Experience in reducing the potential risk of hemorrhagic complications during and after percutaneous nephrolithotomy

Percutaneous nephrolithotomy (PCNL) is one of the most complex interventions in the urological surgery and endoscopy (1,2). This intervention is particularly complicated and at high bleeding risk due to various factors such as patients’ anatomical variants, absence of direct control of organs and their vascularization, need for an ultra-precise puncture, often in unfavorable anatomical conditions, and difficulty in carrying out correct hemostasis.

Hemorrhage during PCNL is still not fully explored and certainly under the spotlight topic. Although blood loss is quantified by the number of transfusions and anemia [hemoglobin (Hb), g/L], sometimes non-anaemic bleeding can also complicate surgeries, reducing the quality of vision and therefore the aimed results. As far as clinical opinion is concerned, we believe that adequate pre- and perioperative planning is essential to reduce intra- and postoperative bleeding (3).

The first important factor to be considered regarding the bleeding risk in patients undergoing PCNL are patients’ characteristics. In fact, if PCNL is not a mandatory choice, retrograde intrarenal surgery, extracorporeal shock wave lithotripsy and pyelolithotomy can represent a valid surgical alternative (4-7). When choosing the right surgical approach, one must consider patient’s anatomy, medical therapy and comorbidities, hospital operative volume as well as the surgeon’s experience in the technique of choice. This makes essential an adequate preoperative evaluation of coagulation factors and anticoagulant/antiplatelet therapy. The patient must be carefully informed about the risks of standard bleeding and the possible consequences in case of massive bleeding that could cause an emergency situation.

Concerning the antiplatelet therapy, newer studies reported safety of continued low dose aspirin use in patients undergoing PCNL, even though these results might be achievable mainly in the hands of experienced surgeons (8).

In our opinion, by far the most important part of perioperative planning is a precise and systematic control of preoperative computed tomography (CT) scan. In this light, the use of techniques for preoperative images three-dimensional (3D) reconstruction, and particularly augmented reality (AR), is the latest innovation in the field of surgical planning, and has been also affecting endourology (9,10). AR technology represents an adjunct to surgery and appears to be of great assistance in aiding puncture during PCNL. However, even if there are several AR techniques feasible for PCNL, to date this technology is still under development.

Whenever possible, we also recommend the use of intraoperative ultrasound to detect major vessels and make the puncture more precise and easier. Currently, ultrasound is increasingly used by endourologists when performing percutaneous surgeries. However, even for experienced endourologists, ultrasound can provide some valuable information at virtually no cost.

Moreover, by taking in consideration not only stone composition and size, but kidney vascularization also, an optimal evaluation and correct preoperative analysis allow to choose the best approach for the patient (11,12). This is the main reason why the availability of contrasted CT scan rather than a plain one becomes helpful. It allows to identify better kidney vascularization and possible anatomical variants. Furthermore, it is useful to obtain urographic images in order to ameliorate the plan of the caliceal puncture as well. However, it is still generally possible to obtain good information on the conformations of the renal pelvis and calyces also with plain CT alone. Furthermore, it is possible to carry out a retrograde pyelography in the initial phase of PCNL/endoscopic combined intrarenal surgery (ECIRS) in order to possibly modify the operative planning.

Regarding the surgical technique, something that is not adequately addressed in the literature, in our opinion, is the effect on bleeding of different tract dilation methods (13). In detail, there are quite opposite results found by different authors. Turna et al. observed decreased bleeding with balloon dilation when compared to Amplatz dilation (14). In contrast, Yamaguchi et al. found that balloon dilation had significantly higher bleeding and transfusion rate when compared to serial dilation (15). Finally, in another study, both Amplatz and balloon dilations were comparable regarding postoperative bleeding (16). Furthermore, similar results were found between one shoot vs. serial dilations (17).

Theoretically, a serial dilation should be less traumatic than one-shot one. However, in expert hands, one-shot dilation is certainly quicker and allows the shirt to be positioned in the shortest time possible, therefore also guaranteeing an anti-bleeding compressive effect. Balloon dilation might provide both advantages of the previous ones.

One of the factors that makes PCNL a surgery at high bleeding risk is difficulty in accurate postoperative haemostatic control. However, even during PCNL it is possible to perform intraoperative hemostasis before ending the procedure. Such hemostasis can be achieved by using bipolar electrocauterization with roller ball and/or by placing the hemostatic agents (18,19). Furthermore, although it is increasingly more common to carry out tubeless or totally tubeless interventions, we must not forget the theoretical compressive and haemostatic power of the nephrostomy tube (and the possibility of inserting the high caliber catheter in case of excessive bleeding). However, there is currently no scientific evidence regarding the usefulness of this practice. Furthermore, some recent reports have brought back into fashion the use of tranexamic acid during PCNL (20).

It is essential to remember that PCNL is a complex surgical procedure, with a median decrease in hemoglobin of about 2 g/dL and a transfusion rate up to 6% (14), potentially risky for the patient even when performed flawlessly. For this reason, in order to reduce possible complications, including hemorrhage, such intervention must be carried out only after adequate surgical training. Training should take place in steps and in high-volume centers, under supervision of experienced endourologists in both, the procedure itself and the treatment of possible complications.

In conclusion, the evaluation of bleeding risk is a fundamental part of process when choosing the right treatment for renal calculi, and should, at least in part, guide the preference for the procedure technique. Patients should be carefully selected for PCNL and surgeons should perfect the technique as much as possible. In this light, an accurate pre- and perioperative analysis becomes of mandatory importance.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, AME Medical Journal. The article has undergone external peer review.

Peer Review File: Available at https://amj.amegroups.com/article/view/10.21037/amj-24-25/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://amj.amegroups.com/article/view/10.21037/amj-24-25/coif). G.M. serves as an unpaid editorial board member of AME Medical Journal from May 2024 to December 2026. The other authors have no conflicts of interest to declare.

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