A Major Complication in Micropercutaneous Nephrolithotomy: Upper Calyceal Perforation with Extrarenal Migration of Stone Fragments due to Increased Intrarenal Pelvic Pressure

Abstract

Micropercutaneous nephrolithotomy is a safe and efficient technique for appropriate sized stones. It is performed through a 4.85 Fr all-seeing needle and stones are fragmented into dust, without the need for tract dilatation, unlike other percutaneous nephrolithotomy types. Even though micropercutaneous nephrolithotomy has many advantages, increase in intrapelvic pressure during surgery may cause rare but serious complications. Herein we report a case of micropercutaneous nephrolithotomy in a 20-year-old woman with a 20 mm right renal pelvis stone and present an undesired outcome of this complication, upper calyceal perforation. Right lower calyceal access was performed with 4.85 Fr all-seeing needle and 2 cm renal pelvis stone was fragmented by 272 μm Holmium-Yag laser system. Upper calyceal perforation and infrahepatic accumulation of stone fragments were detected by fluoroscopy during the surgery. Postoperative imagings revealed perirenal urinoma, perirenal and infrahepatic stone fragments, and lower calyceal stone fragments inside the system. On second postoperative day, minipercutaneous nephrolithotomy and double J catheter insertion procedures were applied for effective drainage and stone clearance. Risk of calyceal perforation and urinoma formation, due to increased intrapelvic pressure during micropercutaneous nephrolithotomy, should be kept in mind.

Comparison of renal pelvic pressure and postoperative fever incidence between standard‐ and mini‐tract percutaneous nephrolithotomy

“…For instance, since the operation of PCNL requires continuous washing to maintain a clear vision field, increased incidence of septicemia could be induced [13]. Furthermore, a certain degree of bleeding is unavoidable with PCNL since kidney is a vascular organ [14]. Unlike SPCNL, MPCNL is equipped with a smaller access tract and does not require serial dilatation, and patients receiving MPCNL may experience smaller Hb drop, decreased trauma, and reduced bleeding amount [15].…”

Micronefrolitotomia Percutânea: Descrição de uma Variante da Técnica Original

“…14,15 A técnica que descrevemos é uma variação da original e faz uso da colocação de uma bainha ureteral para permitir a redução da pressão intra-renal bem como a contínua evacuação dos fragmentos no decorrer do procedimento.…”

Microperc with Self-Assembled Fr 4.85 Visual Needle and Ureteral Access Sheath

“…Thus, less invasive and more refined instruments have been developed, such as those used during mini-PCNL and ultramini-PCNL. [2][3][4][5][6] Bader et al 3 established percutaneous renal tracts using a 16-gauge optical puncture system in 2011. Desai et al 7 first reported on the puncture and disintegration of urinary stones in a single step without tract dilation and named this innovative PCNL "microperc. "…”

“…Thereafter, microperc went on to be used to treat moderate-size renal stones in an effort to reduce tract size and tract-related complications. 4,5,[8][9][10][11][12] Advantages of the single-step procedure without tract dilation are minimal tract bleeding, high likelihood of terminating the procedure without tubes, and reduced postoperative pain and hospitalization. 5,8,13 Nevertheless, microperc has drawbacks.…”

“…First, it is performed without an Amplatz sheath, which is intended to facilitate controlling intrapelvic pressure(IPP) and removing fragments. [5][6][7][8]11,[14][15][16][17] Irrigation fluid may not be actively drained and pressurized irrigation may increase IPP, requiring aspiration through the ureteral catheter during the procedure. 7,8,18 High IPP can cause fluid absorption, intravasation, extravasation, and even renal perforation.…”