Skip to main content

Renal pelvis mucosal artery hemorrhage after percutaneous nephrolithotomy: a rare case report and literature review

Abstract

Background

Following a percutaneous nephrolithotomy (PCNL) procedure, the most common complications are considered to be intraoperative and postoperative bleeding. Many patients with postoperative bleeding can be treated conservatively, causing the perirenal hematoma to resolve spontaneously. The major causes of severe postoperative bleeding are pseudoaneurysms, arteriovenous fistula, and segmental arterial injury. Typically, the first choice of treatment to manage severe bleeding complications is selective angioembolization (SAE) because of the very high success rate associated with this procedure.

Case presentation

This clinical case involves a 56-year-old man who underwent dual-channel PCNL treatment after diagnosing a left kidney staghorn stone and urinary tract infection. The operation was successful, with no apparent signs of bleeding. Tests revealed continued decreasing hemoglobin levels following the procedure. After the conservative treatment failed, renal angiography was performed immediately, indicating renal pelvis mucosal artery hemorrhage. In the three hours post-surgery, the SAE still failed to prevent bleeding. Further discussions led to formulating a new surgical plan using a nephroscope to enter the initial channel where hemostasis began. The hemostasis origin was found precisely in the mucosal artery next to the channel during the operation and was successfully controlled.

Conclusions

This case reveals there is poor communication and inadequate discussions about the potential failures of an SAE procedure. Swift clinical decision-making is imperative when dealing with high-level renal trauma to prevent delays in surgery that can threaten the safety of patients.

Peer Review reports

Background

Technological advancements in surgery have developed minimally invasive endoscopic procedures like PCNL, which has replaced traditional open surgery as the first choice for treating large kidney stones [1]. Although PCNL is a technique that offers a significantly high stone removal rate and low recurrence rate as a primary treatment option, hemorrhage is still the most common complication of PCNL. Typical hemorrhages diagnosed by a renal angiography procedure are pseudoaneurysm, arteriovenous fistula, and staged arterial injury; severe bleeding requires superselective vascular embolization [2, 3]. The latter has a very high success rate, but 0.2% of patients with embolization failure are still at risk of nephrectomy [4]. What follows is a report of a case of PCNL bleeding after the failure of superselective vessel embolization and successful hemostasis after nephroscopy procedure.

Case presentation

The patient was a 56-year-old male. A computerized tomography (CT) scan revealed a staghorn stone in the left kidney. The puncture point was selected under ultrasound guidance, and a vertical incision was made through the skin into the renal calyces of the left kidney. Using a 24-Fr fascial dilator to establish a clear passage, it is determined that the left renal lower calyx stone cannot be broken. To reevaluate the procedure, another puncture point is created, with a vertical skin incision into the left lower renal calyx group. The passage was dilated to 18-Fr, resulting in a successful operation process by completely removing the stone; F20 and F16 drainage tubes were retained. Post-surgery, the color of the fluid from drainage was dark red, and the hemoglobin decreased by 10 g/d. After the conservative treatment failed, the CT scan revealed renal pelvis mucosal artery hemorrhage (Fig. 1). A selective angioembolization (SAE) was performed immediately, but the operation was considered unsuccessful after 3 h of intervention therapy failed to control bleeding. There were several reasons for the failure of SAE: the blood vessels were too thin; the opening was at an angle opposite to the renal artery trunk; the renal artery trunk was thick, therefore unable to support it to enter its opening, and was too deep into the distal end, and the opening may have been at a complicated angle. Considering the patient's condition may deteriorate, the decision was made to immediately prepare for emergency hemostasis surgery. This necessity was explained to the patient’s family, along with the potential consequences of nephrectomy if hemostasis failed to achieve further hemostasis. After the patient was anesthetized, the kidney was entered along the original channel. The nephroscope cleared the clot in the renal pelvis, and the mucosal bleeding point at the junction of the renal pelvis and ureter was identified. Electrocoagulation treatment was used to successfully control bleeding after surgery. Careful inspection of the fluid in each cup revealed no bleeding or large stones remained (Additional file 1: Video 1). The hemoglobin value of the patient was monitored gradually after the operation, and there was no recurring bleeding after the patient was discharged from the hospital.

Fig. 1
figure 1

The arrow indicates rupture and bleeding of the mucosal artery of the renal pelvis

Discussion and conclusions

PCNL is an effective method for treating large and complex kidney stones. Postoperative bleeding is one of the most common clinical complications following PCNL surgery. Severe bleeding complications can precipitate organ damage and even endanger the life of the patient [5, 6]. Most postoperative bleeding can be controlled by conservative treatment, and the frequency to control severe bleeding complications that require superselective vascular embolization is around 0.8% [7].

In this case, no apparent signs of bleeding were found during the operation. After the fistula was opened, the drainage fluid was discovered to be deeper in color, and the hemoglobin continued to decrease. An enhanced CT scan revealed a bleeding renal pelvis mucosal artery, but the failure of SAE required the surgeon to quickly decide on the patient's subsequent treatment. Consequently, the doctor decided to prevent further blood loss using nephroscopy procedure based on the analysis of 2 surgical videos. Blood loss was successfully controlled upon finding the exact bleeding point, and further damage to kidney function was prevented.

SAE has become the treatment of choice for severe, continuous, or intermittent bleeding after PCNL. A pseudoaneurysm, arteriovenous fistula, and segmental arterial injury are the most common effects of renal angiography [3]. Although SAE has a very high surgical success rate, some patients still experience repeated embolization failures. Those patients with hemodynamic problems cannot tolerate the angiography technique. Consequently, urgent additional treatment is required to control the development of the condition. In his analysis of patients with acute pulmonary embolism, Alireza [8] concluded that massive postoperative bleeding caused by acute embolism or other causes of PCNL must be treated with emergency partial nephrectomy or nephrectomy surgery. The principles of this type of surgery should be similar to a laparotomy surgical procedure used for patients with severe kidney damage for renal repair. Previously, there have been no reported cases of severe renal pelvis mucosal arterial bleeding leading to shock. Moreover, the successful management of severe bleeding complications after percutaneous nephroscopy also shows that nephrectomy is not the only cause of SAE failure.

Finding the exact bleeding point using a nephroscope for accurate hemostasis may also achieve unexpected results. According to previous studies many risk factors can predict the occurrence of bleeding after a PCNL procedure: multiple puncture sites; the type of kidney stones detected; high body mass index; prolonged operative time; history of ipsilateral renal calculi, and urinary tract infection are some of the causes that instigate severe bleeding after PCNL [9, 10]. In this report, the patient was considered for ipsilateral renal stone surgery while having a urinary tract infection. The risk of severe bleeding was significantly increased due to the complexity of dual-channel PCNL during the operation. This outcome also demonstrates that clinicians should be required to closely observe the changes of the patient's condition and assess the risk of postoperative complications.

For patients with severe bleeding after percutaneous nephrolithotomy and for those who experienced SAE failure, it is necessary to analyze the cause of failure and the patient’s condition immediately to ensure the integrity of the organs as much as possible.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

References

  1. Wollin DA, Preminger GM. Percutaneous nephrolithotomy: complications and how to deal with them. Urolithiasis. 2018;46(1):87–97.

    Article  Google Scholar 

  2. Kim HY, Lee KW, Lee DS. Critical causes in severe bleeding requiring angioembolization after percutaneous nephrolithotomy. BMC Urol. 2020;20(1):22.

    Article  Google Scholar 

  3. Du N, Ma JQ, Luo JJ, Liu QX, Zhang ZH, Yang MJ, Yu TZ, Tao Y, Liu R, Zhang W, Yan ZP. The efficacy and safety of transcatheter arterial embolization to treat renal hemorrhage after percutaneous nephrolithotomy. Biomed Res Int. 2019;2019:6265183.

    PubMed  PubMed Central  Google Scholar 

  4. Desai M, De Lisa A, Turna B, Rioja J, Walfridsson H, D'Addessi A, Wong C, Rosette On Behalf Of The Croes Pcnl Study Group J. The clinical research office of the endourological society percutaneous nephrolithotomy global study: staghorn versus nonstaghorn stones. J Endourol. 2011; 25(8):1263–8.

  5. Kyriazis I, Panagopoulos V, Kallidonis P, Özsoy M, Vasilas M, Liatsikos E. Complications in percutaneous nephrolithotomy. World J Urol. 2015;33(8):1069–77.

    Article  Google Scholar 

  6. Zhang LW, Fei X, Song Y. The clinical efficacy of novel vacuum suction ureteroscopic lithotripsy in the treatment of upper ureteral calculi. World J Urol. 2021;39(11):4261–5.

    Article  Google Scholar 

  7. Ding X, Guan J, Tian J, Hou Y, Wang C, Wang Y. Subcostal artery bleeding after percutaneous nephrolithotomy: a case report and literature review. J Int Med Res. 2018;46(10):4350–3.

    Article  Google Scholar 

  8. Aminsharifi A, Irani D, Eslahi A. Massive hemorrhage after percutaneous nephrolithotomy: saving the kidney when angioembolization has failed or is unavailable. Int J Surg. 2014;12(8):872–6.

    Article  Google Scholar 

  9. Wang Y, Jiang F, Wang Y, Hou Y, Zhang H, Chen Q, Xu N, Lu Z, Hu J, Lu J, Wang X, Hao Y, Wang C. Post-percutaneous nephrolithotomy septic shock and severe hemorrhage: a study of risk factors. Urol Int. 2012;88(3):307–10.

    CAS  Article  Google Scholar 

  10. Aghamir SM, Elmimehr R, Modaresi SS, Salavati A. Comparing bleeding complications of double and single access totally tubeless PCNL: is it safe to obtain more accesses? Urol Int. 2016;96(1):73–6.

    Article  Google Scholar 

Download references

Acknowledgements

Not applicable.

Funding

Not applicable.

Author information

Authors and Affiliations

Authors

Contributions

LWZ: wrote the manuscript. XF: revised the manuscript. YS: checked all data and revised the manuscript. All authors read and approved the final manuscript.

Corresponding authors

Correspondence to Xiang Fei or Yan Song.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Written informed consent was obtained from the patient and the legal guardian for publication of this Case Report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.

Competing interests

All of the authors declare that they have no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1. Video. 1 Control the bleeding under the nephroscope.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Zhang, L.W., Fei, X. & Song, Y. Renal pelvis mucosal artery hemorrhage after percutaneous nephrolithotomy: a rare case report and literature review. BMC Urol 22, 100 (2022). https://doi.org/10.1186/s12894-022-01049-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12894-022-01049-w

Keywords

  • Percutaneous nephrolithotomy
  • Bleeding
  • Renal pelvis mucosal artery
  • Selective angioembolization