Collaborative Review – Stone Disease Incidence, Prevention, and Management of Complications Following Percutaneous Nephrolitholapaxy Christian Seitz a, *, Mahesh Desai b , Axel Ha ¨cker c , Oliver W. Hakenberg d , Evangelos Liatsikos e , Udo Nagele f , David Tolley g a Department of Urology, St. John of God Hospital, Teaching Hospital of the Medical University of Vienna, Austria; b Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India; c Department of Urology, University Hospital Mannheim, Germany; d Department of Urology, University Hospital Rostock, Germany; e Department of Urology, University of Patras, Greece; f Department of Urology, General Hospital Hall in Tyrol, Austria; g Department of Urology, Western General Hospital, Edinburgh, United Kingdom 1. Introduction Percutaneous nephrolitholapaxy (PNL) has been an essential technique for 35 yr for kidney stone removal, avoiding complications of open surgery [1]. PNL is the first-line approach for large, multiple, or inferior calyx renal stones according to the European Association of Urology (EAU) guidelines [2]. PNL generally is safe EUROPEAN UROLOGY 61 (2012) 146–158 available at www.sciencedirect.com journal homepage: www.europeanurology.com Article info Article history: Accepted September 15, 2011 Published online ahead of print on September 28, 2011 Keywords: Clavien Complication Incidence Management PCNL Percutaneous nephrolitholapaxy PNL Prevention Review Urolithiasis Abstract Context: Incidence, prevention, and management of complications of percutaneous nephrolitholapaxy (PNL) still lack consensus. Objective: To review the epidemiology of complications and their prevention and management. Evidence acquisition: A literature review was performed using the PubMed database between 2001 and May 1, 2011, restricted to human species, adults, and the English language. The Medline search used a strategy including medical subject headings (MeSH) and free-text protocols with the keywords percutaneous, nephrolithotomy, PCNL, PNL, urolithiasis, complications, and Clavien, and the MeSH terms nephrostomy, percutaneous/ adverse effects, and intraoperative complications or postoperative complications. Evidence synthesis: Assessing the epidemiology of complications is difficult because definitions of complications and their management still lack consensus. For a reproduc- ible quality assessment, data should be obtained in a standardized manner, allowing for comparison. An approach is the validated Dindo-modified Clavien system, which was originally reported by seven studies. No deviation from the normal postoperative course (Clavien 0) was observed in 76.7% of PNL procedures. Including deviations from the normal postoperative course without the need for pharmacologic treatment or inter- ventions (Clavien 1) would add up to 88.1%. Clavien 2 complications including blood transfusion and parenteral nutrition occurred in 7%; Clavien 3 complications requiring intervention in 4.1.%; Clavien 4, life-threatening complications, in 0.6%; and Clavien 5, mortality, in 0.04%. High-quality data on complication management of rare but poten- tially debilitating complications are scarce and consist mainly of case reports. Conclusions: Complications after PNL can be kept to a minimum in experienced hands with the development of new techniques and improved technology. A modified procedure-specific Clavien classification should be established that would need to be validated in prospective trials. # 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved. * Corresponding author. St. John of God Hospital, Teaching Hospital of the Medical University of Vienna, Johannes von Gott Platz 1, 1020 Vienna, Austria. Tel. +43 1 211213550; Fax: +43 1 211213552. E-mail address: drseitz@gmx.at (C. Seitz). 0302-2838/$ – see back matter # 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2011.09.016