As the appraisal of open stone surgery began to reach its peak, advancement continued in the development of less invasive techniques for accessing renal stones. While the first PCN was performed by Thomas Hillier in 1865, Willard Goodwin in 1955 published his work on PCN for hydronephrosis, that it gained acceptance. More than 20 years later [1-3] this example led to the recognition that the same access could also be used as a working channel, resulting in the percutaneous removal of a kidney stone. Over the past 30 years, PCNL has largely replaced open renal surgery for the management of large kidney stone [4].

It has since evolved and been refined with the development of purposely designed instruments, endoscopes and accessories, and has remained a standard treatment for different varieties of renal stones since the eighties [5]. Compared to open renal surgery, PCNL is associated with shorter hospital stays and allows the patient an earlier return to work and activities of daily living. Furthermore, as PCNL is both less invasive and less expensive to perform than open procedures, it has become the treatment method of choice for large renal calculi [6]. Acute hemorrhage is the most common significant complication of percutaneous access into the upper urinary tract collecting system. PCN alone results in haemorrhage requiring transfusion in 0.5% to 4% of procedures [7-9] With the addition of percutaneous nephrolithotripsy, likely owing to the larger caliber of the percutaneous tract and increased intrarenal manipulation, the incidence of hemorrhage to the point of transfusion rises to 6% to 20% [10-14].

Postoperative haemorrhage can occur with the nephrostomy tube in place, at time of tube removal, or after discharge from the hospital. About 1% of patients having percutaneous renal surgery are complicated by delayed haemorrhage requiring treatment [15-17] Delayed haemorrhage is usually due to vascular complication, e.g.: arteriovenous fistulas or arterial pseudo aneurysms,with the latter being more common. Arterial pseudoaneurysm arises from a transected or punctured artery that leaks in to a contained Hematoma cavity.

This complication is likely to happen because of an artery transected partially or end on during percutaneous nephrolithotomy puncture, which could subsequently bleed in to contained space. This transected arterial branch may be either partially thrombosed or in spasm initially, leading to its non-recognition in the operating room ,as the patient increases his /her activity ,the occluding clot may possible get dislodged, accounting for the delayed occurrence of haematuria [18].

Methods

Data from 75 patients, who underwent PCNL procedures between January 2013 to June 2017 and developed delayed hematuria, were retrospectively reviewed and included in our study. Selection criteria for PCNL was stone size ≥ 2 cm in adult patients. Children, patients with active infection and bleeding disorders were not included in study.

Preoperative patient evaluation included history, clinical examination, serum creatinine level, complete blood count, coagulation profile. All patients who have urinary tract infections were treated according to their culture sensitivity. Patients who were taking aspirin or other anticoagulants were stopped a week before.

All patients were evaluated with contrast enhances computed tomography (CT) before the procedure. All procedures were performed in prone position after insertion of ureteric catheter. Percutaneous renal access was established under C-arm fluoroscopic guidance through the poster lateral plane of the kidney by Urologist.

Dilatation of tract was performed by serial Aalken dilators technique. Stones were removed following fragmentation with an ultrasonic lithotripter and a nephrostomy tube was placed at the end of the procedure. After 48 hours antegrade pyelography was done and nephrostomy tube removed after confirming patency and absence of significant residual stone.

The patients were discharged next day of nephrostomy removal, if there were no complications.

Overall, a total of five patients presented and were admitted in our department with delayed intermittent haematuria following PCNL procedures. Initially, patients were managed conservatively by bed rest, bladder clots removal and irrigation, IV Fluid, antibiotics with diagnostic imaging ultrasound and non-contrast abdomen CT and serial follow up with blood tests.

Angiography was performed in selected cases to evaluate and treat possible AV malformation. All patients characteristics, including age, sex, stone size, operation time, number of renal accesses, access site (subcostal or supracostal), calyx punctures, and number of blood transfusions were recorded.

See Table 1 for patient demographic (Figures 1 and 2).

Table 1: Patients Demographic.

Figure 1: Sex distribution.

Figure 2: patients with delayed haematuria.

Among all, 53 were male and 22 were female. Five patients (6.6%), out of 75 patients, had delayed haematuria, and only in two patients (2.66%) vascular injury was confirmed. All five patients were male and one patient had malrotated kidney. All patients, who developed this complication, had comorbidities. Mean age of patient was 47.8 years. Average stone size in longest diameter was 2.95(2-5 cm). Out of five patients; four were known hypertensive, controlled by medicines.

Average time for onset of hematuria was 13.2 days.

Four patients, those who have angiography, in two patients it was unremarkable and in one patient it showed pseudo aneurysm, therefore super selective angio embolization was done. He did well initially, hematuria was settled but after two days, gradually it started again. It leads to clots formation in renal pelvis followed by renal impairment. His other kidney was also relatively small, therefore we did ureteroscopic clots removal and stenting, but unfortunately he developed big renal hematoma and severe sepsis that necessitated nephrectomy as life saving measure. Another patient, angiography confirm vascular injury and leak, it was treated by balloon angioplasty.

Another patient that has extensive urolithiasis with CKD and Hypertension and solitary functioning kidney. His angiography was normal. We did for him cystoscopy and stenting earlier on admission due to renal impairment. During course of conservative management he develops sepsis. We replace stent and continue supportive treatment, including hemodialysis, so he recovered well and discharged. One patient who present on 5th post op day, he also bleed during primary surgery for PCNL, so procedure was abandoned. Bleeding was controlled by nephrostomy insertion. He didn’t require transfusion either during or in peri- operative period. His angiography was also normal. He had Hypertension, hyperuricemeia and .treated for lymphoma about 10yrs before. One patient was admitted for delayed hematuria on 8th post op day, He had Diabetes Mellitus, Hypertension, HBsAG +VE, Glaucoma, and refuse for angiography. He was managed with conservative treatment. Only two patients whose angiography was positive needs blood transfusion, rest were treated conservatively without significant drop in hemoglobin.

In era of endourology and minimally invasive surgery PCNL is standard treatment of large renal stones, as it is safe and efficient. However minor to major complications can occurs during and after surgery [19-22].

Bleeding is one of most common complications. Fortunately majority of these are minor and self-limiting and managed conservatively but some time it necessitate the intervention. Haemorrhage related to PCNL has reported incidence varies from 0.8% to 7.6% [23-26]. In our study we observe delayed haematuria in five patients that is about 6.6% and only two patients prove vascular injury that is only 2.66%.

As kidney has got very high blood flow, 25% of cardiac output. Some bleeding is natural with the procedure. While it requires transfusion in 3% to 25% of cases PCNL [27-29]. Venous bleeding can usually be controlled with nephrostomy insertion, while severe arterial bleeding requires angiography and selective angioembolization. Reported incidence is 0.3-1.4% [30,31] that is slight higher in our study, and result may vary in larger scale study with increased number of patients. Excessive bleeding usually arises from injury of segmental arteries, which are surrounded by dense renal parenchyma, thus easier to temponade with nephrostomy sheath or tube [32].

The Bleeding can occur during renal puncture, tract dilatation, and manipulation of nephroscope or in post-operative period [33]. Patients with arteriosclerosis of renal artery branches accelerated by aging, hypertension, or diabetes mellitus are presumably are at higher risk of bleeding. Arteriosclerosis may impair the ability of self-healing properties of arterial wall because of loss of normal muscle and elastic layers. Bleeding tendency is frequently noted in patients with uremia and liver cirrhosis and those under anti-coagulant agent treatment. Kidneys those have had retroperitoneal inflammation from renal infection and fixed in the retro peritoneum are specially at higher risks of parenchymal trauma during percutaneous intrarenal surgery [34]. Published data suggests that patient age, ASA grade, stone burden and operation duration are associated with increased risk of vascular complications [35]. Kessarris .et al reported in his study of 2200 PCNL, that age, gender, medical illness, stone burden, number of renal punctures, and procedure duration were not risk factors [36]. In our study, all patients has some risk factors. In one patent hematuria couldn’t settled with angioembolization, leads to severe sepsis and nephrectomy.

Nephrectomy related to PCNL is rare but reported in literature. Kernohan et al reported a case of complete embolization of renal artery which resulted in loss of kidney. Selective embolization was not successful due to abnormal arteries which made it impossible to embolize the feeding artery selectively [37] Stephen R, et al [38]reported nephrectomy due to cardiovascular instability secondary to haemorrhage [35]. Another study from Pakistan reported nephrectomy due to massive delayed bleeding after PCNL, due to unavailability of interventional radiology facilities [38].

Transfusion requirement influenced by many factors, including operative techniques, surgeons experience, stone complexity, and patient status. Lam et al reported that improved skills and the presence of flexible nephroscope decreased rate of blood transfusions.

In some studies it was reported that multiple parenchyma punctures were associated with vascular injuries and increased blood transfusions.

El-Nahas et al. [28] observed that stag horn stones and upper calyx punctures were significant risk factor for severe bleeding. All patients, who presented with delayed haematuria have complex stone disease along with co morbid risk factors. Mean operation time was 116.25 minutes, all patients were approached by lower calyx.

In our study we did angiography in 4 patients, two have normal angiography and one patient showed Pseudoaneurysm ,therefor embolization was done ,but that didn’t works, and he start hematuria in 48hrs in same admission and end up with nephrectomy due sepsis and hemodynamic instability. El-Nahas et al. [28] reported that success rate of controlling the bleeding after PCNL was 92.3% and 72.3% of patients were successfully treated with single session without any complication. This study suggest that about 28% failure of angioembolization, this may be similar to our study ,where one patient re start bleeding that end up with lifesaving nephrectomy. This is similar to literature. Limitations of our study were low number of patients and retrospective study. Probably, a multicentric prospective study can result in a more precise outcome.

Delayed haematuria is one of rare and serious outcome of PCNL, mostly It is secondary to vascular complication e.g., pseudo aneurysms. Presence of risk factors increases chances of haematuria. Conservative treatment is effective and still the treatment option. Angiography can be an option for non-responder with possible embolization if indicated.