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

Abstract

The management protocol for colon perforation during percutaneous nephrolithotomy (PCNL) is controversial because of the scarcity of reported cases and their management diversity. We present our management experience of colon perforation during PCNL. All PCNL operations between April 2004 and September 2016 in our center (N = 11,376) were reviewed for the occurrence and management of colon perforation. We typically performed PCNL with insertion of nephrostomy tube before mid-2007. After mid-2007, we typically performed tubeless PCNL and inspected access tract for evidence of organ injury especially colon perforation during nephroscope removal. Seventeen colon perforations happened during the study period. The first three cases were diagnosed postoperatively and in two patients open surgery was employed for treatment. The next 14 cases were diagnosed intraoperatively (n = 12) or in the early postoperative period (n = 2) and were managed by broad spectrum antibiotics, bowel rest, and urinary Double-J and Foley's catheter insertion. Percutaneous retroperitoneal drain was inserted for only one patient after intraoperative diagnosis of colon perforation. The other 13 patients were managed without insertion of such drains. For one patient, postoperative insertion of retroperitoneal drain was attempted because of collection of urine. In other patients (n = 12), the management was effective with no need for an operation. Complications according to Clavien-Dindo grade in these 17 patients were grades II, IIIa, and IIIb in 13, 1, and 3 patients, respectively. Colon perforation during PCNL that is diagnosed intraoperatively or in the early postoperative period can be managed conservatively. It seems possible not to insert colostomy or retroperitoneal drains in stable patients with early or intraoperative diagnosis. In cases of delayed diagnosis, or deterioration of the patient on tubeless management, the standard protocol should be performed including insertion of colonic or retroperitoneal drain or surgery especially in patients with signs or symptoms of peritonitis or persistent fever.