Management of Colon Perforation During Percutaneous Nephrolithotomy: 12 Years of Experience in a Referral Center

Introduction

Colonic injury is a rare complication of percutaneous nephrolithotomy (PCNL). In most published series, colon injury is reported at a rate of <1% of cases in prone position. ^{1 –4}

The main principle for conservative management of retroperitoneal colon perforation is separate drainage of the colon and urinary collecting system. The offending nephrostomy tube is pulled back into the colon and a retrograde ureteral stent is inserted. The patient is given broad-spectrum antibiotic and bowel rest for a few days, and if there is no evidence of peritonitis, low-residue diet can be started. Colonic tube is removed after confirming absence of nephrocolonic fistula by contrast study. ^1,2,5 If a patient develops peritonitis or sepsis, open surgical repair may be required. ^1,2 Nevertheless, because of the rarity of this complication and the limited number of reported patients, there are still controversies on its management protocol. ⁶ Some authors suggested the insertion of retroperitoneal drains instead of colostomy drain ⁵ and some argue against bowel rest. The largest published series of colon perforation during PCNL by El-Nahas et al. included only 15 patients. ¹

We present our experience with management of colon perforation in PCNL during 12 years' of experience in a referral center with more than 11,000 PCNL operations.

Materials and Methods

From August 2004 to September 2016, 11,376 PCNL procedures were performed in our center. PCNL is typically performed in our center under fluoroscopic control in prone position as summarized hereunder. After retrograde ureteral catheterization under general anesthesia and securing the patient in the prone position, contrast material is injected through the ureteral catheter. Then, percutaneous access is achieved under C-arm fluoroscopy guidance using an 18-gauge needle. The puncture site is selected medial to the posterior auxiliary line. The nephrostomy tract is dilated by single step Amplatz dilators. Then an Amplatz sheath is passed into the calix over the dilator. We use 24F rigid nephroscope to localize calculi within the pelvicaliceal system and stone fragmentation is done using pneumatic and/or ultrasonic Master Swiss LithoClast device.

From 2004 to mid-2007, PCNL was typically accomplished leaving a nephrostomy tube at the end of operation. After mid-2007, most PCNL procedures have been performed without insertion of nephrostomy tube at the end of operation (tubeless PCNL). Insertion of ureteral catheter is at the discretion of the operating surgeon. In tubeless PCNL, during Amplatz removal, we diligently inspect the tract to find any organ injury and specifically colon injury.

Hospital files of patients with colonic perforation were reviewed to extract patients' and operations' data, time and mode of diagnosis of colonic injury, and the management protocol in each patient.

Results

A total of 943 PCNL operations were performed between 2004 and mid-2007 and 10,433 PCNL operations were performed from mid-2007 to July 2016.

Colon perforation was observed in 17 patients during the study period. Details of these patients' demographic data and their operative data are given in Table 1.

Our first three cases of colon perforation were diagnosed 2 to 3 days after standard PCNL and were managed with pulling back the nephrostomy tube into the colon and retrograde ureteral Double-J stent insertion. The first two patients were subsequently treated by abdominal exploration and primary repair because of abdominal tenderness in the operation side and our fear from delayed intervention in colonic injuries. In the third patient, colostomy tube was spontaneously dislodged out of the body and the patient refused reinsertion of the tube or any other invasive intervention. He was managed by broad spectrum antibiotics and bowel rest. He did not develop persistent or high-grade fever or signs/symptoms of peritonitis. Consequently, the experience of this patient together with scant reports of tubeless management of colon injuries during PCNL ⁷ promoted us to try management of colon injury during PCNL with no drain insertion into colon or retroperitoneum when the diagnosis was made intraoperatively or in the early postoperative period in stable patients. Therefore, after this case, a substantial number of our colon perforation cases were managed without insertion of colonic or retroperitoneal drain at the discretion of the operating surgeon as explained hereunder.

In seven patients, colon perforation became evident upon introducing the nephroscope into the access sheath where dilation had fallen short of renal parenchyma, leaving the Amplatz sheath within the bowel. In these patients, the operation was terminated without taking another access for stone treatment. These patients had a subtle postoperative course. In five patients, colon perforation was evident during nephroscope and Amplatz sheath removal when the access tract was continuously observed. Retroperitoneal drain was inserted only in one of these patients (Table 1). In two patients, the diagnosis was made postoperatively incidentally in postoperative kidney, ureter, and bladder radiograph (Fig. 1) or in work-up for fever and/or abdominal pain. In one of these patients, placement of retroperitoneal drain and urinary Double-J stent was necessary because of postoperative urinary leak and urinary collection in the flank (Table 1).

OPEN IN VIEWER

FIG. 1.

Preoperative (A) KUB and postoperative (B) KUB in a patient with incidental diagnosis of colon injury based on contrast in colon on postoperative KUB. KUB = kidney, ureter, and bladder radiograph.

All patients with colon perforation were kept nil per os (NPO) for 2 to 4 days. Broad spectrum antibiotics were started upon diagnosis and patients were kept hospitalized. Prescribed antibiotics consisted of intravenous preparations of (1) a cephalosporin (usually cephalothin or ceftriaxone), (2) with an aminoglycoside (usually gentamycin or amikacin), and (3) with metronidazole.

Then low-residue diet was started for patients. In two diabetic patients, total parenteral nutrition was started based on consultation with general surgery colleagues. Patients were requested to have defecation before discharge. Patients were followed in outpatient clinic at 2 and 6 weeks after discharge with physical examination, abdominopelvic ultrasonography, serum creatinine, and blood urea nitrogen.

In tubeless PCNLs with colon perforation, no need for open exploration or repair of colon perforation was observed. Low-grade fever lasting <48 hours was observed in five patients. Temporary passage of liquid stool was observed in two patients lasting <24 hours and with total amount <100 mL. Complications according to Dindo–Clavien grade were at least grade II based on the need for starting wide spectrum antibiotics and bowel rest. Clavien grade II complication was observed in 13 patients, grade IIIa in 1 patient, and grade IIIb in 3 patients.

During follow-up visits, no consequence because of colon perforation was observed in patients' physical examination. Patients had normal bowel habits. Abdominopelvic ultrasonography and renal functional tests were within normal limits. Six weeks after the operation, no patient had evidence of urinary or colonic extravasation on computed tomography with intravenous and oral contrast.

As already explained, in nine patients colon perforation was diagnosed after entry and before lithotripsy in whom the PCNL was terminated upon diagnosis of colon injury. Four of these patients referred for later PCNL and underwent a second uneventful PCNL with a more superior and medial access tract.

Discussion

PCNL is the treatment of choice for large renal stones. Complications occur at a rate of 3% to 8%. ^1,6 One rare but potentially serious complication is colon perforation. There is still little consensus on the management strategy for colon perforation. ^1,6 Some authors have reported effective observation of stable patients or patients who have denied further treatment. ^2,7,8 Some surgeons have advocated the adequacy of observing stable patients with broad spectrum antibiotics and ureteral Double-J stent. ¹ In 1998, Wolf et al. summarized the principles of managing colon perforation, which included adequate drainage of colon and urinary collecting system. ⁹ The currently advocated and usual treatment of colon perforation during PCNL is to insert a colostomy drain or a retroperitoneal drain. An important point to consider is immediate diagnosis to prevent potential complications. ¹⁰ In a recent review article on the management of PCNL complications, insertion of retroperitoneal drain in case of colon injury was suggested. ⁵ Nevertheless, the total number of reported cases of colonic perforation is <60 and most reports are in series with a few cases of colon injury, ^1,5 making evidence-based recommendations on the management protocol for colon perforation difficult. The strength of recommendation for management of colonic perforation is grade D.

El-Nahas et al. managed 13/15 colon perforations conservatively with drainage tube insertion into the colon and removal after confirming complete healing of the injured colon by barium enema study on the 8th postoperative day. In their study, colocutaneous fistula at the tube site persisted in two patients despite conservative management and required temporary colostomy. ¹

Kachrilas et al. reviewed 5 cases of colon perforation (0.3%) in 1620 cases of PCNL >10-year experience. Most of colon perforations (4/5) occurred in their initial 50 cases of supine PCNL and were managed conservatively with a colostomy tube and Double-J stent without further complications. ¹¹

Gerspach et al. reported five cases of colon injury in >1000 PCNL operations performed between 1990 and 1995. One case was diagnosed in the recovery room by nephrostography, which was performed because of fever. This patient was managed by removing the nephrostomy, bowel rest, insertion of Double-J stent and Foley's catheter and broad spectrum antibiotics with no sequela. He also reported another case of colon perforation diagnosed 2 days after the operation who did not accept any other treatment after removal of nephrostomy tube and was managed by observation with no complications. ²

In most of the published series, diagnosis has been made postoperatively by leakage of fecal material from nephrostomy or patients' signs and symptoms, which necessitated imaging studies. ⁶ The cases of colon injuries diagnosed intraoperatively are really few and constitute 24% of all reported cases of colonic perforation. More than 75% of cases were diagnosed postoperatively during investigations for patients' complaints. Therefore, the experience for management of colonic perforation that is diagnosed during operation or in the early postoperative period is really scarce. ^1,2

The most important predisposing factor in occurrence of colon injury is the presence of retrorenal colon. ¹ The frequency of retrorenal colon is estimated to be between 1% and 10% in different studies ^{12 –14} but the observation of colon injury in PCNL is much lower and around 0.2% to 0.8%. ¹⁵ In the Clinical Research Office of the Endourology Society (CROES) study, colon injury was reported in <20 patients giving an estimate of <0.3%. ^16,17 In this study, five cases were diagnosed only by carefully watching the percutaneous tract while withdrawing the nephroscope in tubeless patients.

One decade has passed since the introduction of tubeless PCNLs and many articles have asserted the safety of tubeless PCNLs in a large number of PCNL candidates. ^{18 –20} Tubeless PCNLs provide a unique opportunity to observe the access tract during withdrawal of nephroscope. Careful observation of the access tract in case of a need for inspection of the tract for any reason like bleeding had previously been asserted by some authors. ^9,10 If colon injury is diagnosed by inspecting its inner mucosal surface, the diagnosis is made intraoperatively and conservative measures are immediately considered. In cases of suspicious colon injury during tract observance, imaging studies will determine the occurrence of injury. Our series indicates that in cases of intraoperative diagnosis, if no colonic or retroperitoneal drain is inserted, a benign course is anticipated in most patients with conservative treatments. It is possible that omission of colonic drain will help to heal the perforated colon more rapidly while the patient is on bowel rest.

We think that for stable patients in whom the diagnosis has been made intraoperatively or in the early postoperative period, a benign course is expected by simply observing the patient on broad spectrum antibiotics and a urinary drainage without inserting a colostomy or retroperitoneal drain. We think that omission of the colostomy drain can speed up the healing of colon wall while the patient is NPO with little fecal material and can theoretically decrease the chance of colocutaneous fistula. We further advise to investigate the access tract in PCNL cases, which are decided to be tubeless after termination of nephroscopy and during withdrawal of nephroscope to diagnose colon injuries in the earliest possible time.

Conclusions

Colon perforation in PCNL, which is diagnosed intraoperatively or in the early postoperative period, can be managed by broad spectrum antibiotics, bowel rest, and urinary Double-J and Foley's catheter insertion in stable patients without insertion of colonic or retroperitoneal drain. Close monitoring of the patient is recommended for signs/symptoms of peritonitis or persistent fever, which usually indicate the need for a more aggressive intervention. In cases of delayed diagnosis, standard protocols should be performed, including insertion of colonic or retroperitoneal drain.