.1 ). The nephrostomy tube must sometimes be removed so that the bleeding site may be localized during these procedures. When renal angiography and embolization are unsuccessful, open surgical exploration with vascular repair or nephrectomy may be necessary. El-Nahas and colleagues reported on 39 (1.3%) of 2909 patients (3878 PCNL procedures) over a 10-year period who had severe perioperative bleeding requiring renal angiography and embolization. Twenty-nine of these patients had severe bleeding before discharge, where the other 10 patients developed bleeding after discharge at a mean of 6.3 days. Renal angiography with selective embolization was successful in treating 36 of the 39 patients. The other three patients required exploration, and one required nephrectomy. These investigators identified upper calyx puncture, solitary kidney, staghorn stone, multiple punctures, and operator inexperience as significant risk factors for severe bleeding. In another large series, Srivastava and colleagues identified stone size as the only significant risk factor predicting these serious vascular complications. A similar series noted that tubeless surgery was associated with postoperative bleeding as well.

Pseudoaneurysm and vascular injury requiring selective angioembolization. A, Renal US scan demonstrating the “yin-yang” sign of vascular disease. B, Renal angiogram demonstrating a pseudoaneurysm of an midpole vessel (arrow). C, Selective embolization of the pseudoaneurysm, coils seen occluding the vascular injury (arrow).

(B, C courtesy of Dr. Brian Eisner.)

Kessaris and colleagues reported that 17 of 2200 patients (0.8%) who underwent PRS over a 10-year period required angiography and embolization for uncontrolled significant bleeding. Twenty-four percent of these patients presented in the immediate postoperative period (<24 hours), 41% in the early postoperative period (2–7 days), and 35% in the late postoperative period (>7 days). Superselective or selective angiographic embolization of such lesions, using Gianturco coils, absorbable gelatin sponges, or platinum microcoils, is generally quite successful. This study reported success in 15 of 17 such cases with selective or superselective embolization. Failures of angioembolization have been related to the number of percutaneous access sites, more than two bleeding sites found on angiography, and use of gelatin sponge alone for embolization.

Another cause of perioperative bleeding after PRS is perinephric hemorrhage ( Fig. 28.2 ). This complication should be suspected in patients who have decreasing hemoglobin with clear urine draining from both the nephrostomy tube and the bladder. Perinephric hemorrhage can occur in cases with difficult access or in cases with thin parenchyma where bleeding occurs extrarenally, rather than into the collecting system. Malpositioning of the working sheath outside the renal parenchyma is another possible cause.

Perinephric/subcapsular hematoma displacing the left kidney after attempted percutaneous nephrostomy tube placement by interventional radiology.

“Sandwich therapy” with shock wave lithotripsy and subsequent second-look PCNL is another potential risk factor. In these situations, subcapsular or perinephric hemorrhage caused by shock wave lithotripsy may be exacerbated by further tract and collecting system manipulation. Patients in whom this is suspected should be evaluated with CT scan. This situation can typically be treated conservatively with monitoring of hemoglobin, serial physical examinations, hemodynamic parameters, and imaging as needed because the bleeding is usually confined to the retroperitoneal space. Affected patients should be treated with blood transfusions as needed, and rarely exploration may be required if hemodynamic instability cannot be controlled or if bleeding is persistent.

Perforation and Extravasation

Perforation of the collecting system can occur any time during PRS ( Fig. 28.3 ). When the working sheath is located outside the collecting system secondary to perforation, large amounts of fluid can extravasate. Additionally, newer access methods including micropercutaneous nephrolithotomy may introduce a significant increase in renal pelvic pressure leading to perforation. Lee and associates reported that perforation with extravasation occurred in 7% of 582 cases of PCNL. Perforation should be suspected if perirenal or renal sinus fat is visualized, if other perirenal structures are visualized, or if the patient’s abdomen or flank becomes distended. Large amounts of fluid can quickly accumulate in the retroperitoneal space or, less commonly, the abdominal cavity. This fluid can cause difficulties in ventilating the patient during the procedure, electrolyte and hemodynamic abnormalities secondary to fluid absorption, and ileus postoperatively.

Renal pelvis injury/perforation with extravasation. A, Initial access with balloon dilator with wires in position. B, Perforation noted intraoperatively as nephrostogram demonstrates extravasation. C, Postoperative nephrostogram after 36 hours confirms healing of the renal pelvis. D, Nephrostogram at 1 week upon removal of nephrostomy tube shows complete resolution of extravasation.

(Courtesy of Dr. Brian Eisner.)

CT- or US-guided percutaneous drainage of the fluid is sometimes necessary if the patient is having respiratory distress, if prolonged ileus does not resolve spontaneously, or if infection of the fluid is suspected. Once perforation is recognized, serious consideration should be given to terminating the procedure. If the procedure is nearly completed, it may be possible to complete it with low-flow irrigation, provided the patient remains stable. Concerns that arise when the procedure is continued are stone migration outside the collecting system and tumor cell spillage during percutaneous resection of urothelial carcinoma, both discussed later in this chapter. Once the procedure is terminated, a nephrostomy tube should be left in place. Most perforations heal in 72 hours, but it may be prudent to wait 7 days and perform a nephrostogram to confirm closure of the perforation before going back to complete the stone extraction or tumor removal. On rare occasions, open surgical repair or nephrectomy may be necessary. This complication can be limited by paying close attention to proper access and dilation techniques (e.g., preventing sheath placement significantly beyond the balloon or sequential dilator, preventing dilation of and avoiding access sheath placement through narrow infundibuli), by taking care to keep the working sheath in the collecting system, by judicious stone fragmentation, and by fluoroscopic monitoring of nephrostomy tube insertion and removal.

Ureteral Avulsion

Ureteral avulsion is an extremely rare complication of PRS. It is most commonly caused by attempts at basketing of large, impacted ureteral stones, but it can also occur with dilation or incision of the UPJ and tumor resection. Additionally, a “scabbard” injury can occur rarely when performing antegrade ureteroscopy (typically in cases where the ureter has not been pre-stented or is narrow at baseline and with greater risk when using a semirigid ureteroscope in a retrograde manner) where the ureteroscope is down the ureter; the proximal shaft of the scope is larger in caliber than the tip, therefore the proximal shaft may be tight in the ureter. When removing the scope, the tissue adheres to the scope and can lead to an injury in that region of the ureter where the scope is trapped. If this is occurring, very gentle removal of the scope is needed, and occasionally injection of lubrication via the scope or adjacent to the scope down the ureter can allow the ureteroscope to be removed safely. This can also theoretically occur if larger fragments or a high volume of fragments are left adjacent to the ureteroscope as the ureteroscope is advanced distally to treat additional stones. The friction in the ureter with these fragments as the ureteroscope is removed can give resistance, and great care is needed to gently remove the scope to avoid an avulsion type of injury.

This complication mandates prompt open surgical exploration, although, when necessary, nephrostomy tube drainage may be used as a temporizing measure to allow stabilization of the patient. Occasionally, a percutaneous drain will need to be inserted into the potential urinoma if the nephrostomy tube alone is not able to adequately drain the majority of the urine produced by the affected kidney. This complication can be avoided by making sure stones are fragmented into pieces small enough to be removed by an extraction device, as well as by adhering to proper endopyelotomy, endoureterotomy, and resection techniques. Furthermore, when dealing with a narrow ureter that is unable to handle the capacity of a ureteroscope, safe dilation techniques are possible, or placement of a ureteral stent with return to the operating room several days later after passive dilation has likely occurred.

Extrarenal and Extraureteral Stone Fragment Migration

Extrarenal and extraureteral stone fragments are generally not of any clinical consequence, provided the urine and stone are not infected and the stone is far enough from the collecting system and ureter not to cause periureteral inflammation with subsequent stricture formation ( Fig. 28.4 ). Intraperitoneal migration of stone fragments has also been reported; in this case open extraction was performed with success in order to prevent further peritoneal complications. Endoscopic retrieval should not be attempted in most cases because this may enlarge the perforation. The occurrence of this complication can be minimized by avoiding collecting system perforation or, if one has occurred, recognizing it and stopping the procedure, as well as applying proper stone removal techniques.

Left extraureteral stone. A, CT scan postoperatively demonstrates a stone fragment (arrow) adjacent to the ureteral stent in the region of the proximal ureter. B, Postoperative intravenous pyelogram reveals that the stone fragment lies adjacent to the left proximal ureter causing mild extrinsic compression (arrow) but no significant hydronephrosis and drainage of contrast material distally.

(Courtesy of Dr. Joshua Wein and Dr. Rupa Patel.)

Stricture

The development of a stricture following PRS occurs rarely, with a reported incidence of <1%. The most commonly affected segments are the proximal ureter and the UPJ. Strictures can form as a result of inflammation secondary to stone impaction or from procedural trauma including intracorporeal lithotripsy and periureteral urine and/or stone extravasation. Patients who have undergone previous cutaneous urinary diversion and undergo PRS for proximal ureteral calculi may be at increased risk for stricture formation because of an intense inflammatory response (obliterative pyeloureteritis) that may be secondary to infection and other local factors. Ureteral strictures can be asymptomatic, and patients undergoing PRS should be routinely evaluated for this complication with postoperative imaging. Most ureteral strictures that develop after PRS can be managed with endourologic techniques, provided the stricture is <1 cm and is not in a radiated field. However, open or laparoscopic reconstruction may be required in patients with more extensive strictures or in patients in whom an endoscopic approach has failed.

Infundibular Stenosis

Infundibular stenosis is a rare complication that can occur after PRS. Parsons and colleagues reported a 2% incidence following PCNL. They identified prolonged operative time, large stone burden requiring multiple procedures, and extended postoperative nephrostomy tube drainage as independent risk factors for this occurrence. These investigators postulated that factors that increase local inflammation could include prolonged instrumentation or the use of large amounts of energy to break up stones. This complication is usually detected in the first year after PRS. Goel and associates noted a case of the formation of an excluded calyx, which was seen 2 weeks post PRS in a patient presenting with fevers, obstructed upper pole, and nonvisualization of this calyx on excretory urography. This was treated with nephrostomy placement and eventual antegrade creation of neo-infundibulum with holmium:YAG laser. Infundibular stenosis should be managed endourologically, as in the above case, with open surgery reserved for those in whom this approach fails. For patients who are asymptomatic without evidence of impaired renal function, close observation is an option.

Retained Foreign Bodies

On occasion, a piece of equipment used in a percutaneous procedure can break off in the renal collecting system. This can occur during any stage of the procedure, including during postoperative renal embolization. Lynch and associates reported on a piece of plastic drape that was translocated into the collecting system during tract dilation, while Kaba and colleagues noted the migration of a 2-cm fragment of ureteral catheter that was found on fluoroscopy to have migrated into the left lung, possibly intravascularly. Instruments should be inspected periodically during and at the end of procedures to ensure that nothing is broken or missing. Every effort should be made to find the foreign body and remove it because it can act as a nidus for stone formation or infection or cause a granulomatous reaction within the kidney.

The foreign body can usually be extracted with a rigid or flexible nephroscope and graspers or a basket. Fluoroscopy can aid in removal of the foreign body if it is radio­opaque. If the foreign body is discovered after nephrostomy tube removal, a retrograde ureteroscopic approach can be performed. If this fails, percutaneous extraction may be necessary. This complication can be limited by replacing instruments before instrument fatigue develops. Careful manipulation of wires, laser fibers, other lithotripter devices, baskets, and tubes can also minimize the inci­dence of this complication. Postoperatively, the tips of nephrostomy tubes, such as Malecot catheters, may become entrapped in the collecting system as a result of the ingrowth of fibrous and inflammatory tissue. If this occurs, it can be managed using a ureteroscopic approach or the creation of a new nephrostomy tract and endoscopic removal of this tissue.

Tumor Seeding

Tumor seeding of the nephrostomy tube tract is a potential but rare complication of percutaneous resection of urothelial carcinoma. It has been reported after resection of poorly differentiated, locally invasive disease. More commonly, it has been noted in association with percutaneous drainage of an obstructed system in patients with urothelial carcinoma. Numerous series have performed percutaneous resection without evidence of tract seeding with long-term follow-up. This complication can be minimized by proper selection of patients with low-grade, noninvasive tumors. Special care should be taken to maintain proper position of the working sheath, to perform the procedure with low-pressure irrigation, to have low-pressure postoperative drainage with properly sized nephrostomy tubes, and to decrease operative times in these patients, when possible.

Nephrocutaneous Fistula

Nephrocutaneous fistula formation is a rare occurrence after PRS. It is usually caused by distal obstruction secondary to ureteral edema, obstructing stone, blood clot, or stricture. Delayed development of nephrocutaneous fistulas has been reported to occur in patients with genitourinary tuberculosis. Fibrin glue has been used to assist with healing of the fistula, although this is usually unnecessary; relief of the distal obstruction by either placement of a ureteral stent or removal of stone usually allows the fistula to close without additional treatment at the fistula site.

Injury Resulting From Energy Sources

The continued advances in design of lithotripsy and ablative energy sources have aided the performance of PRS. Although these advances have improved efficacy and safety, the potential for energy-related complications should not be underestimated. Intracorporeal damage from these sources can range from minor to extensive. To avoid these complications, the surgeon should have a thorough knowledge of each energy source before it is used.

Ultrasonic lithotripsy is a commonly used energy-source technique for PCNL. Collecting system or ureteral perforation can occur with this device, especially if excessive pressure is applied to these tissues. The probe can become clogged with debris, thus causing overheating that could result in thermal injury. As mentioned earlier, a piece of the lithotripter can break off. A single case report noted that the tip of an ultrasonic lithotripter broke off and migrated to the left pulmonary artery.

As a result of the development of newer devices with better safety profiles, electrohydraulic lithotripsy is used less frequently for PCNL. The most common complications associated with electrohydraulic lithotripsy are perforation of the collecting system and bleeding, which are managed as previously described.

The holmium laser is commonly used for lithotripsy, for incision of strictures, and for the ablation of upper tract tumors. Although the laser has been shown to have an excellent safety profile, complications can still occur. These include hemorrhage, perforation of the collecting system, and thermal injury. Investigators have also reported that heat generated from the laser can interact with hydrogen gas and can generate an explosion in the collecting system that leads to perforation and hemorrhage. These complications can be minimized with careful technique and use of appropriate energy settings, which have not been standardized at this time. The typical energy settings during PCNL range from 0.5 to 3.0 joules and from 6 to 30 hertz, with a single study showing that higher power energy settings were associated with an increased risk of injury as 6/38 patients were found to have proximal ureteral stricture postoperatively.

Pneumatic lithotripters and hybrid devices (pneumatic and US) are also used during PCNL. A small risk of perforation and hemorrhage also exists with these devices.

Electrocautery and electroresection are used during PRS for resection of tumors and to control bleeding. The patient should be properly grounded to prevent thermal burns. Only nonconductive materials should be in contact with the collecting system and ureter to prevent current dispersal that could lead to thermal injury. Maintaining proper orientation with respect to adjacent vascular structures can minimize the risk of hemorrhage. When electrocautery or electroresection is performed, sterile glycine is typically used as irrigant, with an associated risk of fluid absorption and secondary hyponatremia. Maintaining the lowest possible irrigation pressures and limiting resection time can minimize this risk. Bipolar electrocautery devices can instead be used with sterile saline irrigation, thereby reducing the risk of hyponatremia from fluid absorption.

Intraoperative Hemorrhage

Patients undergoing PRS are at risk for significant intraoperative bleeding and subsequent blood transfusion. The transfusion rates from various contemporary series have ranged from 1% to 34%. Several factors have been shown to be associated with an increased risk for transfusion. These include surgical technique, surgeon experience, preoperative anemia, advanced patient age, increased stone surface area, and the need for multiple tracts. Intraoperative complications such as infundibular tear or pelvic wall tear have been shown to significantly increase blood loss. Other factors that have been shown to predict increased blood loss during PRS include diabetes, longer operating time, and increased parenchymal thickness.

Proper preoperative workup of the patient is necessary to decrease risks of intraoperative hemorrhage. Perioperative use of anticoagulation is a controversial topic and should be discontinued in the proper time frame to allow the anticoagulant effect to wear off whenever possible. However, with the increased use of anticoagulants, studies are now being performed to evaluate the safety in performing PRS while on anticoagulation. Current evidence demonstrates that some medications such as aspirin, which were typically stopped in the perioperative period, need not necessarily be witheld. Leavitt and colleagues performed a retrospective review of 321 patients showing that perioperative use of aspirin is not associated with higher rates of bleeding complications. While there is no guideline for management of these medications at this time, proper discontinuation and administration of other anticoagulation therapies allow for successful PRS without an increase in bleeding or thromboembolic complications. Lange and associates evaluated the safety and efficacy of perioperative removable inferior vena cava filter placement in patients who were at significant risk for a venous thromboembolic event, allowing for complete discontinuation of these medications; bleeding and thrombotic complications were absent, although this may not be a satisfactory option in all patients.

Operative technique is a modifiable risk factor, and certain principles, if followed, can help to reduce the risk of significant blood loss. For the prone approach, the collecting system should be accessed through a posterior calyx along the direction of the infundibulum. This technique avoids the blood vessels that course adjacent to the infundibulum. The posterior calyx that provides the most direct access to the targeted stone should be chosen. Once access is established, the tract should be dilated only up to the peripheral aspect of the collecting system. Care should be taken not to dilate the tract too far medially because this increases the risk of pelvic wall tear and injury to the hilar vessels. Stoller and colleagues reported that renal pelvic perforation is a risk factor for excessive blood loss.

The impact on blood loss by the method of tract dilation is controversial. Davidoff and Bellman found that the use of balloon dilators was associated with significantly less blood loss and lower transfusion rates when compared with the Amplatz serial dilators. More recently, the Endourological Society Percutaneous Nephrolithotomy Study Group found that balloon dilation and larger sheath size were associated with bleeding and transfusion risk, although on multivariate analysis only sheath size remained significant. Another series demonstrated that Alken serial dilators were associated with significantly greater blood loss than were either balloon dilators or Amplatz dilators. Turna and colleagues reported that Amplatz serial dilators were associated with significantly greater blood loss compared with balloon dilation. However, Osman and associates reported on 300 patients who had tracts dilated with Alken dilators, none of whom required a transfusion. Other investigators have found no difference in blood loss among methods of dilation, including a one-shot dilation with a 25- or 30Fr Amplatz dilator. Additional experimental techniques for tract creation and dilation are under investigation, including a method utilizing bipolar plasma vaporization of the renal tissue for tract formation, which was noted to be safe and effective in decreasing operative blood loss.

Once access is obtained and the tract is dilated, a working sheath is often placed. Tract and sheath size appear to be one of the strongest risk factors for operative blood loss, but regardless of tract size, care must be taken to keep the working sheath in the collecting system to limit parenchymal bleeding. Excessive torquing of rigid instruments through the working sheath may injure renal parenchyma and vasculature and therefore should be avoided. Flexible nephroscopy or placement of additional nephrostomy tracts should be performed instead, as demonstrated by Lam and colleagues. These investigators reported that the use of multiple tracts and flexible instruments decreased transfusion rates for their patients undergoing percutaneous nephrolithotomy (PCNL) in the treatment of staghorn calculi. Accessing the appropriate calyx, or using multiple access tracts when appropriate, can reduce the amount of blood loss and the number of complications. Care must also be taken when removing stone fragments through an access sheath because sharp fragments can tear the sheath. Further manipulation of the fragments and sheath can lead to significant bleeding.

When access is achieved and the working sheath is in place, it is not unusual for some bleeding to continue. However, if bleeding is such that visibility is compromised, certain measures should be taken. First, the surgeon should assess the position of the working sheath. If the end of the sheath has withdrawn into the parenchyma, simply repositioning the sheath back into the collecting system may correct the problem. If this maneuver does not correct the problem, or if the sheath is not malpositioned to begin with, then other interventions need to be undertaken. Inflation of a 30Fr dilating balloon in the tract for 10 to 20 minutes with subsequent placement of a large nephrostomy tube (24–28Fr) usually controls the bleeding. If bleeding persists, the nephrostomy tube should be clamped for 2 to 3 hours to allow the blood to clot and tamponade the injured vessel(s). Administration of mannitol may hasten this process by causing renal swelling within the capsule that may help tamponade vessels along the nephrostomy tract. The nephrostomy tube is left to straight drainage when unclamped if the patient has no signs of continued bleeding.

If these maneuvers are unsuccessful, a specialized nephrostomy tamponade catheter can be inserted (Kaye, Cook Medical, Spencer, IN). This catheter has a peripherally located balloon that is inflated in the nephrostomy tract while urine drains through the inner core. The catheter is typically left inflated for 2 to 4 days. The aforementioned measures are usually successful in controlling bleeding from peripheral vessels along the nephrostomy tract. Significant bleeding can also arise from injury to the main renal vein, and this bleeding can be controlled using a tamponade approach. Gupta and colleagues reported successful management of this complication in four patients by inflating a Council balloon catheter adjacent to the point of venous injury. Additionally, Millard and associates noted the success of a hemostatic “sandwich” method whereby two nephrostomy tubes are left, one with the balloon inflated within the collecting system and the second inflated just under the skin within the tract; the region between the balloons was injected with hemostatic sealant with excellent hemostasis. When these measures fail, or when significant arterial injury is suspected, then one should proceed expeditiously to renal angiography with selective embolization.

Postoperative Hemorrhage

Patients continue to be at risk for significant bleeding for the first several weeks postoperatively. Most patients who bleed postoperatively can be managed conservatively, but approximately 1% will require invasive treatments. If bleeding occurs with the nephrostomy tube in place, the measures discussed earlier may be employed, although it should be noted that large-bore nephrostomy tubes (>18Fr) are associated with lower bleeding complications than small-bore tubes. If significant bleeding from the tract is encountered after removal of the tube, digital tamponade should be performed with subsequent placement of a tamponade catheter or large nephrostomy tube under fluoroscopic guidance. If a nephrostomy tube is placed, it should be clamped. The patient should then be placed on bed rest and transfused as needed. Renal angiography with selective angioembolization should be performed on patients who continue to require blood transfusions or who become hemodynamically unstable.

Delayed bleeding often occurs approximately 1 to 3 weeks postoperatively. When angiography is performed on these patients, the most common causes of bleeding are laceration of a segmental artery, arteriovenous malformation, pseudoaneurysm, and arteriovenous fistula. Renal angiography with selective embolization is highly effective in treating these lesions ( Fig. 28.1 ). The nephrostomy tube must sometimes be removed so that the bleeding site may be localized during these procedures. When renal angiography and embolization are unsuccessful, open surgical exploration with vascular repair or nephrectomy may be necessary. El-Nahas and colleagues reported on 39 (1.3%) of 2909 patients (3878 PCNL procedures) over a 10-year period who had severe perioperative bleeding requiring renal angiography and embolization. Twenty-nine of these patients had severe bleeding before discharge, where the other 10 patients developed bleeding after discharge at a mean of 6.3 days. Renal angiography with selective embolization was successful in treating 36 of the 39 patients. The other three patients required exploration, and one required nephrectomy. These investigators identified upper calyx puncture, solitary kidney, staghorn stone, multiple punctures, and operator inexperience as significant risk factors for severe bleeding. In another large series, Srivastava and colleagues identified stone size as the only significant risk factor predicting these serious vascular complications. A similar series noted that tubeless surgery was associated with postoperative bleeding as well.

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