**5.2.5 Injury to intra-abdominal viscera**

Injuries to organs adjacent to the kidneys have been reported in less than 1% of cases (M Tan 2010), and of these, splenic injury is the most commonly reported. Liver laceration is less common, and seldom requires intervention (Lee, Smith et al. 1987).

The risk of splenic injury is increased if a higher supracostal approach (10th-11th ribs) is used, or if the approach is made during inspiration. Should a trans-splenic tract is made, the primary concern is that of hemorrhage with risk of shock, and these may have to be managed surgically. However, conservative management may be considered in selected cases, particularly if the patient is asymptomatic and stable, and this was reported by Carey in a patient who sustained splenic injury that occurred during percutaneous nephrolithotomy (Carey, Siddiq et al. 2006). The patient was managed conservatively, with no serious consequences and the patient was discharged following removal of the nephrostomy catheter.

Percutaneous Nephrostomy 313

The most common urological complications in transplanted kidneys are ureteral obstruction and leakage (Mostafa, Abbaszadeh et al. 2008). These should be recognized and treated early to prevent graft failure. Ureteral obstruction is most commonly due to stricture at the ureterovesical junction anastomosis, brought about by fibrosis secondary to ischemia or rejection and therefore presents late. Mostafa reported good success rates in the treatment of these strictures, by using stents and balloon dilatations inserted via the percutaneous nephrostomy tracts. Early ureteral obstruction on the other hand may be related to other factors such as blood clots, calculus, edema or ischemic necrosis. Similarly, percutaneous

Percutaneous nephrostomy is a widely used urological procedure, providing urinary diversion and access to the urinary tracts for other interventions. While demonstrating a good safety profile, many aspects of the procedure are associated with risks of complications, which may be contributed by various factors from the moment the patient is prepared until after the procedure. The performing physician must not only be well versed with the techniques involved, but he or she should also be well acquainted with the

Carey, R. I., F. M. Siddiq, et al. (2006). Conservative management of a splenic injury related

Cormio, L., P. Annese, et al. (2007). Percutaneous nephrostomy in supine position. *Urology*

Cowan, N. (2008). The Genitourinary Tract; Technique and Anatomy. *Grainger & Allison's* 

Dyer, R. B., J. D. Regan, et al. (2002). Percutaneous nephrostomy with extensions of the

El-Nahas, A. R., A. A. Shokeir, et al. (2006). Colonic perforation during percutaneous

Goodwin, W. E., W. C. Casey, et al. (1955). Percutaneous trocar (needle) nephrostomy in

Gupta, S., M. Gulati, et al. (1997). Percutaneous nephrostomy with real-time sonographic

Hopper, K. D., J. L. Sherman, et al. (1987). The variable anteroposterior position of the

Hruby, W. (1990). Percutaneous Nephrostomy. *Interventional Radiology*. P. R. Robert F. Dondelinger, Jean Claude Kurdziel, Sydney Wallace, Thieme: 234 - 244. Kaskarelis, I. S., M. G. Papadaki, et al. (2001). Complications of percutaneous nephrostomy,

Lee, W., A. Smith, et al. (1987). Complications of percutaneous nephrolithotomy. *Am. J.* 

percutaneous insertion of ureteral endoprosthesis, and replacement procedures.

*Diagnostic Radiology, A Textbook of Medical Imaging*. A. K. D. A. Adam, Churchill

associated risks and complications so that these may be detected and treated early.

to percutaneous nephrostolithotomy. *JSLS* 10(4): 504-506.

technique: step by step. *Radiographics* 22(3): 503-525.

hydronephrosis. *J Am Med Assoc* 157(11): 891-894.

guidance. *Acta Radiol* 38(3): 454-457.

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*Roentgenol.* 148(1): 177-180.

nephrolithotomy: study of risk factors. *Urology* 67(5): 937-941.

retroperitoneal colon to the kidneys. *Invest Radiol* 22(4): 298-302.

interventions may be performed in the treatment of these cases.

**7. Conclusion** 

**8. References** 

69(2): 377-380.

Livingstone. 1: 813-822.

Fig. 14. Computed tomography scan showing extravasation of contrast from the dilated left collecting system through the left PCN tract (t) into the descending colon (d). In this case the tract had matured without any appreciable extravasation of contrast into the retroperitoneal space.

Fig. 15. Withdrawal of the PCN into the colon to be used as a percutaneous colostomy tube (T) was performed after confirmation of good anterograde urinary drainage via the double-J stent (j). Subsequent tube review confirmed closure of the colorenal fistula.

#### **5.2.6 Death**

Percutaneous nephrostomy has a low mortality rate, with published data reporting rates of 0.03% (Hruby 1990) and 0.3% (Lee, Smith et al. 1987). Various major complications may contribute to death following the procedure, particularly in relation to severe hemorrhage and sepsis, but it may also be contributed by other complications provoked by the procedure itself. Myocardial infarction and cardiac arrest have been reported (von der Recke, Nielsen et al. 1994). Lee reported deaths in 2 patients, one of which was attributed to respiratory failure related to underlying severe interstitial pulmonary fibrosis, while the other was due to myocardial infarction in an obese diabetic patient with hypertension. The presence of comorbidities is therefore an important predisposing factor. Patients who require general anesthesia may also be at risk of developing associated complications. However the mortality rate for percutaneous nephrostomy remains lower than conventional surgery for patients who require urological intervention but are not good candidates for conventional surgery (Lee, Patel et al. 1994).
