Outcomes of Conservative Management of Splenic Injury Incurred During Percutaneous Nephrolithotomy

Splenic injury is a rare complication after left-sided percutaneous nephrolithotomy (PCNL). Although initial observation is often espoused, the natural history of nonoperative conservative management is not well established and the implications of splenic injury are not fully defined in this context. We sought to describe outcomes of conservative management of splenic injury incurred at PCNL. We performed a multi-institutional retrospective review of individual patients who underwent PCNL complicated by trans-splenic nephrostomy access injury. Demographic info, intraoperative data, management strategies, and outcomes were reviewed. Nine patients suffered splenic injury after left PCNL. All patients had supracostal upper pole access under fluoroscopic guidance. Splenic injury was identified by computed tomography (CT) in the eight of nine (89%) who had imaging on first postoperative day. All eight patients were managed conservatively with nephrostomy dwell time of 2-21 days, one of whom (11%) required blood transfusion. The remaining patient (11%)-who had tubeless PCNL without postoperative imaging presented 5 days postoperatively with a delayed bleed and underwent emergent splenectomy. Seven of the nine (78%) were managed nonoperatively and without need for transfusion or embolization. The majority of patients incurring splenic injury during PCNL can be managed conservatively with maintenance of nephrostomy tube for ≥2 days. Consequences of unrecognized splenic injury may include splenic bleed and may prompt transfusion and/or splenectomy, underscoring role of routine postoperative CT to allow timely diagnosis, particularly in those undergoing upper pole supracostal left-sided percutaneous renal access.