PCNL

PREOP REVIEW POINTS
Sterile urine cultures or properly treated
Can be prone, supine or lateral
Access types include "eye of the needle" or "trangulation" using 21 or 18ga Chiba needle or an 18ga diamond tip needle
Place a safety wire, dilate tract with Amplatz dilators or balloon
Access should be superior and posterior, attempting to go through plane of Brodel
Bleeding commonly comes from comes from renal pelvis or infundibular dilation, can be venous or arterial
Venous bleeding gets pressure from balloon dilator. arterial gets IR embolization
If significant collecting system injury, end procedure as quickly as possible, place nephrostomy tube or stent
Use saline
F/u imaging 6-8wks after surgery (some get CT scan before neph tube removed)

GENERAL
This is an excellent review of PCNL technique. (10)

COMPLICATIONS
Bacteremia has been reported to occur in up to 37% of patients and 74% of patients have postoperative fever after PCNL, overt fulminant sepsis occurs in only 0.2-1.3% of patients. Post operative hemorrhage occurs in 0.4-11% of patients undergoing PCNL. Hydropneumothorax occurs in 5-16% of cases involving supracostal access. Bowel injury occurs in less than 0.5% of cases. (9)

INTERESTING STUDIES
Two clinical trials demonstrated a benefit of 1 week of antibiotic therapy prior to PCNL, even in the setting of a negative pre-operative urine culture. (7,8,9)

The PCNL Global Study showed transfusion rates at 5.7%, earlier studies showed higher rates between 12-23%. (6)

A study of 67 patients showed PCNL while patient was still on aspirin had no statistically significant increase in bleeding complicaitons, major complications or transfusions. (1) Other studies have also reported continuing aspirin to be safe. (2,3,4,5)