Management of colonic perforation during percutaneous nephrolithotomy in horseshoe kidney

Open Pyelolithotomy in a Pelvic Ectopic Kidney: Case Report and Current Literature Review

BACKGROUND: Advances in urology have significantly reduced the indications for open surgery to treat staghorn kidney stones. Nevertheless, according to our experience, open surgery is still the preferred treatment for rare cases of the ectopic pelvic kidney. CASE PRESENTATION: A 49-year-old man complained about pain in the lower umbilical region for five months. The pain drastically changed into a sharp pain two months before. The vital sign is normal; on physical examination, the palpation of the suprapubic area elicits pain when pressed, no mass is detected. The abdominal computed tomography without contrast showed a right ectopic kidney located anteriorly of the fifth lumbar to the second sacrum. There was also mild hydronephrosis (grade I) and staghorn stones measuring 4 cm x 2.3 cm. The stone was surgically treated with open pyelolithotomy through a midline infra umbilical incision. The patient was discharged five days postoperatively without distinct complications. CONCLUSION: Open surgery can represent a valid alternative in the treatment of kidney stones of very selected cases, including anomalous kidneys, in a setting where resources are limited.

The risk factors associated with colonic injury during percutaneous renal stone surgery – a literature review

Objective:

A focused literature review was conducted of colonic injuries occurring during percutaneous nephrolithotomy (PCNL) procedures to determine the importance of patient position, identifiable risk factors and methods to avoid colonic injury.

Method:

A MEDLINE literature search was performed from PubMed and Scopus databases to retrieve all articles relating to colonic injuries occurring during PCNL. Incidence of colonic injury, patient management, position, side of stone and recognised risk factors were compiled for analysis.

Results:

Of the 35,054 PCNLs carried out, 87 colonic perforations were identified, which results in a 0.25% chance of perforation. A total of 65.5% (57/87) of colonic perforations occurred during left-hand punctures, and 54.0% (47/87) occurred in the prone position. Retrorenal colon, posterior colon, previous renal tract surgery, horseshoe kidney and mobile kidneys were the most common risk factors identified.

Discussion:

The risk of colonic perforation during PCNL was 0.25% across these studies. It more commonly occurred in the prone position and on the left-hand side. Only four perforations were noted to be in the supine position. A retrorenal colon is implicated as the most common identifiable risk factor. Careful preoperative work-up, planning and intraoperative use of ultrasound combined with fluoroscopy is the best method of preventing a colonic injury.

Level of evidence:

Not applicable for this multicentre audit.

Transgluteal CT-Guided Percutaneous Renal Access for Percutaneous Nephrolithotomy in a Pelvic Horseshoe Kidney

CT-guided percutaneous renal access has been described as a safe and effective access technique in patients with complex anatomy, including ectopic kidney, retrorenal colon, spinal dysraphism, hepatomegaly, and splenomegaly. In comparison to conventional intraoperative fluoroscopic-guided access, CT imaging allows for delineation of surrounding structures that are at risk for injury during percutaneous access. However, previous reports indicate that pelvic kidneys might be inaccessible percutaneously without laparoscopic assistance. Herein, we present a novel transgluteal route to renal access for percutaneous nephrolithotomy (PCNL) in a patient with a pelvic horseshoe kidney and severe spinal deformity.

Laparoscopic pyelolithotomy in a horseshoe kidney

The horseshoe kidney is the most frequent renal anomaly, with a prevalence of 0.25% and a male to female ratio of 2:1. In this article we aimed to report a 50-year-old man who had left kidney stones accompanied with a horseshoe kidney. In this case percutaneous nephrolithotomy was deemed to be a risky procedure due to malrotation of the pelviocalyceal system and possible interposition of bowel loops between kidney and the abdominal wall. Therefore, we preferred laparoscopic pyelolithotomy. At the end of the procedure, the patient was stone-free. We observed no complication. The patient was discharged after 72 hours. We assume that laparoscopic pyelolithotomy is a safe and effective approach for renal pelvic stone in case of horseshoe kidney.

Colon Radiological Delineation Technique Prior to Percutaneous Nephrolithotomy in Patients With Horseshoe Kidney

OBJECTIVE

To develop a technique that helps avoid colonic injury during percutaneous nephrolithotomy (PCNL) in these patients.

PATIENTS AND METHODS

PCNL was prospectively performed in a cohort of adults with renal stones in a horseshoe kidney (HSK). PCNLs were done using a standardized technique in prone position in all patients. The colon was radiologically delineated by injecting air-through a catheter in the anal canal-to help localize its position in relation to the pelvicalyceal system (PCS). Patients were observed in hospital for 48 hours postoperatively to detect any potential complications related to the PCNL or to the colon insufflation modification.

RESULTS

Thirteen adult patients (11 men and 2 women) with renal stones in a HSK were included in the study. The colon was well radiologically delineated with air in all cases. The PCS was successfully accessed, subcostally, with a single access at the upper calyx in 11 cases and multiple accesses in 2 cases. The colon was in the way of the puncture in 2 cases in which we used a more medial access and the colon was successfully avoided. Stones were completely removed during the PCNL in 11 of the 13 cases (84.6%). One case necessitated intraoperative blood transfusion. No other complications were reported by any of the patients who were discharged home after 48 hours.

CONCLUSION

Colonic radiological delineation technique is helpful in accessing the PCS quickly, saving the colon, and causing no discomfort to patients with renal stones in a HSK.

An unusual presentation of colon perforation following percutaneous nephrolithotomy

Colon perforation is a rare but serious complication of percutaneous nephrolithotomy (PCNL), meriting particular attention to its signs and symptoms for prompt diagnosis and treatment. We report an unusual presentation of colon perforation following tubeless PCNL, characterized by sore throat, pneumomediastinum, and neck and shoulder crepitus. In addition to the details of this case, we review the current literature on bowel injury during PCNL and its management.

Preoperative evaluation of pediatric kidney stone prior to percutaneous nephrolithotomy: is computed tomography really necessary?

The objective of the study was to investigate the precise role of computed tomography (CT) in preoperative radiologic evaluation and surgical planning of kidney stone in children prior to percutaneous nephrolithotomy (PNL). A total of 113 pediatric patients (aged ≤18 years) undergoing PNL for renal stone(s) in three referral hospitals between March 2010 and August 2012 were retrospectively evaluated. Depending on the preoperative radiologic evaluation, patients were divided into two groups. Those evaluated with CT were classified as group-1 (n = 50) and the remaining cases undergoing intravenous urography (IVU) examination were classified as group-2 (n = 63). Patient- and procedure-related variables and perioperative measures were compared between the groups. The mean age, stone size and localization were similar in both groups (p = 0.07, p = 0.57, p = 0.6, respectively). Although the postoperative hemoglobin drop was found to be significantly higher in group-2 (1.5 ± 1.3 vs. 0.9 ± 0.6 g/dL, p = 0.005), the mean operation time, fluoroscopic screening time, access number, overall success and complication rates were comparable (p = 0.06, p = 0.94, p = 0.75, p = 041, and p = 0.41, respectively). However, the mean hospitalization time was significantly prolonged in group-2 than in group-1 (p = 0.03). Our findings clearly demonstrate that, despite the key role of preoperative CT in particular patients with anatomically abnormal kidneys, IVU is a valuable alternative imaging modality with comparable radiation doses in children.

Retrograde intrarenal surgery in patients with horseshoe kidneys

Retrograde intrarenal surgery (RIRS) in patients with horseshoe kidneys (HSKs) remains poorly studied. The present study aimed to assess clinical success and stone-free rates in HSK patients with renal stones treated with flexible ureteroscopy. RIRS was attempted in 20 patients with 25 renal stones in HSK from December 2008 to January 2012. The patients were evaluated with imaging studies including plain abdominal radiography, intravenous urogram, abdominal ultrasonography or non-contrast tomography scan. Success rate was defined as stone-free or residual fragment less than 4 mm. Pre-operative, operative and postoperative data were retrospectively analyzed. A total of 20 patients were included in the present study (12 males, 8 females). 9 of 25 renal stones (36 %) were located in the lower calyx of the kidney, whereas 7 (28 %) in the middle calyx, 5 (20 %) in the renal pelvis and 4 (16 %) in the upper calyx. The mean stone size was 17.8 ± 4.5 mm. The stone-free rate was 70 % after a single procedure. 6 patients required shock wave lithotripsy and two of these were completely stone-free. Average hospital stay was 1.4 ± 0.7 days. Minor complications as classified by Clavien I or II occurred in 25 %. No major complications (Clavien III-V) occurred in the study group. RIRS is an effective and safe treatment modality for renal stones in patients with HSK. The procedure has minimal morbidity and high success rate.

Abdominal hypertension characterised by severe haemodynamic changes as a complication of percutanous nephrolithotomy

Percutanous nephrolithotomy (PCNL) was performed on a patient in a prone position. During the first hour of intervention, some unwanted haemodynamic complications arose, which included a decrease in systemic blood pressure, an increase in heart rate and an increase in peak inspiratory pressures. Owing to worsening of those unexplained haemodynamic abnormalities, surgery was terminated. As the patient turned from prone to supine position, abdominal distention was noticed. Later, 3 litres of fluid were removed from the abdomen via peritoneal lavage. Upon fluid removal, a dramatic haemodynamic improvement was observed. The problem was thought to have been caused by a technical error in placing the dilator inside the abdomen, which allowed the irrigation fluid to accumulate inside the abdominal cavity. The aim of this presentation is to raise awareness of intra-abdominal hypertension when the aforementioned haemodynamic abnormalities are detected during PCNL. Early detection and treatment may prevent morbidity and mortality in similar cases.

Colon perforation during percutaneous renal surgery: a 10-year experience in a single endourology centre

The use of percutaneous renal surgery has been recently revolutionised with novel endourological instruments and techniques. However, the incidence, prevention and management of severe complications such as colon perforation still lack consensus. By presenting our 10-year experience, we would like to highlight the diagnosis and management of the rare complication of colon perforation.

Management of injury to the bowel during percutaneous stone removal

Percutaneous endoscopic renal surgery is usually a safe and effective treatment for patients with complex renal calculi, tumors of the collecting system, and ureteropelvic junction obstruction. A unique set of complications, however, can occur with this surgical approach that may involve the targeted kidney and surrounding structures. Bowel injuries represent a very rare complication. Methods of preventing colonic and small intestine injuries, diagnosing their occurrence, and management strategies are reviewed in this article.

Management of colon injury after percutaneous renal surgery

Percutaneous access to the kidney has gained widespread use during the last decades. Iatrogenic colon injury is an uncommon but serious complication. Diagnosis is sometimes delayed, and treatment strategies are still controversial, including conservative management, colostomy, or primary repair. The aim of this review is to identify optimal diagnostic and treatment options for such injuries.

Management of urolithiasis in the congenitally abnormal kidney (horseshoe and ectopic)

PURPOSE OF REVIEW

Urolithiasis in horseshoe and ectopic kidneys presents unique challenges in the decision-making and technical aspects of stone treatment. Specific renal anatomy, stone size and associated conditions such as ureteropelvic junction obstruction are factors that may influence treatment. Detailed review of imaging is important to ensure efficient stone treatment and minimize complications.

RECENT FINDINGS

Widespread use of extracorporeal shockwave lithotripsy for calculi in congenitally abnormal kidneys is now giving way to stone-size and anatomy-appropriate therapeutic decision making. Multiple modalities including shockwave lithotripsy, ureteroscopy, percutaneous nephrolithotomy and laparoscopy are being employed in this group of patients.

SUMMARY

Treatment decisions for stones in horseshoe and ectopic kidneys can be challenging, and must be made on an individual basis taking into account multiple variables.

Facteurs de risques et prise en charge des complications de la néphrolithotomie percutanée

Extra corporeal shock wave lithotripsy (ESWL) has significantly modified the management of urinary lithiasis. It constitutes usually the first line treatment of urinary calculi sized less than 30 mm. Complex and staghorn calculi may be treated either with percutaneous nephrolithotomy (PCNL) or by flexible uteroscopy (URS) with Holmium laser. PCNL is a minimal invasive technique but it carries a potential risk of complications: infection, bleeding, urinary fistulas and perforations of adjacent organs. PCNL complications may be prevented by the strict respect of technical recommendations; their therapeutic management has been properly codified. In order to reduce the risk of their occurrence, the so-called "mini-perc" (mini-percutaneous technique) has been developed for children and can be applied to adults. Technical details of the two techniques and the treatment of PCNL complications had been described before 1985; the current chapter proposes an update on their prevention and management.

Colonic perforation during percutaneous nephrolithotomy: study of risk factors

OBJECTIVES

To identify the risk factors implicated in colonic perforation during percutaneous nephrolithotomy.

METHODS

From 1985 to 2004, 5039 percutaneous nephrolithotomy procedures were performed in our center. Colonic perforation complicated 15 procedures (0.3%). The patient files were retrospectively reviewed for detection of preoperative risk factors as shown by multivariate statistical analysis. The operative details and postoperative course were also studied to determine the time and mode of diagnosis of colonic injury and treatment strategies and outcome.

RESULTS

All injuries were retroperitoneal. The mean patient age was 57 +/- 8.4 years. Of the 15 patients, 11 were men and 4 were women. The left side was affected in 10 patients (66.6%). The right side was injured only in those with horseshoe kidneys or with recurrent disease. Colonic perforation complicated lower caliceal puncture in 12 procedures (80%) and complicated upper caliceal punctures in those with horseshoe kidneys or chronic colonic distension. Significant independent risk factors were advanced patient age and the presence of a horseshoe kidney. The diagnosis was established intraoperatively in 5 patients and postoperatively in 10, 5 of whom presented with colocutaneous fistula. The diagnosis was confirmed with abdominal computed tomography or opacification of the colon during antegrade or retrograde pyelography. Conservative treatment was successful in all but 2 patients who required colostomy.

CONCLUSIONS

Significant independent risk factors for colonic perforation during percutaneous nephrolithotomy were advanced patient age and the presence of a horseshoe kidney. Early diagnosis and proper treatment represent the key to minimizing patient morbidity and avoiding serious complications.

Massive intraabdominal extravasation of fluid: a life threatening complication following percutaneous nephrolithotomy

Percutaneous nephrolithotomy provides an attractive alternative to the surgical removal of renal stones as it is associated with reduced patient morbidity and shortened hospital stay. The advantages of this procedure may, however, be overshadowed by complications like bleeding, extravasation of irrigant fluid and infection, which can be life threatening. We report a case of massive extravasation of irrigant fluid producing severe metabolic acidosis, persistent peritonism and ileus leading to a prolonged hospital stay. The patient also required a further surgery for the complete removal of the stones.

Urinary tract stones--Part II: current status of treatment

The majority of renal and ureteric stones are now managed by minimally invasive techniques, for example nephrostomy, ureteral stents, extracorporeal shockwave lithotripsy or percutaneous nephrolithotomy. A multi-disciplinary approach is necessary, and this review examines the status of modern stone therapy and the contribution of the radiology department.