Rare complication of percutaneous nephrostomy lithotripsy and management
Liu Jui Wen, Hu Sui Wei
Department of Urology, Shuang Ho hospital, Taipei Medical University, Taipei, Taiwan
Introduction: Percutaneous nephrostomy lithotripsy(PCNL) is quite common operation for upper urinary tract stone. According to AUA guideline, PCNL is suggested to perform to upper urinary tract stone burden above 2 cm or lower pole stone above 1 cm. Previous literature shows a lot of complication for this procedure such as kidney perforation, large vessel damage, large blood loss, renal aneurysm formation, nearly organ damage. We show one case report about rare complication for PCNL.
Case report: This 55 years old female patient denied chronic or systemic disease. This time she was suffered from right flank pain and dysuria for 1 week. Lower abdominal discomfort was also noted. She came to local medical department for evaluation and management. Image survey showed right staghorn stone and doctor there suggested her to do further management. She came to our hospital for second opinion. Physical examination showed right severe flank knocking pain. Biochemistry examination showed leukocytosis and CRP elevated, urine analysis showed WBC and bacteria positive result. CT scan showed right complete staghorn stone. So admission for infection control, operation was suggested and she accepted. Follow up lab data after 3 days’ admission showed infection condition was improving. So operation was performed. During PCNL, 1st nephrostomy tract was created by sono-guide through lower calyx and nitinol guidewire inserted. Nitinol guidewire couldn’t fully insert due to stone block and we were afraid about perforation, then we used Hydrophlic coated guidewire (Terumo guidewire). However, this tract didn’t fully enter to collection system and we decide created another tract. The stuck sensation while guide wire drew out. Then procedure was done by 2nd tract through middle calyx by C-arm guiding. Patient felt persistent right flank pain after operation. Percutaneous nephrostomy tube amount was about 20 to 40cc per day so we removed it post operation day 2. She still felt right lower chest breathing pain and persistent right flank pain. So CT scan was done and showed right perirenal hematoma and foreign body over right lower pole of kidney parenchyma. After discussed with patient and relatives, operation as single port retroperitoneal exploratory was arranged. Wound was extended through previous lower calyx tract and single port system was inserted. We traced the location of foreign body by C-arm guiding. 2 residue Terumo guide wire skin was found and removal. Patient was tolerant to all procedure and recovered well post operation. No obvious severe discomfort, wound recovered well and kidney echo showed no hydronephrosis during outpatient department following.
PCNL standard procedure in our hospital: After endotracheal general anesthesia, the patient is placed in lithotomy position. Double J catheter or ureteral catheter is chosen by surgeon’s habit and stone condition. The artificial hydronephrosis will be created. Then patient will be shift to semi-prone or prone position. Sono-guide puncture will be first choice in our practice rather than C-arm guide. Nephrostomy tract will be created by Cook-balloon dilation system. Common guidewire choice is curved tip Nitinol guidewire. The lithotripsy by laser or lithocast is done after stone in the field. The nephrostomy tube will be placed after all procedure.