Conservative Management of Liver Perforation During Percutaneous Nephrolithotomy: Case Couplet Presentation

Abstract

Percutaneous nephrolithotomy (PCNL) remains the recommended intervention for large kidney stones, major complications, although rare, are between 1% and 7%. Literature regarding liver injury during PCNL is sparse, and many incidences occur unnoticed. In general, most liver injuries can be treated conservatively when compared with other organ injury sustained during PCNL. Despite this, there is still significant potential for intraperitoneal bleeding as well as possible hemodynamic instability that may result secondary to the inadvertent access. Our team describes two cases of liver injury during PCNL with focus on presentation and injury management. Both cases were treated conservatively through close clinical monitoring and delayed removal of nephrostomy tube. Both liver injuries were diagnosed primarily through postprocedure axial CT imaging. In general, risk factors include supracostal access, particularly at or above the 11th rib, as well as hepatomegaly. Despite that liver injury is a rare complication of right-sided PCNL, outcomes can result in significant blood loss not diagnosed. We present in this study two instances of effective conservative management of liver injury after PCNL.

Introduction

Percutaneous nephrolithotomy (PCNL) remains the recommended intervention for large kidney stones, major complications, although rare, are between 1% and 7%.¹ Literature regarding liver injury during PCNL is sparse, and many incidences occur unnoticed.² In general, most liver injuries can be treated conservatively when compared with other organ injury sustained during percutaneous renal access. Despite this, there is still significant potential for intraperitoneal bleeding as well as possible hemodynamic instability that may result secondary to the inadvertent access. As a result, it is imperative to those performing PCNL to recognize liver injury and manage patient appropriately. In this study, we describe two cases of liver injury during PCNL with focus on presentation and injury management.

Case Series

Case 1

The first case is a 63-year-old woman with a body mass index (BMI) of 23.2 and a medical history notable for PAD s/p bilateral iliac stents, pulmonary squamous cell carcinoma s/p left upper lobe mass resection, and appendiceal cancer with omental metastasis status post-FOLFOX chemotherapy. As a complication of her omental metastasis, she later presented with small bowel obstruction necessitating diverting loop ileostomy. During work-up for the patient's appendiceal cancer, large right renal stone burden was identified; however, definitive treatment was delayed until after chemotherapy administration. Preoperative imaging demonstrated a normal appearing right kidney with a 1.4 cm renal pelvis stone and a 7 mm lower pole stone. (Fig. 1).

FIG. 1.

Preoperative surgical imaging demonstrating 1.4 cm renal pelvic stone.

During PCNL, an upper pole posterior calix was selected for access given low lying position of the kidney. Percutaneous access was obtained using a fluoroscopy-guided approach. Rigid and flexible nephroscopy were utilized to remove all stones and fragments. Antegrade nephrostogram demonstrated no filling defects and good ureteral drainage. Previously placed ureteral stent was removed and an 8F × 24 cm nephroureteral catheter was placed with nephrostogram demonstrating proper positioning.

Patient did well overnight without complaints and postoperative laboratory work was unremarkable. On postoperative day (POD) 1, a noncontrast CT was performed to assess stone clearance demonstrated transhepatic placement of nephroureteral catheter with associated 2.5 cm hematoma at the right lateral abdominal wall and complete resolution of renal stone burden (Fig. 2A). Patient was managed conservatively with plans for delayed nephroureteral catheter removal at 1–2 weeks post-op. Liver function tests were within normal limits with AST 15, ALT 18, and total bilirubin of 0.6. Hemoglobin decreased from 12.3 immediately postoperatively to 9.1 on POD 2 but subsequently stabilized on POD 3. Patient was discharged to home on POD 3 with nephroureteral catheter capped. She was subsequently seen in the office, doing well and underwent subsequent uncomplicated nephroureteral catheter removal on POD 13. Subsequent CT scan on POD 34 after removal of the nephroureteral showed an unremarkable liver (Fig. 2B).

FIG. 2.

(A) Postoperative imaging demonstrating transhepatic nephroureteral catheter placement with small perihepatic hematoma. (B) CT imaging from POD 34 demonstrating resolution of liver injury. POD, postoperative day.

Case 2

The second case is a 77-year-old man with a BMI of 33.2 and a medical history notable for coronary artery disease s/p coronary artery bypass grafting and percutaneous coronary intervention w/stents on clopidogrel, recurrent urinary tract infections (UTIs), and incontinence. Patient had initially presented to emergency room with urosepsis and acute kidney injury w/hyperkalemia in the presence of a 4 mm right ureterovesical junction stone with multiple bilateral large renal pelvis stones in a horseshoe kidney (Fig. 3). He underwent emergent bilateral ureteral stent insertion and completed meropenem treatment for culture positive extended-spectrum beta-lactamase Coli UTI. Patient was preadmitted to hospital for 2 days of IV meropenem before surgery, with plan for initial right-sided PCNL to be followed by contralateral PCNL during the same admission.

FIG. 3.

Preoperative surgical imaging demonstrating large stone burden in horseshoe kidney.

At the time of PCNL, a right upper pole calix was selected for access given the presence of the horseshoe kidney and punctured using a fluoroscopic approach with puncture between the 11th and 12th rib. Rigid and flexible nephroscopy were utilized to remove all stones and fragments. Antegrade ureterogram and nephrostogram was conducted, which demonstrated no filling defects and good ureteral drainage. An 8F × 24 cm nephroureteral catheter was placed with fluoroscopy and nephrostogram demonstrating proper positioning. Patient tolerated this procedure well with no complaints overnight and remained hemodynamically stable with unremarkable postoperative laboratories. Patient returned to the OR the following day for left-sided PCNL through upper pole calix. Upon removal of all stones, an additional 8F × 24 cm nephroureteral catheter was placed on the left side.

The patient did well overnight without complaints and postoperative laboratories were unremarkable. However, on POD 2 from initial right-sided operation, patient had complaints of cough and shortness of breath with hypoxia necessitating 2L NC O2. Chest imaging and symptoms appeared most consistent with small pleural effusion without pneumothorax. Routine postoperative noncontrast CT was performed and demonstrated that the nephroureteral catheter traversed the inferior right hepatic lobe on its way into the kidney (Fig. 4). Patient was managed conservatively with plans for delayed nephroureteral catheter removal. Liver function tests were within normal limits with AST 10, ALT 6, and total bilirubin of 0.4. Bilateral nephrostomy tube (NT) output was noted to be bloody and serum hemoglobin slowly drifted down with patient receiving 1 U of packed red blood cells (pRBC) on POD 3 1 U on POD 4 with subsequent stabilization of hemoglobin. Nephrostomy output began to clear and left NT was removed on POD 5 and right NT on POD 7. Patient was able to be weaned off supplemental O2 completely and subsequently discharged to subacute rehabilitation facility on POD 10. The patient was feeling well with no complaints at outpatient follow-up visit on POD 24 and had resumed anticoagulation.

FIG. 4.

Postoperative imaging demonstrating transhepatic nephroureteral catheter placement with small perihepatic hematoma.

Discussion

There are few cases reported in the literature regarding liver injury after PCNL, possibly owing to the rarity of the complication and under-reporting because of asymptomatic presentation. Perhaps the greatest risk factor for inadvertent liver injury is supracostal access. Hopper and Yakes³ performed MRI on 43 patients and found that supracostal access obtained at or above the 11th rib would lead to liver injury 14% of the time. Although the majority of large kidney stones can be managed with percutaneous access through a subcostal puncture, large upper pole stones and staghorn calculi may necessitate supracostal puncture. Other risk factors for liver injury include hepatomegaly and malrotated or horseshoe kidneys.

Review of the literature only yields one case report detailing a liver injury during PCNL.⁴ The access was obtained fluoroscopically and through supracostal access into right upper pole calix for multiple upper pole stones. The patient developed severe abdominal pain and gross hematuria per NT in post-anesthesia care unit, leading to capping of NT and IV administration of hemostatic drugs. Ultrasonography identified intrahepatic fluid collection and fluid between upper pole of right kidney and liver. Patient received one pRBC as part of resuscitation. On POD 2, the NT was removed from collection system under fluoroscopic guidance with instillation of fibrin sealant as the tube was removed across the liver parenchyma. The patient was observed for another 5 days and discharged in good condition. In our series, neither patient exhibited abdominal pain, abnormal laboratories, or hemodynamic derangement in the first two postoperative days. In both cases, the liver injury was incidentally detected on routine postoperative CT evaluating for residual stone and liver function tests were normal. Both injuries were effectively managed with supportive treatment and delayed removal of nephrostomy tube with close monitoring.

Because liver injury can be difficult to differentiate from standard postprocedure bleeding, it is imperative to have a low threshold for injury and obtain post-PCNL imaging. The diagnosis may be more apparent in those who have bleeding into the abdominal cavity or through nephrostomy tube as these patients will likely present with abdominal pain. Upon diagnosis, our team advocates for conservative management and close monitoring for drop in hemoglobin or change in vital signs. Both of our patients experienced a drop in hemoglobin while in the hospital; however, only the second patient required two transfusions because of slowly downtrending hemoglobin. Ultimately, he remained stable and levels steadied after the second transfusion. In the setting of normal hemodynamics, the injury can be effectively managed by leaving the nephrostomy tube in place for tamponade effect. When ready to remove the tube, careful removal of the tube over a wire guide may be prudent in the setting of sudden bleeding that may necessitate longer tube dwell time or, if severe, possible embolization. We found that leaving the tube in place for a minimum of 7 days resulted in minimal bleeding upon tube removal. In addition, hematoma was found to be entirely resolved on unrelated subsequent imaging in our first patient on POD 34.

Needless to say, it would be preferable to avoid liver injuries altogether. Careful preoperative planning using CT imaging is required, especially when considering supracostal access in patients with hepatomegaly or horseshoe/malrotated kidneys. If cases where normal anatomic landmarks may be distorted, the use of ultrasonography or CT to assist with percutaneous access is recommended.

Conclusion

Liver injury is a rare complication of right-sided PCNL, and can be managed supportively, provided hemodynamics are stable. Risk factors include supracostal access, particularly at or above the 11th rib, as well as hepatomegaly. The risk of injury can be reduced in complex cases with the use of ultrasonography or CT-guided access.

Abbreviations Used

BMI

body mass index

CT

computed tomography

MRI

magnetic resonance imaging

NT

nephrostomy tube

PCNL

percutaneous nephrolithotomy

POD

postoperative day

pRBC

packed red blood cells

UTI

urinary tract infection

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Cite this article as: Rai A, Koze Z, Hsieh A, Aro T, Smith A, Hoenig D, Okeke Z (2020) Conservative management of liver perforation during percutaneous nephrolithotomy: case couplet presentation, Journal of Endourology Case Reports 6:4, 260–263, DOI: 10.1089/cren.2020.0064.