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

Objectives: To 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 methods: Between 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. Results: During 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 2.25h and median warm ischemia time was 26min (range 24-42min). After a median follow up period of 21 months, the involved renal unit, in all cases, remained functional in the postoperative intravenous urography. Conclusion: Massive 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.