Life-Threatening Post-Percutaneous Nephrolithotomy Hemorrhage with Negative Renal Angiography Successfully Managed Conservatively: A Case Report

Abstract

Life-threatening haemorrhage following percutaneous nephrolithotomy (PCNL) is an uncommon but serious complication, most commonly resulting from renal vascular injuries such as pseudoaneurysm or arteriovenous fistula, which are usually diagnosed and treated using selective renal angiography with transcatheter embolisation. Management becomes particularly challenging when severe bleeding occurs despite negative angiographic findings. We report the case of a 29-year-old man who developed massive haemorrhage on the first postoperative day after an uncomplicated ultrasound-guided PCNL performed through a single posterior lower calyceal access for a 22-mm solitary renal pelvic stone. The patient presented with severe bleeding from the nephrostomy tract, haemodynamic instability, and a decrease in haemoglobin from 13.5 to 8.1 g/dL. Contrast-enhanced computed tomography demonstrated a large right retroperitoneal haematoma, whereas selective renal angiography revealed no pseudoaneurysm, arteriovenous fistula, or active contrast extravasation. The patient received aggressive resuscitation with four units of packed red blood cells and fresh frozen plasma. Following initial resuscitation and haemodynamic stabilisation, conservative management was continued with intensive monitoring, serial haemoglobin measurements, and repeated imaging, resulting in complete recovery without embolisation or surgery. He was discharged on postoperative day 12 with preserved renal function. This case highlights that negative renal angiography does not exclude clinically significant haemorrhage and that carefully selected, haemodynamically stable patients may be successfully managed conservatively under close clinical surveillance.