Renal calyx access does not affect intraoperative blood loss in percutaneous nephrolithotomy: a single-center retrospective study


  • Phawat Luangtangvarodom Division of Urology, Department of Surgery, Thammasat University Hospital, Pathum Thani, Thailand
  • Teerayut Tangpaitoon Division of Urology, Department of Surgery, Thammasat University Hospital, Pathum Thani, Thailand
  • Chatchawet Liwrotsap Division of Urology, Department of Surgery, Thammasat University Hospital, Pathum Thani, Thailand



Nephrolithotomy, percutaneous, urinary calculi, blood loss, surgical


Objective: Percutaneous nephrolithotomy (PCNL) is one of the most effective ways of dealing with large renal calculi but also comes with a risk of intraoperative blood loss. Previous evidence is contradictory as regards the difference in blood loss between different renal calyx access. We conducted this study to compare intraoperative blood loss between different renal access calyx.

Materials and Methods: We conducted a retrospective study analyzing 132 cases of single access PCNL, dividing them into an upper pole group (n = 93) and a non-upper pole group (n = 39). Intraoperative blood loss was calculated from pre-and post-operative hematocrit level, gender, body surface area, and amount of blood transfusion. Blood loss was compared between the two groups using univariable and multivariable analysis.

Results: Overall blood loss was 500 ml (IQR 200-814 ml) with a median blood loss of 461 ml (IQR 158-738 ml) in the upper pole group and 650 ml (IQR 332-1233 ml) in non-upper pole group. Median hematocrit change was 2.9% and 3.9% in the upper and non-upper pole groups, respectively. The blood transfusion rate was 4.5% in the upper pole group and 8.3% in the non-upper pole group. The multivariable analysis did not demonstrate any statistically significant difference in average blood loss, hematocrit change or blood transfusion rate.

Conclusions: Our study did not find any significant difference in intraoperative blood loss between different renal access routes in PCNL.


Krambeck BRMAE. Surgical management for upper urinary tract calculi. In: Partin AW, Dmochowski RR, Kavoussi LR, Peters CA, editors. Campbell- Walsh-Wein Urology. 12th ed. Philadelphia: Elsevier; 2021. p. 2094-113.

Sampaio FJB. surgical anatomy of the kidney in the prone, oblique, and supine positions. In: Smith AD, Badlani GH, Preminger GM, Kavoussi LR, editors. Smith’s textbook of endourology. 3rd ed. New Jersey: Wiley; 2012. p. 63-94.

Tan J, Chen B, He L, Yin G, Jiang Z, Yao K, et al. Renal access through the inferior calyx is associated with higher risk of severe bleeding after percutaneous nephrolithotomy. Arch Med Sci 2015;11:340-5.

Oner S, Okumus MM, Demirbas M, Onen E, Aydos MM, Ustun MH, et al. Factors influencing complications of percutaneous nephrolithotomy: a single-center study. Urol J 2015;12:2317-23.

Oner S, Karagozlu Akgul A, Demirbas M, Onen E, Aydos M, Erdogan A. Upper pole access is safe and effective for pediatric percutaneous nephrolithotomy. J Pediatr Urol 2018;14:183.e1-8.

Ketsuwan C, Pimpanit N, Phengsalae Y, Leenanupunth C, Kongchareonsombat W, Sangkum P. Peri-operative factors affecting blood transfusion re- quirements during PCNL: a retrospective non-randomized study. Res Rep Urol 2020;12:279-85.

Türk C, Knoll T, Petrik A, Sarica K, Straub M, Seitz C. Guidelines on urolithiasis. European Association of Urology 2011.

Fernbach S, Maizels M, Conway J. Ultrasound grading of hydronephrosis: introduction to the system used by the society for fetal urology. Pediatr Radidol 1993;23:478-80.

de la Rosette JJ, Opondo D, Daels FP, Giusti G, Serrano A, Kandasami SV, et al. Categorisation of complications and validation of the Clavien score for percutaneous nephrolithotomy. Eur Urol 2012;62:246-55.

Syahputra FA, Birowo P, Rasyid N, Matondang FA, Noviandrini E, Huseini MH. Blood loss predictive factors and transfusion practice during percutaneous nephrolithotomy of kidney stones: a prospective study. F1000Res 2016;5:1550.

Kukreja R, Desai M, Patel S, Bapat S, Desai M. Factors affecting blood loss during percutaneous nephrolithotomy: prospective study. J Endourol 2004;18:715-22.

Turna B, Nazli O, Demiryoguran S, Mammadov R, Cal C. Percutaneous nephrolithotomy: variables that influence hemorrhage. Urology 2007;69:603-7.

Amri M, Naouar S, Ben Khalifa B, Hmidi N, Braiek S, ElKamel R. Predictive factors of bleeding and fever after percutaneous nephrolithotomy. Tunis Med 2019;97:667-74.

Kim HY, Choe HS, Lee DS, Yoo JM, Lee SJ. Is Absence of hydronephrosis a risk factor for bleeding in conventional percutaneous nephrolithotomy. Urol J 2020;17:8-13.

Ketsuwan C, Kongchareonsombat W, Sangkum P, Kijvikai K, Sananmuang T, Leenanupunth C. Perioperative renal calculus factors affecting percutaneous nephrolithotomy outcomes. Thai J Urol 2019;40:01-8.

Yamaguchi A, Skolarikos A, Buchholz NP, Chomon GB, Grasso M, Saba P, et al. Operating times and bleeding complications in percutaneous nephrolithotomy: a comparison of tract dilation methods in 5,537 patients in the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study. J Endourol 2011;25:933-9.

Haghighi R, Zeraati H, Ghorban Zade M. Ultra-mini-percutaneous nephrolithotomy (PCNL) versus standard PCNL: a randomised clinical trial. Arab J Urol 2017;15:294-8.

Munver R, Delvecchio FC, Newman GE, Preminger GM. Critical analysis of supracostal access for percutaneous renal surgery. J Urol 2001;166:1242-6.

Hurle R, Poma R, Maffezzini M, Manzetti A, Piccinelli A, Taverna G, et al. A simple mathematical

approach to calculate blood loss in radical prostatectomy. Urol Int 2004;72:135-9.

Viprakasit DP, Miller NL. Upper calyx access for percutaneous nephrolithotomy. In: Smith AD, Badlani GH, Preminger GM, Kavoussi LR, editors. Smith’s Textbook of Endourology. 3rd ed. New Jersey: Wiley; 2012. p. 206-13.

Singh R, Kankalia SP, Sabale V, Satav V, Mane D, Mulay A, et al. Comparative evaluation of upper versus lower calyceal approach in percutaneous nephrolithotomy for managing complex renal cal- culi. Urol Ann 2015;7:31-5.

Akman T, Binbay M, Sari E, Yuruk E, Tepeler A, Akcay M, et al. Factors affecting bleeding during percutaneous nephrolithotomy: single surgeon experience. J Endourol 2011;25:327-33.

Ullah S, Ali S, Karimi S, Farooque U, Hussain M, Qureshi F, et al. Frequency of blood transfusion in percutaneous nephrolithotomy. Cureus 2020;12: e11086.

Phaijitwichian S. One-shot dilation versus metallic dilation technique for access in percutaneous nephrolithotomy: comparison of efficacy, access time and fluoroscopic time. Insight Urol 2021;42:154-9.

Labate G, Modi P, Timoney A, Cormio L, Zhang X, Louie M, et al. The percutaneous nephrolithotomy global study: classification of complications. J En- dourol 2011;25:1275-80.

Lojanapiwat B, Prasopsuk S. Upper-pole access for percutaneous nephrolithotomy: comparison of supracostal and infracostal approaches. J Endourol 2006;20:491-4.

Sukumar S, Nair B, Ginil KP, Sanjeevan KV, Sanjay BH. Supracostal access for percutaneous nephrolithotomy: less morbid, more effective. Int Urol Nephrol 2008;40:263-7.

Shilo Y, Kleinmann J, Zisman A, Peer A, Lindner A, Siegel YI. Comparative morbidity for different accesses in percutaneous nephrolithotripsy. Harefuah 2006;145:107-10, 166.




How to Cite

Luangtangvarodom, P., Tangpaitoon, T., & Liwrotsap, C. (2022). Renal calyx access does not affect intraoperative blood loss in percutaneous nephrolithotomy: a single-center retrospective study. Insight Urology, 43(1), 51–57.



Original article