AUA2017 V11-01: Complications of Percutaneous Access during Percutaneous Nephrolithotomy

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INTRODUCTION
The rate of access-related complications for percutaneous nephrolithotomy (PCNL) has been estimated to be approximately 12.5% . Often, complications are the result of inadequate pre-operative preparation for PCNL or incorrect operative methods. In this video, we discuss several important risk factors as well as several tips to address access-related complications of PCNL.

METHODS
Intraoperative risk factors for access-related complications are discussed at length. These include pre-operative considerations and anatomic considerations that would necessitate alternative forms of access, including CT-guided or laparoscopically-guided access. Next, techniques to avoid problems at the time of establishing access are demonstrated and discussed in detail.

RESULTS
Access-related complications are often encountered in patients who require pre-operative anticoagulation or in whom a urinary tract infection may be identified pre-operatively. Addressing these issues preemptively is imperative to patient safety. Further, several risk factors for bowel injury may be addressed with meticulous knowledge of the patient&[prime]s anatomy pre-operatively. In certain cases, anatomic abnormalities necessitate laparoscopic or CT-guided access. Finally, the main difficulties at the time of obtaining access for PCNL are discussed at length, including inadvertent vascular access, extravasation of contrast, guidewire kinking, obstruction of the access tract by a staghorn calculus, bowel injury, and pleural injury. Inadvertent vascular access is often addressed by redirecting the guidewire into the collecting system. In rare cases, use of the access sheath, or balloon, to tamponade bleeding, may be required. Extravasation often necessitates re-puncture, while guidewire kinking may be rectified with the assistance of a rigid, open-ended catheter. Access for staghorn calculi may be achieved with the assistance of retrograde ureteroscopy, or maneuvering past the stone edge with a grasping forceps. Bowel injury should be addressed with drainage of the urinary tract separate from the bowel and broad spectrum antibiotics. Finally, pleural injury necessitates rapid identification to ensure expedient placement of a chest tube.

CONCLUSION
Access-related complications can introduce significant morbidity to an otherwise successful PCNL. We demonstrated some crucial skills to avoid the difficulties that are often encountered at the time of obtaining access, as well as several techniques that can be used in a timely fashion to address access-related injuries.

Funding: None.

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