Predisposing factors for angioembolization in persistent hematuria after percutaneous nephrolithotomy: a retrospective analysis.

Abstract

Background: Hemorrhage is one of the most significant complications of percutaneous nephrolithotomy (PCNL) and may lead to clinically significant persistent hematuria requiring digital subtraction angiography (DSA) and transcatheter arterial embolization (TAE). Identifying predictors of TAE may improve perioperative planning and risk stratification.

Objectives: To determine predictors of need for TAE in patients evaluated with DSA for persistent post-PCNL hemorrhage.

Design: Single-center retrospective observational study.

Methods: From 2021 to 2024, a total of 2947 tubeless PCNL procedures were performed at our institution. Consecutive adult patients who developed clinically significant persistent post-PCNL hemorrhage and underwent DSA were assessed. Persistent hematuria was operationally defined as severe visible hematuria persisting for >24 h despite conservative management or recurrent severe hematuria after initial stabilization. DSA referral followed predefined escalation criteria after failure of conservative measures, including hemodynamic instability, Hb drop ⩾3 g/dL within 24 h or progressive decline, transfusion requirement ⩾2 units within 24 h, and/or recurrent clot retention requiring clot evacuation and/or continuous bladder irrigation. TAE was performed only when DSA demonstrated a culprit vascular lesion.

Results: The mean age of the study population was 55.1 ± 10.6 years, and 68% were male. Among the 100 patients who underwent DSA for persistent post-PCNL hemorrhage, 36 (36%) required TAE, while 64 (64%) had normal angiographic findings and were managed conservatively. On multivariable logistic regression analysis, diabetes mellitus (odds ratio (OR) 7.42), larger stone size (OR 1.27 per mm), higher stone density (OR 1.007 per Hounsfield unit), greater skin-to-stone distance (OR 1.14 per mm), and longer operative time (OR 1.18 per minute) independently predicted the need for TAE. Pseudoaneurysm was identified in 77.8% of embolized patients and arteriovenous fistula in 22.2%. Selective coil embolization achieved 100% clinical success without the need for repeat embolization, surgical exploration, or nephrectomy.

Conclusion: Among patients undergoing DSA for clinically significant persistent post-PCNL hemorrhage, diabetes mellitus, larger stone size, higher stone density, greater skin-to-stone distance, and longer operative time were independently associated with the need for TAE.