Massive hemorrhage after percutaneous nephrolithotomy: Saving the kidney when angioembolization has failed or is unavailable

• Partial nephrectomy/renorrhaphy can efficiently control massive bleeding after PCNL.
• The principles of such surgery resemble renorrhaphy in the setting of renal trauma.
• Renal vessel control during the surgery provides a bloodless field for kidney repair.
• This procedure is quite effective in saving the kidney function.
• As a demanding procedure, adequate surgical experience in the setting of renal trauma is essential.

ObjectivesTo describe the management protocol in cases with massive hemorrhage after percutaneous nephrolithotomy (PCNL) with a failed angioembolization or when angioembolization is not available.Patients and methodsBetween October 2006 and December 2012, the charts of patients who had undergone PCNL and were complicated with massive post procedural bleeding unresponsive to conservative management were reviewed. Those cases in whom angioembolization had failed, or was unavailable, or could not be afforded by the patient were selected and studied. These patients underwent open surgical exploration through a midline transperitoneal or a flank retroperitoneal approach. In both approaches, kidney mobilization outside the Gerota's fascia, temporal renal pedicle clamping and partial nephrectomy or renorrhaphy were done in a stepwise manner.ResultsDuring the study period, we had 8 patients for whom angioembolization had failed (n = 4), was not available (n = 2) or the patient could not afford it (n = 2). Median patients' age was 31 years (range 16–59 years). We did a partial nephrectomy in 2 and renorrhaphy in 6 of patients with a successful outcome. Median operative time was 2.25 h and median warm ischemia time was 26 min (range 24–42 min). After a median follow up period of 21 months, the involved renal unit, in all cases, remained functional in the postoperative intravenous urography.ConclusionMassive hemorrhage after PCNL when angioembolization failed or was not feasible due to any reason could be controlled by partial nephrectomy or renorrhaphy with the same principles as that used for surgical exploration in patients with high grade renal trauma.