PCNL, Clotting Status and Bleeding Risk: Is Pre-operative Clotting Status Justified?
Goonewardene SS*1, Dickinson A2
1Guys and St Thomas Hospitals, London
2Plymouth Hospitals NHS Trust
Patients and Methods
We conducted a retrospective analysis of 100 patients undergoing PCNL over the past year under a single surgeon (AD). We recorded pre-operative clotting status, post-operative haemorrhage, blood transfusion rate and complications. In addition, stent/ nephrostomy insertion, bleeding risk and length of stay was recorded.
32% of procedures were done on the right, 68% on the left. 62% had a nephrostomy inserted post procedure, 6% had antegrade stents. Complete stone clearance was achieved in 72%. Bleeding risk was high in 2 %. The mean length of stay was days 3.0 (range 1 - 9). Average pre-operative APTT ratio was 1.0 (range 0.9 – 1.2), the average INR was 0.9 (range 0.9 – 1.5). Average post-operative haemoglobin drop was 0.8. Post-operative haemorrhage requiring transfusion occurred in no patients. Complications included: blood clots/ minimal bleeding 6.0 %, sepsis in 6%. None of these patients were re-admitted with haemorrhage.
We demonstrate that patients have no significant complications related to pre-operative clotting status. We concluded pre-operative clotting status is not required as routine before this procedure. Results are compared with other published data.
Keywords: Percutaneous Nephrolithotomy; Clotting Status Pre-Operatively
Percutaneous nephrolithotomy (PCNL) monotherapy shows superior results in terms of stone clearance, cost-effectiveness, and also early postoperative convalescence when compared with shockwave lithotripsy (SWL) or open stone surgery [1-3].
PCNL monotherapy as the most effective approach to large volume renal stone disease with a superior overall stone-free rate of 78% .Complication rates as high as 83% have been reported [4-6]. Intraoperative and postoperative hemorrhage is one of the most frequent complications associated with PCNL. Transfusion rates of up to 34% have been reported . About 1% of all PCNL patients complain of delayed postoperative bleeding .
Both intraoperative and postoperative bleeding are a matter of concern for any patient undergoing PCNL. Kukreja et al  reported an 8% blood transfusion rate in 301 PCNL procedures in patients with normal clotting parameters, and Kessaris et al. reported a 0.8% incidence of post-PCNL bleeding requiring embolization . We aim To investigate the intra- and postoperative hemorrhage of percutaneous nephrolithotomy via the standard nephrostomy tract.
Prior papers have demonstrated stone burden was the most influencing predictive factors for PCNL blood loss . Amount of blood requested and cross-matched was found to be much greater than actual blood loss . Even in patients with pre-operative clotting problems, with careful perioperative regulation of anticoagulation therapy and clotting parameters, percutaneous nephrostolithotomy can be performed safely and efficiently in properly selected patients requiring long-term anticoagulation .
A retrospective analysis was conducted among 100 patients undergoing percutaneous nephrolithotomy under a single surgeon (AD). During the operations, all the nephrostomy tracts were dilated with Amplatz to F24 size after successful puncture . The stones were shattered and removed by EMS lithotrity system. We recorded pre-operative clotting status, post-operative haemorrhage, blood transfusion rate and complications. In addition, stent/ nephrostomy insertion, bleeding risk and length of stay was recorded.
32% of procedures (16) were done on the right, 68% (34) on the left. 62% (31) had a nephrostomy inserted post procedure, 6% (3) had antegrade stents Complete stone clearance was achieved in (36) 72. All patients were stratified as normal clotting status. The mean length of stay was 3.0 days (range 1 - 9). Average pre-operative APTT ratio was 1.0 (range 0.9 – 1.2), the average INR was 0.9 (range 0.9 – 1.5)- all has normal pre-operative clotting status. Average post operative haemoglobin drop was 0.8. Post operative haemorrhage requiring transfusion occurred in no patients. Complications included: blood clots/ minimal bleeding (3) 6.0 %, sepsis in (3) 6% Clavien-Dindo grade 2 . None of these patients were re-admitted with haemorrhage. No patients required a return to theatre.
In addition to clotting status, adequate access is a key factor . Whilst USS input has been shown to be part of this, surgeon experience is the core component to lack of complications . 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 .
We conclude according to risk stratification, patients have no significant complications related to pre-operative clotting status. Percutaneous nephrolithotomy through standard nephrostomy tract is safe and does not increase the risk of bleeding with careful operation.
1. Preminger GM, Assimos DG, Lingeman JE, Nakada SY, Pearle MS et al. AUA Nephrolithiasis Guideline Panel. Chapter 1: AUA guideline on management of staghorn calculi: diagnosis and treatment recommendations. J Urol. 2005, 173(6):1991–2000.
6. Liatsikos EN, Kapoor R, Lee B, Jabbour M, Barbalias G et al. Angular percutaneous renal access”. Multiple tracts through a single incision for staghorn calculous treatment in a single session. Eur Urol. 2005, 48(5): 832-837.
10. Rasyid N, Birowo P, Syahputra FA, Matondang FA, Noviandrini E et al. Blood loss predictive factors and transfusion practice during percutaneous nephrolithotomy of kidney stone: A prospective study. Journal of Endourology. 2014, 28: A194.
Cite this article: Goonewardene. PCNL, Clotting Status and Bleeding Risk: Is Pre-operative Clotting Status Justified?. J J Nephro Urol. 2016, 3(1): 024.