Open Journal of Nephrology, 2011, 1, 15-18
doi:10.4236/ojneph.2011.12003 Published Online December 2011 (http://www.SciRP.org/journal/ojneph)
Serious Deterioration of Renal Function after Percutaneous
Nephrolithotomy: A Case Report
Heng Zhang, Houyong Zhou, Bo Song, Zhansong Zhou, Longkun Li*
Urology Centre, Southwest Hospital, Third Military Medical University, Chongqing, China
Received November 4, 2011; revised November 29, 2011; accepted December 11, 2011
Abstract
A 25-year-old man presented with stones in left kidney received the left Percutaneous nephrolithotomy
(PCNL) with holmium laser lithotripsy. All the stones were successfully removed, and all the results were
normal in the first three months followup. However, a deterioration of renal function was confirmed two
years later. No mechanical obstruction was found with ureteroscopy. The deterioration of renal function may
be induced by high internal renal pelvis pressure, injury of the laser energy, potential functional obstruction,
and/or ischemia-reperfusion injury.
Keywords: Percutaneous Nephrolithotomy, Renal Function, Deterioration
1. Introduction
Percutaneous nephrolithotomy (PCNL) is considered to
be one of the standard methods for kidney stones, due to
its advantages of relative high successful rate of stone
clearance, little bleeding and short-time hospitalization.
However, this technique is no t absolutely free from com-
plications, such as bleeding, pelvis perforation, calices
renales laceration, pleural effusion, intestinal perforation,
fluid leakage, urine leakage, infection and renal micro-
vascular arteriovenous fistula [1]. So far, PCNL is still
thought to be safe for renal function with o ptimal results,
but still lack of long-term and systematic research. Here,
we report a case of serious damage of kidney function
after PCNL.
2. Case Presentation
A 25-year-old man presented with left lumbodynia and
percussion pain was confirmed to be with stones in the
lower calices of the left kidney by KUB + IVP. By ultra-
sonography, the left kidney was 164 mm × 94 mm with
mild hydrocephalus, 14 mm of renal sinus interval, and
kidney stone (12 mm × 10 mm) in lower calices renales,
(Figure 1). A normal function in right kidney (filtration
rate of 41.52 ml/min) and a slightly decrease in left (fil-
tration rate of 35.76 ml/min) were revealed by ECT. The
serum creatinie and urea nitrogen were normal. The pa-
tient declined any history of hypertension, diab etes, chronic
nephritis or nephrotic syndrome.
The patient received the left PCNL with holmium laser
lithotripsy under general anesthesia. A single percutane-
ous renal nephrostomy pathway was obtained under ul-
trasonic guidance. The calices were successfully removed
by holmium laser disintegration via a 16F nephrostomy
sheath, with the perfusion flow of 300 mL/min and pres-
sure of 194 mmHg. The whole op eration time (including
the pre-operational catheter implant) was about one hour,
and the litro tripsy time was 25 minutes. The b lood loss wa s
about 50 mL without any temporary postoperative com-
plications. The nephrostomy catheter was removed one
week later and double pigtail stent was removed after a
month.
All the results were normal with a close followup for
three months. Unfortunately, due to some private reasons,
the patient himself quit the further clo se followup. When
he came back two years later, the ultrasonography gram
revealed a significant expanded left kidney (164 mm ×
94 mm), filled with liquid inside and little kidney paren-
chyma (Figure 2). No Kidney stone was found. A dete-
rioration of renal function was confirmed in the left kid-
ney by ECT, with normal in right kidney as a control.
The filtration rate of right kidney was 47.15 ml/min and
the left was 8.31 ml/min. No mechanical obstruction was
confirmed with ureteroscopy. After a deep communica-
tion, the patient himself chosed a close follow-up rather
than further interventions.

H. ZHANG ET AL.
16
(a) (b)
(c) (d)
Figure 1. Pre-operational detection of renal function. (a) diuresis gram. LK: left kidney. RK: right kidney; (b) ultrasono-
graphic gram of the left kidney. A mild hydronephrosis was confirmed. LK: left kidney; ST: stone; (c) plain film of KUB.
Arrow: stone in the left kidney; (d) IVP. With mild hydronephrosis and renal function damage.
(a) (b)
(c) (d)
Figure 2. Post-operative detection of renal function. (a) diuresis gram. LK: left kidney. RK: right kidney; (b) ultrasono-
graphic gram of the left kidney. A serious hydronephrosis w a s c on f ir m e d; (c ) M RU . Si g ni f ic a nt h y dr o ne p hr o si s w as r ev e al e d i n
the left kidney; (d) IVP. Almost no contrast in the left kidney area.

17 H. ZHANG ET AL.
3. Disscusion
PCNL, due to its high success rate of stone clearance and
minimally invasive characteristics, has become the pre-
ferred method for renal and upper ureteral stones, espe-
cially the complex renal calcu li [2]. Despite the evidence
of its safety and efficacy either in adult and pediatric pa-
tients [3], or in pregn ant women [4], PCNL still beh aves
with some complications, including the damages on the
renal function. It was generally believed that the upper
urinary tract obstruction, infection and interstitial renal
scar caused by kidney stones, will eventu ally resu lt in the
damage of renal function. Segura and Liou et al. reported
that PCNL could effectively remove the stones and re-
lieve the obstruction, to maintain or even improve the re-
nal function [5,6]. Regarding to long-term effect, there are
several reports. Kuzgunbay et al. reported that most pa-
tients presenting with kidney-stome disease and ren al in-
sufficiency experience improvement or stabilization of renal
function after PCNL [7]. In another study, Kuzgunbay
et al. reported that patients underwent PCNL ia an ade-
quate treatment modality even in the presence of com-
plete staghorn calculi, comorbid diseases or previous ip-
silateral renal surgery [8]. In another study carried by
El-Nahas et al., it was reported that long-term functional
results of PCNL were satisfactory as 91.5% of kidneys
showed stable or improved GFR [9].
In this case, a serious deterioration of renal function
after percutaneous nephrolithotomy was confirmed. The
preoperative renal function had just mildly declined, but
almost completely lost after PCNL two years later, with-
out an y evidence of secondary ureteral obstruction, chron ic
ne phritis or nephrotic syndrome. Theoretically, there seems
to be some potential mechanisms associated with the renal
function deterioration, such as: 1) high internal renal pel-
vis pressure, due to the necessary pressure by irrigation
for high qualified observation view and stone removal
[10]. But when the perfusion pressure rises to 300 mmHg,
the intrapelvic pressure may rise to more than 40 cmH2O,
which may result in pyelosinus, pyelovenous, and/or pye-
lolymphatic backflow. 2) Injury of the laser energy. La-
ser could disintegrate the stone with delicacy, but could
result in the risk of perforation and injury to the urothe-
lium at the same time. 3) Potential func tional obstruction.
If the pelvis-uretheral junction was damaged, the ureteral
peristaltic movement might be depressed, which might
cause a secondary fun ctional obstru ction. 4) Ischemia-re-
perfusion injury. Once the renal interstitium edema gra-
dually increased, the pressure of interstitium would ex-
ceed that of the renal arteries, resulting in the renal ische-
mia-reperfusion injury, stagnation of artery blood flow
and formation of micro-thrombosis. Even the ischemic
renal necrosis and fibrosis, which influenced by stone
si ze, operation time, preoperative renal function, blood loss
and blood pressure control and so on, can cause the damage
to the renal function. Moreover, the renal function dete-
rioration was correlated with the long-time infection th at
caused by kidney stone, intraoperative mucosal injury,
residual stones and indwelling double-pigtail stent, which
may result in the chronic kidney inflammation and fibro-
sis [11]. Moreover, although the patient was diagnosed
without any metabolic adnormalities, he had not been deeply
checked up. These would remind us to pay attention to
the patients underwent PCNL.
In conclusion, PCNL is still considered as a safe and
effective endoscopic technique for urinary stones. But we
should pay more attention to preserve the renal function
in PCNL, including to adopt small tract, reduce p erfusion
pressure and bleeding, shorten operation time, control preo-
perative and postoperative urinary tract infections, and
maintain the patency of the urin ary drainage.
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