What is the management of hemorrhage after Percutaneous Nephrolithotomy (PCNL)?

Management of Hemorrhage After Percutaneous Nephrolithotomy (PCNL)

Persistent bleeding after PCNL should be managed with conservative measures initially, followed by superselective angioembolization if bleeding does not respond to conservative management, as this approach has a success rate greater than 80%. 1

Initial Assessment and Management

Conservative Management (First-line)

• Control obvious bleeding points using direct pressure
• Establish large-bore IV access for fluid resuscitation
• Obtain baseline blood tests including:
  • Complete blood count
  • Prothrombin time (PT)
  • Activated partial thromboplastin time (aPTT)
  • Fibrinogen levels
  • Blood typing and cross-matching 2
• Use warmed blood products for resuscitation if needed 3
• Monitor vital signs and perfusion status closely
• Mild hematuria is common (present in approximately 50% of patients after percutaneous procedures) and typically resolves with conservative management 3

Hemostatic Sandwich Technique (For Refractory Tract Bleeding)

For tract bleeding that doesn't respond to pressure or conventional nephrostomy tube:

1. Place a 5F angiographic reentry catheter through the kidney into the bladder
2. Position a 22F Councill-tip catheter balloon to occlude the inner surface of the nephrostomy tract
3. Place a 16F Councill-tip catheter with uninflated balloon just under the skin surface
4. Inject gelatin matrix hemostatic sealant to fill the tract
5. Inflate the outer balloon to completely seal the tract 4

Indications for Angiography and Embolization

Proceed to angiography and potential embolization when:

• Bleeding persists despite conservative measures
• Hemodynamic instability develops
• Significant drop in hemoglobin requiring multiple transfusions
• Persistent hematuria beyond expected duration (typically >48 hours) 1

Angioembolization Procedure

• Superselective angioembolization is highly effective with success rates >80% 1
• Common findings on angiography:
  • Pseudoaneurysm (most common - found in approximately 50% of cases)
  • Arteriovenous fistula
  • Combination of both 5
• Embolic materials include:
  • Metallic coils
  • Gelfoam
  • Combination of both 5

Risk Factors for Severe Post-PCNL Hemorrhage

Understanding risk factors can help identify patients at higher risk:

• Stone-related factors:
  • Larger stone size 5
  • Increased stone complexity 6
  • Multiple stones 7
• Procedure-related factors:
  • Multiple access tracts 6
  • Inferior calyceal puncture (3.25% risk vs. 0.3% for middle calyx) 7
  • Injury to the pelvicalyceal system during procedure 6
• Patient-related factors:
  • History of ipsilateral renal surgery 6
  • Solitary kidney 7

Post-Treatment Care

• Admit to critical care for monitoring after treatment for severe hemorrhage
• Regularly assess:
  • Coagulation parameters
  • Hemoglobin
  • Blood gases
• Monitor wound drains to identify ongoing bleeding 2
• Initiate standard venous thromboprophylaxis once bleeding is controlled 2
• Be aware of potential post-infarction syndrome following angioembolization 1

Complication Rates

According to the Society of Interventional Radiology quality improvement guidelines:

• Hemorrhage requiring transfusion following PCNL: up to 15%
• Vascular injury requiring embolization or nephrectomy: approximately 1% 3

Pitfalls to Avoid

• Delaying angiography in patients with significant ongoing bleeding
• Failing to recognize risk factors for severe hemorrhage before the procedure
• Using only conservative measures for too long in cases of severe bleeding
• Not considering multiple vascular lesions (failure rate of angioembolization is higher when more than two bleeding sites are identified) 1