Minimizing and managing bleeding after percutaneous nephrolithotomy.

PURPOSE OF REVIEW: As urologists will continue to rely on percutaneous nephrolithotomy, a clear understanding of its associated bleeding risks and management is mandatory. RECENT
FINDINGS: Despite advances in lithotripsy technology, bleeding continues to be a cause of patient morbidity in percutaneous nephrolithotomy. Although most patients can be managed conservatively, a subset of patients will require endovascular embolization for vascular control. Investigators have identified risk factors and described management options. The use of different dilators and tract size continues to be examined. Additionally, novel applications of proclotting agents as well as direct renal and tract electrocauterization immediately postpercutaneous nephrolithotomy have been reported to decrease transfusions. Finally, initial access obtained by the urologist is associated with less bleeding and higher stone-free rates.
SUMMARY: Optimal renal access is the most critical factor influencing surgical success and minimizing overall blood loss. Although real-time ultrasonography may add to the safety of the initial access, surgeon experience is the key factor. As such, the urologist must be actively involved in tract placement. Clinically significant bleeding can be treated conservatively in a majority of cases with tamponade nephrostomy tubes with or without transfusions. Arterial hemorrhage, pseudoaneurysms, and arterial-venous fistulas, however, require prompt intervention with angiographic embolization.