Gastrointestinal system complications in percutaneous nephrolithotomy: a systematic review

To evaluate gastrointestinal tract complications of percutaneous nephrolithotomy (PCNL), to determine risk factors, and to develop strategies for diagnosis and treatment.

A literature review was conducted for the studies published in the English language in the databases of PubMed and Scopus between July 1985 and June 2013. The key words for digital literature search were limited to the following: "percutaneous nephrolithotomy complications, ([splenic injury, liver injury, gallbladder injury and biliary peritonitis, colonic injury] during/after [percutaneous nephrolithotomy]), complication, Clavien, Clavien-Dindo classification, management, review, PNL, PCNL."

A total of 16 articles on splenic injury were reviewed. There was no consensus in the literature regarding the management of splenic injuries. A conservative approach with new treatment modalities is the most widely accepted method in the literature. A total of seven articles on gallbladder injury were reviewed. All gallbladder injuries resulted in cholecystectomy. The time of diagnosis is the most significant parameter determining choice between laparoscopy and laparotomy. A total of seven articles on liver injury were reviewed. The liver injury generally provides the best response to a conservative approach among other solid organ injuries. A total of 11 articles on bowel injury were reviewed. Bowel injury mostly results in exploratory laparotomy. Unlike colon injuries, bowel injuries are more complex to manage with conservative measures because of the challenges in diagnosis and the fact that the injury is located in the intraperitoneal area. A total of 28 articles, which comprised a large case series with colon injuries, consisted of collaborative reviews and meta-analyses were reviewed. In total, 51 colon injuries (0.5%) were evaluated occurring in 13,424 patients in supine and prone PCNL series. Conservative approaches have proven to be effective in colon injuries in the absence of large perforations and intraperitoneal involvement.

There is a downward trend in gastrointestinal complications from PCNL because of the technologic advances that guide the diagnosis and treatment. Paradoxically, the rate of complications is higher in complex kidney stones such as those in a horseshoe kidney and pelvic and malrotated kidney that represent anatomic challenges for intervention. The most important point is to determine the risk factors for preoperative planning of the procedure and to diagnose the complications for proper management early.