title: Massive hemorrhage after percutaneous nephrolithotomy: saving the kidney when angioembolization has failed or is unavailable.
abstract: OBJECTIVE
  To describe the management protocol in cases with massive hemorrhage after percutaneous nephrolithotomy (PCNL) with a failed angioembolization or when angioembolization is not available.
  
  
  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 2.25 h and median warm ischemia time was 26 min (range 24-42 min). After a median follow up period of 21 months, the involved renal unit, in all cases, remained functional in the postoperative intravenous urography.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Urology, Shiraz University of Medical Sciences, Shiraz, Iran; Laparoscopy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. Electronic address: aminsharifi_ar@yahoo.com.
authors.forename: Alireza
authors.initials: A
authors.lastname: Aminsharifi
authors.affiliation: Department of Urology, Shiraz University of Medical Sciences, Shiraz, Iran.
authors.forename: Dariush
authors.initials: D
authors.lastname: Irani
authors.affiliation: Department of Urology, Shiraz University of Medical Sciences, Shiraz, Iran.
authors.forename: Ali
authors.initials: A
authors.lastname: Eslahi
mesh_terms: D000293:Adolescent; D000328:Adult; D003250:Constriction; D004621:Embolization, Therapeutic / Q000379:methods; D005260:Female; D006801:Humans; D007668:Kidney / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000379:methods; D009403:Nephrostomy, Percutaneous / Q000009:adverse effects*; D061646:Operative Time; D019106:Postoperative Hemorrhage / Q000628:therapy*; D016879:Salvage Therapy / Q000379:methods*; D017211:Treatment Failure; D055815:Young Adult
keywords: Angioembolization; Bleeding; Percutaneous nephrolithotomy (PCNL); Renal calculi