Main Complications of Percutaneous Nephrolithotomy (PCNL)
The most common complication of PCNL is fever (10.8%), followed by bleeding requiring transfusion (7%), with serious complications including sepsis (0.5%) and mortality (0.05%) being rare but important to recognize. 1
Infectious Complications
Fever is the most frequent complication, occurring in approximately 10.8% of patients. 1 This infectious complication can progress to more serious manifestations:
- Sepsis occurs in 0.5% of cases and represents a life-threatening complication requiring immediate recognition and treatment. 1
- Septic shock has been reported in 4.7% of patients in some series, with mortality occurring in 0.78% of cases. 2
- Both positive urine culture and positive stone culture significantly increase the risk of postoperative complications (p = 0.002 and p = 0.017, respectively). 3
- The most common bacteria identified are Enterococcus faecalis (26% in stones, 20% in urine) and Escherichia coli (20% in urine). 3
Critical pitfall: Antibiotic prophylaxis started at the beginning of surgery cannot always prevent infectious complications, emphasizing the importance of treating any pre-existing UTI before proceeding with PCNL. 2
Hemorrhagic Complications
Bleeding requiring transfusion occurs in 7% of patients. 1 Risk factors for postoperative bleeding include:
- Prolonged operation time (adjusted OR 4.4, p < 0.05) 2
- Intraoperative transfusion requirement (adjusted OR 10, p < 0.01) 2
- Postoperative fever (adjusted OR 4.9, p < 0.01) 2
Late vascular complications are rare but serious:
- Arteriovenous fistula with or without pseudoaneurysm occurs in less than 2% of cases. 4
- These typically require embolization (0.4% of cases). 1
Mini-PCNL (12-22 F) reduces blood loss and transfusion rates compared to standard PCNL (>22 F) without significant differences in stone-free rates or other complications. 1
Thoracic Complications
Pleural complications occur in 1.5% of patients and include: 1
These complications are more common with upper pole access and require chest imaging for diagnosis. 4
Urinary Tract Complications
Extravasation of urine occurred in 52 of 720 cases (7.2%) in one large series. 4 Management includes:
- Proper drainage with nephrostomy tube or double-J stent placement 4
- Urinoma formation is rare (0.2%) but requires drainage when it occurs. 1
Ureteral stricture with obstruction is a late complication occurring in less than 2% of patients. 4
Organ Injury
Adjacent organ injury occurs in 0.4% of cases. 1 Prevention strategies include:
- Preoperative imaging with ultrasound or CT to identify interposed organs (liver, spleen, bowel) 5
- Careful puncture technique using fluoroscopy or ultrasound guidance 5
- Ultrasound guidance reduces radiation exposure and has lower complication rates compared to fluoroscopy alone. 1
Subcapsular Hematoma
Subcapsular hematoma is a rare late complication (less than 2% of cases) that may require intervention if symptomatic. 4
Stone Fragment Migration
Migration of stone fragments into the retroperitoneum occurred in 7 of 720 cases (1%) and requires recognition and appropriate management. 4
Risk Mitigation Strategies
To minimize complications:
- Use single-step dilation to potentially shorten operative time and reduce complications. 1
- Employ ultrasound guidance for puncture to reduce radiation and complication rates. 1
- Consider tubeless PCNL (no nephrostomy tube) in uncomplicated cases to reduce pain and hospital stay. 1
- Limit irrigation fluid volume to less than 20 liters, as volumes exceeding this threshold significantly increase hypothermia (adjusted OR 7.4, p < 0.05) and cardiovascular changes. 2
- Use normal saline for irrigation to prevent electrolyte abnormalities and hemolysis. 5
- Perform flexible nephroscopy to identify residual fragments and prevent future stone events. 5
Mortality
Mortality from PCNL is extremely rare at 0.05%. 1 This low rate reflects the overall safety of the procedure when performed with appropriate patient selection and technique.