A 48 year-old-male applied to the urology clinic with left flank pain in January 2002. He has a stone disease history of 15 years. On ultrasonography, he had multiple stones, the largest being 27 × 12 milimeters and moderate dilation in the left kidney with normal echogenity and 9–13 milimeters of cortical thickness. He also had small stones in the right kidney, which were silent clinically. An intravenous urogram revealed several stones, normal filtration function at 5 minutes and marked pelvicalyxeal ectasia in the left kidney. Two stones located at the lower pole of the right were also encountered. There was no abnormality in blood biochemistry, urine analysis and urine culture. In complete blood cell count, his hemoglobin and platelet counts were 16.9 g/dl and 224000/ml, respectively. Decision for therapy was to perform PNL and written consent of the patient was obtained for both the operation and publishing of the outcomes.
After placing a 6 Fr ureteral stent to the kidney under general anesthesia, the patient was positioned in prone and a puncture was made to the lower-calyx on the posterior axillary line below 11th rib by fluoroscopic guidence. Dilation to 30 Fr with Amplatz dilators was achieved, and the renal sheath was placed uneventfully. After passing an antegrade safety guidewire to the ureter, the stones were visualized by the nephroscope, two of which were grasped without need for lithotripsy.
A large stone of aproximately 20 × 15 milimeters was visualised than, and pneumatic lithotripsy was applied with the default setting for 150 pulses, the stone being fragmented with no bleeding at all. Two fragments of five and seven milimeters were grasped without difficulty and an attempt was made to grasp a fragment of 12 × 7 milimeters with serrated and sharpened edges (Figure 1). The surgeon was not able to introduce that stone into the renal sheath with the angle of catching so he left it inside the kidney, draw the forceps back and manipulated the sheath for a better angle of visualization and grasping. The sheath was drawn half centimeter back and under clear vision, rotated clockwise to settle the stone to the tip. There was some resistence to the movement, which was attributed to the stone fragments around, and the rotation was forced by the surgeon till the stone was settled appropriately. At that moment, the surgeon noticed sudden massive bleeding, blurring the vision and clotting in and outside the renal sheath. The anesthesiologist was alerted, excess irrigation was delivered to the system and some aspiration was made to clear the clots, but the blood was still obscuring vision. The nephroscope was withdrawn and a clamped 24 Fr Foley catheter was introduced to the kidney inflating the balloon with 3 cc of saline for compression. The inflation volume was decided according to the visual estimation of the space at the bleeding kidney site. After five minutes, the bleeding has ceased and the surgeon decided to have a look at the collecting system, aspirated the clot inside the sheath and kidney and introduced the nephroscope. The stone fragment was still located at the tip and there was a deep rupture at the sidewall of the sheath (Figure 2). The fragment was catched by a grasping forceps, but it was buried tightly to the wall and the surgeon was again unable to grasp it. With some gentle manipulation, the fragment was pushed back into the collecting system, causing some bleeding. The Foley catheter was introduced again, settled in place for another five minutes and after cessation of the bleeding, the renal sheath was withdrawn with counterclockwise twisting motion, leaving the Foley in place. The stop-valve inflation limb of the Foley catheter was cut from its stem to remove it through the sheath, deflating the baloon. The tube was clamped for 20 minutes and there appeared no sign of bleeding afterwards.
The procedure lasted for 120 minutes, hemoglobin level dropped to 9.1 g/l and blood pressure to 80/55 mmHg at the time of bleeding and a total of 1600 ml of blood was transfused to the patient. Hemoglobin level and blood pressure at the end of the procedure were 12.4 g/l and 110/60 mmHg respectively, so no need to intensive care was encountered.
There was no major bleeding for the first two days postoperatively, so the ureteral stent was removed on day three. The patient was taken to a second look PNL on day six and using the same nephrostomy tract for access, all the stone burden was removed uneventfully. After proving the patency of ureter by means of an antegrade pyeloureterography, the nephrostomy tube was remaved on fourth day postoperatively
Postoperative ultrasonography did not reveal any perirenal collection.