What are the risks and complications associated with vesicolithotripsy?

Risks and Complications of Vesicolithotripsy

Vesicolithotripsy carries significant risks including bleeding, infection, ureteral injury, and sepsis, with complication rates of approximately 10% for minor complications and 2.5% for major complications requiring intervention.

General Complications

• Bleeding is a common complication, with mild hematuria occurring in approximately 50% of patients, though clinically significant bleeding requiring transfusion is less common 1
• Infection and sepsis are serious risks, especially in the presence of infected stones or obstructed systems 1
• Ureteral perforation occurs in up to 14% of cases, particularly when electrohydraulic lithotripsy is used 2
• Ureteral avulsion is a rare but serious complication during endoscopic manipulation 2
• Incomplete stone clearance with residual fragments can lead to stone regrowth in 21-59% of cases 1

Infectious Complications

• Bacteriuria can occur in 7.7-23% of cases even with non-infected stones 1
• Sepsis is reported in approximately 0.15% of procedures 1
• In patients with obstructing stones and suspected infection, urgent drainage of the collecting system is mandatory before proceeding with stone treatment 1
• Antimicrobial prophylaxis should be administered prior to stone intervention based on prior urine culture results and local antibiogram patterns 1

Tissue and Organ Complications

• Renal complications include symptomatic hematoma (0.21%) and asymptomatic hematoma (1.2%) 1
• Cardiovascular effects such as dysrhythmias can occur in 11-29% of cases 1
• Less common complications include bowel injury, splenic injury, gallbladder puncture, and pneumothorax 1
• Pneumothorax risk increases with upper-pole calyceal puncture approaches 1

Procedure-Specific Complications

• For percutaneous approaches, complications include catheter displacement, bleeding, and sepsis 1
• Electrohydraulic lithotripsy should not be utilized as first-line modality for intra-ureteral lithotripsy due to its propensity to damage ureteral mucosa 1
• Stent-related discomfort is common, though can be managed with α-blockers and anti-muscarinic therapy 1

Risk Factors for Complications

• Diabetes and renal calculi are potential risk factors for postprocedural sepsis 1
• Thrombocytopenia increases the risk of bleeding complications 1
• Stone size >20mm is associated with higher complication rates and lower success rates for certain approaches 1
• Infected stones significantly increase the risk of infectious complications 1

Prevention and Management of Complications

• Proper acoustic coupling between treatment head and skin is crucial to prevent shockwave deflection in lithotripsy 1
• Use of a safety guide wire is recommended to facilitate rapid reaccess to the collecting system in case of injuries 2
• In cases with purulent urine, the procedure should be aborted, drainage established, and antibiotics continued 2
• Stepwise energy ramping during lithotripsy minimizes renal injury 1
• Decreasing frequency from 120 to 60-90/min improves stone-free rates and reduces tissue damage 1

Special Considerations

• In patients with cardiac pacemakers, precautions are needed as lithotripsy can result in pacing responses including reprogramming, inhibition, and noise reversion mode 1
• For pacemaker-dependent patients, pre-operative reprogramming to an asynchronous or triggered mode should be considered 1
• In patients with large renal stone burden (>20mm), percutaneous nephrolithotomy (PCNL) offers higher stone-free rates than other approaches 1

Understanding these risks and complications is essential for proper patient counseling and management during vesicolithotripsy procedures. The choice of approach should be guided by stone characteristics, patient factors, and available expertise to minimize morbidity and mortality.