Gallbladder perforation in a patient undergoing PCNL: Case report and literature review

Abstract

Percutaneous nephrolithotripsy (PCNL) is an effective therapeutic approach in cases of lithiasis, which is prone to complications. In this report we present a case of a 52-year-old female patient with recurrent episodes of lithiasis and, after PCNL, evolution with pain and abdominal distension on the 2nd post-operative day due to a perforation of the gallbladder. An exploratory laparotomy was performed, leading to clinical improvement, and the patient was discharged from the hospital on the 7th day after resolving the choleperitoneum. This report addresses a rare, life-threatening complication of PCNL with limited literature available on the subject.

1 Introduction

Gallbladder perforation is a rare complication of percutaneous nephrolithotripsy (PCNL) and increases the severity of the case when it occurs. PCNL is a minimally invasive, safe and effective method for treating lithiasis, being the therapy of choice for larger stones. In addition to its advantages such as short hospitalization and recovery time, it is clear that every procedure has risks, the most common of which are: fever (21–32 %), bleeding (10–18 %) and urinary extravasation (7.2 %). Biliary tract injury is rarely described in the literature and generally presents with symptoms of peritonitis and its subsequent diagnosis can significantly compromise the prognosis. In this report, a case of a patient with a history of surgical approaches to remove stones and effective management of this condition will be analyzed.

2 Goal

To report the case of a patient who developed choleperitoneum resulting from a gallbladder perforation while undergoing percutaneous nephrolithotripsy.

3 Method

The information was obtained through a review of the medical records, interviews with the patient, photographic records of the diagnostic methods to which the patient was subjected and a literature review in the MedLine database (via PubMed), LILACS and Cochrane Database of Systematic Reviews with the terms: complications of percutaneous nephrolithotripsy ([ gallbladder injury, biliary peritonitis ] during/after [percutaneous nephrolithotripsy]) in the period from 1983 to 2024, with articles not related to the topic being excluded.

4 Case report

VIDS, 52 years old, female and suffering from recurrent nephrolithiasis. The patient has a BMI of 20.5 and a thin body type. Regarding her personal history, she denies smoking or using illicit drugs, only social drinking. She reports being hypertensive, using losartan, and denies DM or other comorbidities. Among the previous surgeries performed were a double J implant for pyelonephritis and a Cesarean section. The first diagnosis of lithiasis was made at the age of 15, and since then she has undergone a series of surgical procedures, such as 13 sessions of Extracorporeal Lithiasis (ESWL), implantation of a double J catheter for obstructive pyelonephritis and 5 Percutaneous Nephrolithotripsy surgeries (4 on the right and 1 on the left).

Therefore, she was electively admitted to a tertiary hospital in Santos, São Paulo, for a percutaneous nephrolithotripsy on the right side due to a 2.8 × 1.9 cm stone in the middle calyx of the right kidney, residual from a percutaneous procedure performed approximately six months ago for staghorn calculus. The surgical procedure was performed on 09/29/2023 with the patient in the prone position after the placement of a urethral catheter. An initial x-ray image was obtained ( Fig. 1 ).

Two punctures were initially attempted in the lower calyx without success (no return of urine or adequate guidewire progression), as shown in Fig. 2 – Arrow A. Subsequently, two punctures were attempted in the upper calyx, also without success, as demonstrated in Fig. 2 – Arrow B. Finally, the last puncture was performed in Fig. 2 – Arrow C. We used the one-shot dilatation (OSD) (30Fr) which successfully provided access to the urinary tract and enabled the removal of two stones. There was success and the surgery was performed without any major complications, with lithotripsy of the stone and placement of the double J catheter and nephrostomy.