Injury to Biliary Tract During Percutaneous Nephrolithotomy: Minimally Invasive Management of a Dreadful Complication

Abstract

Background: Percutaneous nephrolithotomy (PCNL) is an effective minimally invasive surgical modality for the management of renal calculi. It is generally considered safe with commonly encountered complications being urinary extravasation, fever, and bleeding. Injury to the biliary tract or puncture of the gallbladder is an extremely rare but a grave complication of PCNL.

Case Presentation: We present a case of a 70-year-old man who underwent PCNL for an obstructing right renal pelvic calculus. Upon middle caliceal puncture to access the pelvicaliceal system, an unexpected green aspirate suggestive of bile was noted egressing through the puncture needle when stiletto was detached. The needle was swiftly withdrawn and percutaneous renal access was effective on the second puncture to complete the procedure. In the postoperative period, biliary ascites was confirmed on imaging, which was managed in a minimally invasive manner with an ultrasonography-guided abdominal drain insertion. The patient recovered well and was discharged home.

Conclusion: Biliary ascites with or without peritonitis is a rare but potentially fatal consequence of biliary tract injury that can occur during PCNL. If there is recognition of biliary aspirate during a percutaneous renal procedure, aggressive management, including diverting the biliary fluid in appropriately selected cases, can obviate the need for emergent open or laparoscopic surgical intervention as highlighted in our case.

Introduction and Background

Percutaneous nephrolithotomy (PCNL) is an effective minimally invasive surgical modality for the management of renal calculi. It is largely considered safe with commonly encountered complications being fever (21%–32%), bleeding (10%–18%), and urinary extravasation (7.2%). Infrequently, it can be associated with complications such as urosepsis (1%–2%), thoracic complications (<2%), and solid organ injury.¹ PCNL-related colonic injury is rare and constitutes 0.2% to 0.8% of all cases, and the rate of other gastrointestinal complications is <0.1%. Puncture of the gallbladder or biliary tract injury is an extremely rare but a grave complication of PCNL.² Few cases have been reported in the literature highlighting the rarity of this complication. We present a case of biliary tract injury during PCNL and its effective management in a minimally invasive manner.

Presentation of Case

A 70-year-old thinly built and poorly nourished man with a history of hypertension and ischemic heart disease presented with right-sided flank pain of 2-month duration. Evaluation with a plain CT of kidney, ureter, and bladder radiograph (Fig. 1a, b) showed moderate to gross right hydronephrosis secondary to an obstructing renal pelvic calculus measuring 20 × 14 × 9 mm (average Hounsfield units +800 to +1000) for which right PCNL was planned. Under general anesthesia after cystoscopy, initial ureteral catheterization followed by retrograde pyelography was performed. The patient was placed in prone position to access the pelvicaliceal system (PCS) under fluoroscopy guidance. Upon posterior middle caliceal puncture with 18-gauge two-part needle using the bull's eye technique, green aspirate (bile) was noted upon aspiration with a 2-cc syringe from the needle when stiletto was detached. The needle was quickly withdrawn and access to the PCS through lower posterior calix was effective on the second attempt. A 0.032″ straight-tip hydrophilic glidewire was passed into the PCS and parked in the bladder. Serial dilatation of the tract was carried out by telescopic Alken's metal dilators up to 26F. A 26F Amplatz sheath was placed, and 24F rigid nephroscope was used for PCNL. The pelvic calculus was fragmented using pneumatic lithotripter to achieve complete stone clearance. A 5F Double-J stent was placed along with a nephrostomy drain. On postoperative day 1, the patient had complaints of vomiting and right-sided abdominal pain. Contrast-enhanced CT abdomen and pelvis revealed an ill-defined nonenhancing fluid collection in the gallbladder fossa and the subhepatic region extending into the right paracolic gutter (Fig. 2a, b). The gallbladder was distended; however, the walls of mid and distal common bile duct (CBD) could not be delineated. In consultation with general surgery and medical gastroenterology, magnetic resonance cholangiopancreatography (MRCP) was performed, which showed dilated intrahepatic biliary radicals but did not reveal any inclusion defects (Fig. 2c, d). The right and left hepatic ducts were observed till the confluence and the gallbladder was normal in size and distended. The CBD was normal in course and caliber without any filling defects. The patient was managed with ultrasonography-guided pig-tailed abdominal drain insertion to drain biliary ascites (Fig. 3). Drain output was 800 mL on day 1; drain fluid analysis revealed elevated levels of bilirubin (29 mg/dL). Abdominal drain output showed a decreasing trend for the next few days, nephrostomy drain was removed on day-3 and the patient recovered well. The patient was discharged home on postoperative day 8 (POD-8) in a stable condition with abdominal drain in situ. He returned for follow-up on POD-14, an ultrasonography abdomen was obtained on an outpatient basis, which did not reveal any residual intra-abdominal collection. The drain was pulled out uneventfully.

FIG. 1.

(a, b) Pre-operative CT-Kidney Ureter Bladder (Plain) showing an obstructing radiodense renal calculus (yellow arrow) in the right renal pelvis causing moderate to gross hydroureteronephrosis.

FIG. 2.

(a, b) Contrast-enhanced CT of abdomen shows an ill-defined nonenhancing fluid collection (yellow arrows) in the gallbladder fossa and in the subhepatic region extending into the right paracolic gutter. (c, d) MRCP showing dilated intrahepatic biliary radicals (c) and normal anatomy of biliary tree (d) with collection in gallbladder fossa. MRCP, magnetic resonance cholangiopancreatography.

FIG. 3.

Abdominal drain and collection bag showing bilious fluid. The fluid analysis revealed elevated bilirubin levels (29 mg/dL).

Discussion and Review of Literature

Biliary ascites with or without peritonitis is a rare but potentially fatal consequence of biliary tract injury occurring during percutaneous renal procedures, including PCNL. There are nine cases of biliary tract injury secondary to percutaneous urologic interventions reported in the literature, most requiring either open or laparoscopic interventions.² Among them, a recent report of minimally invasive management included interventions such as endoscopic retrograde cholangiopancreatography (ERCP) with CBD stenting and abdominal drain insertion.³ To the best of our knowledge, this is the first report of a biliary tract injury managed with a minimally invasive ultrasonography-guided abdominal drain insertion.

It is documented that laterally directed percutaneous access to the PCS increases the risk of injury to the colon. Correspondingly, a medially directed puncture can be associated with an increased risk of gallbladder puncture or biliary tract injury.⁴ Various possible risk factors for such an injury are reported in the literature: (1) thinly built or underweight patient (2) mid-polar right renal access, (3) distance between calix and gallbladder <2 cm and (4) Mucocele (hydrops) of gallbladder (5) deep puncture leading to through and through puncture through the PCS. In our case, a thinly built and malnourished patient along with a deep medially placed mid-calix puncture is the plausible explanation for the biliary tract injury. However, the exact site of injury in the biliary tract could not be identified in our case. We used Bull's eye technique to gain access to PCS, and the depth of the needle was being monitored during the procedure in an oblique and a 90° view on C-arm. However, the right kidney was mobile and there was a misjudgment of the depth required to access the PCS because of mobility of the right kidney. There was a sudden feeling of giving away; the needle looked like being stationed in the PCS, but it was not.

Intraoperative ultrasonography in adjunct to fluoroscopy-guided puncture can also aid in preventing this complication. However, a gallbladder injury during an ultrasonography-guided percutaneous renal procedure is also known to occur.

Prompt intraoperative recognition holds the key as a gush of green aspirate in the puncture needle gives a clear indication of a breach in the continuity of the biliary tract. Any further manipulations, such as placing a guidewire or serial tract dilatation, are best avoided as they can lead to worsening of the injury. In the presented case, the initial puncture into the middle calix was misdirected; upon removal of stiletto and aspiration with a 2-cc syringe, bile was aspirated. The needle was quickly withdrawn without further manipulation. The surgical team anticipated a minor puncture injury to the biliary tract. Hence, the patient was observed for any worsening of vital signs; tachycardia and hypotension. After 20–25 minutes of watchful observation, a decision was taken to attempt a second puncture to access the PCS. If there are no intraoperative signs of biliary tract injury, there should be a low threshold to consider early imaging (ultrasonography or MRI) in case of postoperative pain abdomen, dyspeptic symptoms, abdominal distention, or signs of peritonitis.

Management of this infrequent complication is directed by its clinical presentation. Most reported cases were managed by either open or laparoscopic cholecystectomy. If bile is aspirated while performing any percutaneous renal procedure, it is prudent to abandon the procedure and closely observe the patient for signs of peritonitis. In case of early recognition and a stable patient without any signs of peritonitis, diverting the bile away from the injury site can be attempted by percutaneous cholecystostomy or ERCP with CBD stenting. An ultrasonography-guided abdominal drain was adequate in our case as there was a decreasing volume of drain output and absence of any recognizable injury to the biliary tree on MRCP, hence averting the need for any further intervention. The patient recovered well and was doing well on the last follow-up. We must acknowledge that biliary ascites leading to biliary peritonitis may not always permit conservative and minimally invasive management of this infrequent and grave complication.

Abbreviations Used

CBD

common bile duct

CT

computed tomography

ERCP

endoscopic retrograde cholangiopancreatography

MRCP

magnetic resonance cholangiopancreatography

MRI

magnetic resonance imaging

PCNL

percutaneous nephrolithotomy

PCS

pelvicaliceal system

POD

postoperative day

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Cite this article as: Sharma M, Prabha V, Devaraju S (2020) Injury to biliary tract during percutaneous nephrolithotomy: minimally invasive management of a dreadful complication, Journal of Endourology Case Reports 6:4, 380–383, DOI: 10.1089/cren.2020.0038.