Management of Colon Perforation During Percutaneous Nephrolithotomy in Patients with Complex Anatomy: A Case Series

Abstract

Percutaneous nephrolithotomy (PCNL), first described in 1976, is the gold standard for the management of large kidney stones, with stone-free rates as high as 95% in contemporary literature. Colonic injuries during PCNL are a rare complication with an estimated incidence of 0.3%–0.5%. However, given the high morbidity incurred and the necessity of prompt operative intervention, it is imperative that practitioners have a low suspicion threshold for such injuries, particularly in those patients with altered or complex anatomy. This case series addresses peri- and postoperative outcomes of colon perforation during PCNL in patients with complex anatomy and reviews the technical challenges of surgery with potential methods to avoid injury in the future. Herein we review three instances of colonic injuries and their subsequent management to highlight both the presentation and the optimal management of these rare occurrences.

Introduction

Percutaneous nephrolithotomy (PCNL) is the gold standard for management of large kidney stones, with stone-free rates as high as 95%. Major complication rates for PCNL vary between 1% and 7% and are often associated with difficult anatomy and patient comorbidity. Colonic injuries during PCNL are a rare complication with an estimated incidence of 0.3%–0.5%.¹ However, given the high morbidity incurred and the necessity of prompt operative intervention, it is imperative that practitioners have a low suspicion threshold for such injuries, particularly in those patients with altered or complex anatomy. Herein we present three instances of colonic injury after PCNL with a focus on presentation and optimal patient management.

Case Series

Case 1

Our first case is an 82-year-old female with a body mass index of 25.2 kg/m² and a medical history notable for psoriasis and nephrolithiasis with a stone discovered incidentally on imaging performed for evaluation of rectal bleeding. Preoperative imaging showed a horseshoe kidney with dilated extrarenal pelvises and a dilated left collecting system with colon along Brodel's line. Multiple >2 cm stones were seen obstructing multiple calices in the left kidney (Fig. 1A). In addition, a 2.5 cm stone was seen obstructing the left proximal ureter.

FIG. 1.

(A) Preoperative CT with stone; (B) postoperative CT showing NT placement into colon. NT, nephrostomy tube.

The patient was taken for PCNL and a lower pole calix was selected for access (upper pole access appeared to necessitate significant torque for stone clearance) and punctured using a fluoroscopic approach. Rigid and flexible nephroscopy were utilized to remove all stones and fragments. Antegrade nephrostogram was conducted that showed no filling defects, but did show slow ureteral drainage. A 24F Malecot-type re-entry tube was placed with nephrostogram showing proper positioning.

Overnight, the patient developed abdominal distention with pain and elevated blood pressure. On POD 1, a noncontrast CT showed that the re-entry tube traversed a segment of the descending colon on its way into the kidney. The patient was taken to the operating room (OR) where the previous percutaneous access was used to place two guidewires, one of which was used to place a 6 × 24 Double-J stent. An angled catheter was used to place a guidewire into the colon and a 20F council tip catheter was placed as a colostomy tube (Fig. 1B). The patient progressed well with subsequent return of gastrointestinal system function and was discharged home on POD 5 with ciprofloxacin and flagyl. Her diet was advanced to a low-residue diet over the next week and she had the colostomy tube removed on POD 11 with subsequent uncomplicated ureteral stent removal 2 weeks later.

Case 2

The second patient of this series is a 60-year-old wheelchair-confined female with a history of cerebral palsy with limb spasticity/developmental delay and idiopathic thrombocytopenia. She initially presented to an outside hospital with urosepsis and was found to have a 1.8 cm right renal pelvis stone and a 1 cm right lower pole stone (Fig. 2A). She underwent emergent right ureteral stent insertion for decompression, was treated with culture-specific antibiotics, and was scheduled for right PCNL.

FIG. 2.

(A) Postoperative CT scan with colonic injury; (B) postoperative CT scan with oral contrast and resolution of nephrocolonic fistula on POD 21.

Intraoperatively, the stent was noted to be heavily encrusted proximally and distally. The right ureteral orifice was identified after fragmenting the distal encrustation and ureteral access was obtained. The kidney was noted to be supracostal and hypermobile and the initial puncture was unable to be dilated. Repeat puncture, targeting the superior coil of the ureteral stent, was effective and the tract was dilated. Subsequent nephroscopy showed a large stone encrusting the proximal tip of the stent and two 1.5 cm stones in the lower calices. These stones were removed using Cyberwand lithotripsy and rigid graspers. The stent was removed through the sheath and an antegrade nephrostogram was repeated, showing good antegrade flow. The Amplatz sheath was then removed and replaced with a 24F Malecot type re-entry tube.

The patient did well on POD 1 and CT showed nephrostomy tube (NT) in place without residual stone burden (Fig. 2B). On POD 2, the patient developed fever to 102.4°F and profuse watery diarrhea with positive Clostridium difficile testing. On POD 3, feculent drainage was noted around right NT, raising suspicion for colonic injury (Fig. 2A). The patient was then taken to the OR and had right ureteral stent placed in retrograde manner. The nephrostomy tube was retracted under fluoroscopic guidance until Malecot wings were within the colon lumen. The Malecot was exchanged for a 20F council tip foley over a guidewire. Colostogram confirmed tube positioning. The ureteral stent was exchanged and operation was concluded.

The patient's subsequent recovery was complicated by continued diarrhea and candidal urinary tract infection. The patient improved on IV vancomycin and diflucan, with complete resolution of fevers and diarrhea by POD 17. Colostomy was removed on POD 21 after CT colostogram (Fig. 2B) showed no evidence of leak/fistula. Foley was removed on POD 23 and effective void trial and ureteral stent was removed on POD 30.

Case 3

The third patient of our series is a 46-year old morbidly obese hypertensive male with bilateral staghorn calculi and a history of chronic kidney disease with a baseline creatinine of 5 (Fig. 3A). The patient was admitted for planned staged bilateral PCNL procedures, with plan for intervention on the right kidney first.

FIG. 3.

(A) Preoperative CT scan showing significant right stone burden; (B) postoperative CT scan showing nephrostomy tube through central region calix.

The patient was taken to the OR where a ureteral catheter was placed and retrograde pyelogram was performed. A central region calix was punctured and dilated to 30F. Nephroscopy was performed and all visible stone was removed using Cyberwand lithotripsy and rigid graspers. After nephrostogram showed stone clearance, the ureteral stent was removed and a Malecot re-entry tube was placed. Repeat nephrostogram confirmed good tube placement and operation was concluded.

The patient did well postoperatively with POD 1 CT showing complete removal of right-sided stones and good positioning of nephrostomy tube (Fig. 3B). On POD 2, he was taken for an uncomplicated left-sided PCNL. Intraoperatively, a right nephrostogram was performed that showed an unrecognized colon injury, with contrast outlining the ascending colon (Fig. 4). After recognition of this injury, two guidewires were placed, one of which was used to place a 6 × 28 Double-J right ureteral stent. The remaining wire was used to pass a 16F council tip foley in the colon, with positioning confirmed with a colostogram. The operation was then concluded. The patient recovered well and underwent left NT removal on POD 5. The patient was discharged home on a low residual diet with right colostomy tube in place. Colostomy tube and ureteral stent were removed in a staged manner as an outpatient.

FIG. 4.

Right nephrostogram showing colonic outline.

Discussion

PCNL is the standard of care for large kidney stones. It is generally regarded as a safe and minimally invasive approach with a relatively low complication rate when compared with open surgery. Colonic injury is a relatively rare complication and most often occurs in patients with a retrorenal colon.² Other risk factors such as prior renal or colonic surgery, highly mobile kidneys, pelvic kidney, Ogilvie's syndrome, kyphoscoliosis, and severe patient contractures can increase rate of colonic injury by altering normal anatomic landmarks.

Early diagnosis of colonic injury, before nephrostomy tube removal, results in up to 86% chance of success with conservative management.³ Thus, it is important to maintain a low threshold of suspicion for potential aberrant percutaneous access, especially in the setting of abdominal distention or unexplained fever. Other physical examination findings include passage of gas/feces through or around the nephrostomy tract, postoperative diarrhea, and hematochezia, and can progress to formation of intra-abdominal abscess, fistulae formation, or fulminant sepsis if unrecognized.

Upon diagnosis of colonic injury, our team strongly advocates for placement of Double-J ureteral stent and foley catheter to fully divert urine from colonic injury. Here, the nephrostomy tracts were used to place catheters into the colon to act as colostomy tubes. In concordance with published literature, we recommend a colostogram at 4–7 days to evaluate the integrity of the medial colonic wall. In the absence of persistent extravasation or nephrocolonic communication, the foley can be removed and the colostomy tube withdrawn into the retroperitoneal space. If colostomy output remains low over the next 2–3 days, the colostomy tube can be removed. However, if the patient at any time develops sepsis, peritonitis, intraperitoneal colonic perforation, or clinical instability, we recommend urgent surgical exploration with the assistance of colorectal surgery colleagues, as colonic resection and/or colostomy creation may be indicated.

One way to offset the challenges associated with access in patients with complex renal anatomy and large habitus is to use ultrasound or CT guidance for real-time observation. Ultrasound and CT allows the user to identify structures in the retroperitoneum and determine the shortest route to the collecting system. A meta-analysis by Yang et al.⁴ compared complication rates between ultrasound-guided and fluoroscopic-guided PCNL and demonstrated a comparable stone-free rate and a statistically significantly lower complication rate.

Conclusion

In this series of cases detailing colonic injury during PCNL, we sought to describe patient presentation, intraoperative and postoperative course, and our reflections regarding management of these injuries. We found that prompt detection of the injuries was critical to preventing invasive interventions and leading to good patient outcomes. We hope that our readers will be vigilant for the signs and symptoms of colonic injury and consider the use of ultrasound while obtaining access, particularly in complex cases.

Abbreviations Used

CT

computed tomography

NT

nephrostomy tube

OR

operating room

PCNL

percutaneous nephrolithotomy

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Cite this article as: Rai A, Kozel Z, Hsieh A, Aro T, Smith A, Hoenig D, Okeke Z (2020) Management of colon perforation during percutaneous nephrolithotomy in patients with complex anatomy: a case series, Journal of Endourology Case Reports 6:4, 416–420, DOI: 10.1089/cren.2020.0058.