A Rare Complication of Amplatz Sheath: Amplatz Sheath Rupture During Percutaneous Nephrolithotomy

Abstract

Introduction: Amplatz sheaths are hollow tubes that serve as the portal for the insertion of the nephroscope during percutaneous nephrolithotomy (PCNL). Breakage of this tube during the procedure is rare, but when it does occur it should be recognized and addressed promptly.

Case Presentation: A 46-year-old Caucasian male patient was scheduled for PCNL. The Amplatz sheath was inserted in the usual manner over a balloon dilator and nephroscopy was performed. Profuse bleeding was encountered early. Upon meticulous endoscopic navigation, the broken Amplatz tube was recognized and replaced. This allowed us to identify and remove the fragment of the Amplatz tube, followed by stone fragmentation and removal.

Conclusion: Our experience highlights the importance of recognizing this rare complication of a broken Amplatz sheath that should be managed promptly and effectively through endoscopic means without the need to abort the planned PCNL.

Introduction

Since its introduction for stone surgery in 1976, percutaneous nephrolithotomy (PCNL) has evolved rapidly with advancing technologies and techniques and remains the primary treatment for renal stones >2.5 cm and staghorn stones in the guidelines. As endoscopes and auxiliary instruments develop, higher success is achieved in PCNL surgery with fewer complications. The success of the technique includes faster recovery time, shorter length of hospital stay, and better cosmetic effect.

As with any operation, PCNL surgery has complications. These can occur intraoperatively, as well as postoperatively. The intraoperative complications include acute bleeding requiring transfusion, perforation of the collecting system, pneumothorax, and adjacent organ injuries. Besides all these, complications may develop because of the instruments used during surgery. These complications may include events such as guidewire, forceps, or Amplatz sheath rupture. If one of these happens, it can be difficult to remove it from the collecting system. We will attempt to explain an intraoperative complication and its solution that we have not encountered in the literature.

Case Report

A 46-year-old white Caucasian patient presented to our clinic with complaints of left flank pain. The patient with no pathologic finding on physical examination had no history of chronic disease and surgery. His renal ultrasonography revealed dilation in the left renal pelvis, and the unenhanced CT showed a stone of 5 cm in diameter filling the left renal pelvis. The laboratory results were reported as follows: creatinine 1.2 mg/dL; blood urea nitrogen 40 mg/dL; hemoglobin 14.1 g/dL; white blood cell 6700/μL. His complete urinalysis was interpreted as an abundance of red blood cells on microscopic examination. No pathologic finding was noted in the urine culture. The patient was scheduled for a PCNL operation.

After the induction of general anesthesia, an open-end ureteral catheter was placed in the left kidney under fluoroscopy. The patient was then placed in the prone position. Giving contrast media through the open-end catheter under fluoroscopy. The renal pelvis was entered by an 18-gauge needle and a guidewire was placed in the kidney. During these stages, no contrast media extravasation was observed under fluoroscopy. A balloon dilator with a length of 15 cm was advanced to the kidney through the guidewire and inflated at a pressure of 13 atmospheres with a diameter of 12 mm. Resistance was encountered during the advancement of the Amplatz sheath by sliding through the balloon dilator to the kidney. The Amplatz sheath advanced under fluoroscopy was observed to be close to the twelfth rib, but continued to be advanced considering that its tract is correct. After placing the Amplatz sheath, the endoscopic view was obtained by entering with a nephroscope.

After the nephroscope was placed, it was observed that too much blood drained into the Amplatz sheath, and the irrigation fluid coming into the operating channel of the nephroscope did not allow to obtain a clear view. The irrigation fluid serum was increased, the manual pressure pump of a Y-shaped TUR set was squeezed to obtain a good view, and the renal pelvis and stone were observed. No pathologic appearance was noted on fluoroscopy. After excess bleeding and unclear view despite reaching the renal pelvis and stone with the nephroscope, a 30F Amplatz dilator was advanced inside the Amplatz sheath through the guidewire to the kidney. The Amplatz sheath was removed through the dilator and it was observed that a piece of the Amplatz sheath was broken and ruptured (Fig. 1). The ruptured part of the Amplatz sheath was observed in the renal parenchyma reaching the outside under fluoroscopy.

FIG. 1.

Removed Amplatz sheath.

A 30F Amplatz dilator was then advanced through the guidewire to the kidney and a new Amplatz sheath was placed in the renal pelvis through the dilator. The nephroscope was entered, the ruptured piece was targeted under fluoroscopy, and it was found with maneuvers and removed with the help of a grasping forceps (Fig. 2). Then, the renal pelvis and stone were observed by re-entering the nephroscope. No bleeding was observed and a clear view was obtained. Afterward, the stones were broken with the help of lithotripsy tools, and stone pieces were removed from the kidney using grasping forceps. The procedure was terminated by placing an 18F nephrostomy tube after observing that the stone is free under endoscopic view and fluoroscopy. It was thought that the ruptured piece was cut off by the twelfth rib during the advancement of the Amplatz sheath (Fig. 3).

FIG. 2.

Removal of the ruptured piece of the Amplatz sheath.

FIG. 3.

Ruptured piece of the Amplatz sheath.

Discussion

An Amplatz sheath is a plastic cylinder with beveled edges and variable diameters that is placed by sliding outside the dilators. The role of these sheaths is to protect the percutaneous route during the intervention and allow easy access.¹ They also prevent leakage, allowing excess irrigation fluid and stone pieces to be drained. They compress blood vessels in the system, preventing stones from escaping into the surrounding adipose tissue.² Although the Amplatz sheath was in the right trace during the case, extravasation occurred from the blood vessels caused by the rupture and a clear view could not be obtained.

Tabibi et al. compared the split Amplatz sheath and intact Amplatz sheath and concluded that the split Amplatz sheath facilitated the removal of larger pieces of stone, providing shorter fluoroscopy, lithotripsy, and operative time.³ In the study, it was reported that there was no significant difference with the other group in terms of electrolyte disorder that may occur after a fluid leak from the split Amplatz sheath. In our case, unlike the split Amplatz sheath, the longitudinal split of the Amplatz sheath from two sides and rupture distorted the visual clarity so that the operation could not be continued. It is seen that studies have mostly been conducted on and discussed the size of the Amplatz sheath in the literature regarding the Amplatz sheath.

Thirugnanasambandam et al. concluded that smaller Amplatz sheaths for small stones reduce bleeding, kidney failure rates, and postoperative discomfort compared with larger Amplatz sheaths.⁴ If a thinner Amplatz sheath was used in our case, the complication may not have occurred, but we did not consider preferring a thinner Amplatz sheath preoperatively because of the size of the stone since it would prolong the anesthesia and operative time.

In conclusion, each stage of PCNL surgery should be kept under control by the surgeon and any complication should be intervened in a short time. During the stages of PCNL surgery, all causes should be examined in unusual situations, and besides the nephroscope, complications that may be caused by auxiliary instruments should be kept in mind. The development of such complications should be taken into consideration in insertions adjacent to the ribs, especially the high subcostal and intercostal insertions.

Declaration

This study has not been published elsewhere before.

Abbreviations Used

CT

computed tomography

PCNL

percutaneous nephrolithotomy

Disclosure Statement

No conflict of interest has been declared between the authors.

Funding Information

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Cite this article as: Kurt HA, Demirci E (2020) A rare complication of Amplatz sheath: Amplatz sheath rupture during percutaneous nephrolithotomy, Journal of Endourology Case Reports 6:4, 399–401, DOI: 10.1089/cren.2020.0053.