Fig. 7.

Surgical trauma after attempted PCNL. During a PCNL procedure, a 24 Fr dilator perforated the left renal collecting system. Initially a Foley catheter was placed through the defect, with the balloon inflated next to posterior gastric lumen ( a ). The CT Abdomen demonstrated a left anterior perinephric hematoma, with evidence of contrast extravasation, from the left renal vessels, tracking into the lower pelvis. There was also left renal collecting system contrast extravasation, in keeping with a perforated renal collecting system, surrounding the left kidney, posterior to the gastric lumen, around the liver and interspersed in the right upper quadrant small bowel mesentery. ( b ) In the OR, urology placed an internal double-J ureteral stent. A guidewire was placed, percutaneously entering the left kidney, traversing to the lesser sac, looping back into the left renal collecting system/ureter, subsequently terminating in the bladder. Angiography was then performed. The mesenteric vessels were uninjured ( c ). Left renal artery angiography ( d ) demonstrated irregularity and luminal narrowing consistent with arterial injury involving a left lower pole segmental artery (red arrow). This was embolized with 3 mm and 4 mm coils. Final injection of contrast into the Foley catheter demonstrated filling of the collecting system with extravasation into the retroperitoneum ( e ). This access was subsequently used to place a percutaneous nephroureteral stent ( f ). With prolonged decompression of the collecting system, the hemorrhage into the collecting system ultimately dissipated.