經皮腎鏡取石術後結腸穿孔之病例報告及文獻回顧

梁柏崧、張建祥

彰化基督教醫院 外科部 泌尿外科

Colonic perforation after percutaneous nephrolithotomy: A case report and literature review

Po-Sung Liang, Jian-Xiang Chang

Division of Urology, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan

Introduction: Colonic injury after percutaneous nephrolithotomy (PCNL) is an unusual but serious complication. We presented a case of 77-year-old man with lower pole renal stone treated with PCNL complicated with colon perforation.  

Case presentation: A 77-year-old male with history of diabetes mellitus and left inguinal hernia post herniorrhaphy presented to urologic clinic with gross hematuria and left flank pain for days. The renal sonography and X ray showed lower calyceal stone in the left kidney. Then, left one-stage PCNL + double-J stenting was subsequently performed. The procedure was uneventful with complete stone clearance. However, after removal of the percutaneous nephrostomy (PCN) tube on postoperative day 2, fever was noted with abnormal stool-like discharge drained from left PCN wound. Abdominal computed tomography (CT) was arranged and revealed hypodense tract-like lesion with surrounding fat strands among left posterior abdominal wall, descending colon and left renal calyx with air content. Penetrating injury to descending colon with fistula formation was impressed. Colorectal surgeon was consulted, and loop T-colostomy was performed for the descending colon perforation. About 50 days following colostomy, lower gastrointestinal (LGI) series showed no obvious leakage of contrast medium nor colonic obstruction. Then, takedown of loop T-colostomy was conducted. The recovery course was smooth. The clinical course of the patient is consistent with published series, in which colonic injury after PCNL is infrequent but often diagnosed several days postoperatively rather than intraoperatively. Several studies recommend conservative treatment for extraperitoneal colonic perforations in stable patients, including nephro-colic communication separation, ureteral stenting, PCN tube repositioning or removal, bowel rest, total parenteral nutrition, broad-spectrum antibiotics, and selective diversion or drainage. In our patient, loop colostomy was performed, followed by staged reversal once imaging confirmed no persistent leakage, which aligns with more aggressive but still evidence‑based approaches for high‑risk or septic presentations. From a preventive standpoint, this case highlights the significance of pre-procedural cross-sectional imaging for detecting retrorenal colon and other anatomical variants (such as renal malrotation or horseshoe kidney), particularly in elderly, thin patients and left-sided lower pole punctures. To minimize colonic injury risk, retrorenal colons should be addressed with fluoroscopic and ultrasonographic guidance, medial and cranial puncture site adjustment, or alternative approaches (RIRS, supine PCNL with image guidance).

Conclusions: PCNL is a safe treatment for large renal stones, but high-risk patients, such as the elderly and those undergoing left lower-pole access with a possible retrorenal colon, may experience serious colonic perforation. Clinicians should suspect adjacent bowel injury and arrange imaging immediately if postoperative fever, abnormal discharge, or gas from the nephrostomy site is observed to avoid delayed diagnosis, sepsis, or the need for more invasive surgery. Early imaging, surgical diversion, and bowel continuity restoration led to a favorable outcome in this patient, emphasizing the need for preoperative evaluation of anatomic variations and bowel position in high-risk PCNL candidates, and postoperative monitoring for early warning signs to reduce complications.