Colonic Injury During Percutaneous Nephrolithotomy: A Case- Illustrated Review of Risk Factors, Diagnosis, and Management Strategies

Colonic Injury During Percutaneous Nephrolithotomy: A Case- Illustrated Review of Risk Factors, Diagnosis, and Management Strategies | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Colonic Injury During Percutaneous Nephrolithotomy: A Case- Illustrated Review of Risk Factors, Diagnosis, and Management Strategies Botao Yu, Chunling Wang, Ningying Zhou, Min Yin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8357872/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 19 You are reading this latest preprint version Abstract Background Colonic injury is a rare but potentially serious complication of percutaneous nephrolithotomy (PCNL). Owing to its low incidence and heterogeneous clinical presentation, current evidence regarding risk factors, diagnostic pathways, and optimal management remains fragmented and largely case based. Methods A structured literature review was conducted to identify published reports of colonic injury associated with PCNL from 1985 to 2025. Data on anatomical context, procedural characteristics, diagnostic timing, management strategies, and outcomes were qualitatively synthesized. A representative clinical case from our institution is presented to illustrate key diagnostic challenges and management principles identified in the literature. Results Published evidence indicates that colonic injury during PCNL occurs in approximately 0.2%–0.8% of procedures. Frequently reported risk factors include unfavorable colon–kidney anatomy (particularly retro renal or posterolateral colon), left-sided access, prone positioning, high intercostal or lateral puncture trajectories, and limited visualization during access creation. Most injuries are retroperitoneal and are diagnosed postoperatively, often prompted by symptoms disproportionate to the expected recovery course. Contrast-enhanced computed tomography (CT) plays a central role in diagnosis and in distinguishing retroperitoneal from intraperitoneal injury patterns. When recognized early, most retroperitoneal injuries can be successfully managed conservatively, whereas intraperitoneal contamination or clinical deterioration necessitates surgical intervention. Conclusions Colonic injury during PCNL is a rare but multifactorial complication arising from the interplay of anatomical, technical, and operator-related factors rather than anatomical predisposition alone. Early recognition and appropriate stratification allow conservative management in most retroperitoneal injuries, whereas intraperitoneal involvement generally necessitates surgical intervention. Percutaneous nephrolithotomy Colonic injury Renal access Risk factors Computed tomography Conservative management Figures Figure 1 1. Background Percutaneous nephrolithotomy (PCNL) is widely established as the standard treatment for large and complex renal calculi ( 1 ). Although most complications associated with PCNL are minor, injury to adjacent organs represents a rare but potentially serious event ( 2 , 3 ). Among these complications, colonic injury is particularly concerning because of its variable clinical presentation, diagnostic challenges, and the potential for significant morbidity if not promptly recognized ( 4 – 6 ). The reported incidence of colonic injury during PCNL is low, generally ranging from approximately 0.2% to 0.8%, which limits the feasibility of prospective investigation and has resulted in a predominance of case-based evidence in the literature ( 2 , 7 ). Consequently, current understanding of this complication is largely derived from individual case reports, small case series, and retrospective analyses. While these reports have traditionally emphasized anatomical risk factors, most notably the presence of a retro renal or posterolateral colon, this explanation alone does not fully account for all documented cases ( 4 , 8 – 10 ). Computed tomography (CT) based anatomical studies have demonstrated that the spatial relationship between the colon and kidney is highly variable and influenced by patient positioning, body habitus, and laterality ( 11 – 14 ). Preoperative imaging has therefore been advocated as a key preventive measure for identifying patients at increased risk. However, colonic injury has also been reported in patients without overt anatomical predisposition on preoperative imaging, suggesting that factors beyond static anatomical relationships contribute to injury risk ( 15 , 16 ). Procedural characteristics related to renal access creation have emerged as additional contributors to colonic injury. High intercostal puncture, lateral access trajectories, deviation from the posterior calyceal axis, and limited visualization during ultrasound-guided puncture have all been implicated in reported cases ( 4 , 5 , 17 ). These risks may be amplified in patients with obesity or in technically challenging access scenarios, where visualization of the needle path is suboptimal and repeated puncture attempts are required ( 18 , 19 ). In addition to anatomical and technical considerations, operator-related factors may theoretically influence the risk of colonic injury during PCNL, however, such factors have not been specifically analyzed in PCNL-related studies and are instead inferred from broader surgical literature ( 20 , 21 ). The interaction between anatomical context, procedural strategy, and operator performance likely underlies the multifactorial nature of colonic injury during PCNL. Management strategies for colonic injury range from conservative treatment to surgical intervention, depending largely on the extent of injury and the presence of intraperitoneal contamination ( 5 , 22 ). Accumulated evidence suggests that early diagnosis, particularly through cross-sectional imaging, facilitates successful nonoperative management in the majority of retroperitoneal injuries ( 23 – 25 ). Nonetheless, the absence of integrated frameworks linking risk assessment, diagnosis, and management continues to pose challenges for clinical decision making. In this context, we present a case-illustrated review of colonic injury associated with PCNL. By synthesizing published evidence on anatomical, procedural, and operator-related risk factors, diagnostic pathways, and management strategies, and contextualizing these findings with a representative clinical case, we aim to offer a clinically oriented synthesis to aid risk awareness, early recognition, and management of this uncommon but clinically significant complication. 2. Methods 2.1 Literature Review Strategy A targeted narrative review of the literature was performed to identify published reports describing colonic injury associated with PCNL between January 1985 and March 2025. PubMed was searched using combinations of procedure-related terms (“percutaneous nephrolithotomy” OR “PCNL”) and complication-related terms (“colonic injury,” “colon perforation,” OR “bowel injury”). The search was limited to human studies published in English. In addition, reference lists of relevant articles were manually reviewed to identify additional publications of relevance that may not have been captured by the initial search. 2.2 Study Selection and Data Synthesis Publications were considered eligible if they reported clinical cases, case series, retrospective analyses, or narrative or systematic reviews describing colonic injury associated with PCNL. Only studies in which colonic injury was explicitly documented and discussed were included. Studies focusing exclusively on PCNL techniques, anesthesia, or overall surgical outcomes without specific reference to colonic or bowel injury were excluded. Reports describing gastrointestinal injuries unrelated to PCNL, as well as studies addressing non-colonic bowel injuries (e.g., jejunal or duodenal injury), were excluded unless colonic involvement was specifically described. From each included publication, key information was extracted, including publication year, study design, number of reported cases, anatomical and procedural context, diagnostic timing and imaging findings, management strategies, and clinical outcomes. 2.3 Illustrative Case To complement the narrative synthesis of the literature, a representative clinical case from our institution is presented to illustrate practical diagnostic challenges and conservative management principles described in the reviewed reports. This case is included for illustrative purpose only and was not incorporated into the literature synthesis. 3. Results 3.1 Literature Identification and Overview of Included Evidence A focused PubMed search was performed to identify publications describing colonic injury in the context of PCNL. The body of literature informing this review consisted predominantly of case reports, small case series, retrospective analyses, and narrative or systematic reviews documenting PCNL-related colonic injury. The included evidence spans publications from 1988 to 2025. Key characteristics of the included studies, including publication year, number of reported cases, identified risk factors, management strategies, and clinical outcomes, are summarized in Table 1 . Table 1 Reported Colonic Injuries Associated with Percutaneous Nephrolithotomy (1988–2025) Author (Year) Cases (n) Key Risk Factors Management Strategy Outcome Rodrigues Netto (31) (1988) 1 Posteriorly located colon; close colon–kidney relationship; minimal retroperitoneal fat; lateral renal puncture Surgical management (exploratory laparotomy with colostomy) Full recovery after surgical repair Goswami (23) (2001) 1 Horseshoe kidney; retro renal colon; upper calyceal puncture Conservative management Full recovery Noor Buchholz (8) (2004) 1 Retro renal colon; extremely lateral access Surgical repair (hemicolectomy) Severe postoperative complications; eventual recovery El-Nahas (4) (2006) 15 Advanced age; horseshoe kidney; lower calyceal puncture; left-sided access; multiple tracts Conservative management in most cases; temporary colostomy in selected patients Overall favorable outcomes; recovery in all patients Juan (24) (2006) 1 Lower calyceal puncture; retro renal colon; prone position Conservative management Full recovery Chubak (32) (2014) 1 Lower-pole access; subcostal lateral puncture; prone position; obesity Surgical repair with diverting colostomy Full recovery after surgery AslZare (33) (2014) 11 Lower calyceal puncture; prior ipsilateral renal or abdominal surgery Conservative management in most cases; temporary colostomy in selected patients Favorable outcomes with recovery in all patients Öztürk (7) (2015) 1 Female sex; lateral puncture trajectory in the absence of retro renal colon Conservative management Full recovery without fistula formation Akbulut (5) (2015) 22 Lower calyceal puncture; retro renal colon; previous ipsilateral renal surgery Conservative management for extraperitoneal perforation; open surgical repair or colostomy for intraperitoneal perforation or failed conservative treatment All patients recovered; colostomies were successfully closed without mortality Balasar (11) (2015) 2 Absence of preoperative CT imaging; lower pole renal access Not reported Not reported Elghoneimy (28) (2016) 3 Low BMI; supracostal or relatively lateral puncture; absence of classic retro renal colon on CT Conservative management Full recovery Maghsoudi (28) (2017) 17 Lower-pole access; retro renal colon; prone position Primarily conservative; surgery reserved for complicated cases Favorable in all patients; no long-term bowel or urinary sequelae; no mortality Rai (29) (2020) 3 Complex renal anatomy; lower-pole or nonstandard access Conservative management Favorable outcomes in all patients Güler (30) (2020) 1 Reverse rotation anomalous kidney; posterior axillary line access; thin body habitus Conservative management Full recovery Boutros (22) (2024) 1 Malrotated pelvic kidney; lower-pole access Emergent surgical repair with hemicolectomy Survival after surgical intervention Summary of published reports describing colonic injury associated with percutaneous nephrolithotomy (1988–2025), including case reports and case series. Key risk factors, management approaches, and clinical outcomes are summarized based on available literature. 3.2 Reported Risk Factors for Colonic Injury during PCNL Across the studies summarized in Table 1 , colonic injury during PCNL was consistently associated with a convergence of anatomical vulnerability and procedural characteristics rather than a single isolated cause. From an anatomical perspective, an abnormal colon–kidney relationship was the most frequently reported predisposing factor, most commonly described as a retro renal or posterolateral colon. Importantly, however, several reports documented colonic injury even in the absence of classic retro renal anatomy, indicating that normal preoperative imaging does not fully exclude bowel injury risk. Beyond colon position alone, additional patient-specific anatomical factors reflecting individual heterogeneity were identified. These included complex or anomalous renal configurations such as horseshoe kidney, renal malrotation, and ectopic or pelvic kidneys, all of which may distort renal orientation and alter the expected spatial relationship between the kidney and adjacent bowel. In some cases, a paucity of retroperitoneal fat or a low body mass index was also noted, potentially reducing the protective buffer between the colon and the access tract. Procedural characteristics repeatedly associated with colonic injury included left-sided renal access, lower-pole or nonstandard calyceal puncture trajectories, and relatively lateral or posterior axillary line entry points. Several reports emphasized that tract dilation proceeded without abnormal resistance or warning signs, underscoring that tactile feedback during access creation may be unreliable for excluding inadvertent colonic traversal. Additional contributory factors reported in case series included multiple access tracts, prior ipsilateral renal or abdominal surgery, and the absence of preoperative cross-sectional imaging, each of which may further compound injury risk through altered anatomy or limited procedural planning. 3.3 Diagnostic Timing and Imaging Findings As summarized in Table 1 , colonic injury associated with PCNL was more frequently diagnosed in the postoperative period than identified intraoperatively. Across reported cases, intraoperative warning signs were often absent, and tract dilation commonly proceeded without abnormal resistance, limiting real-time recognition of bowel involvement. Postoperative clinical presentation was variable and frequently atypical, including unexpected nephrostomy output, disproportionate inflammatory responses, or nonspecific abdominal or flank discomfort following an initially unremarkable procedure. In several reports, early symptoms were mild or subtle, contributing to delayed clinical suspicion and postponed diagnostic evaluation. Cross-sectional imaging, most notably computed tomography, emerged as the principal diagnostic modality across the included studies. CT enabled direct assessment of the nephrostomy tract in relation to the colon and was critical for distinguishing retroperitoneal from intraperitoneal perforation patterns. In cases with delayed presentation, imaging findings played a decisive role not only in confirming the diagnosis but also in stratifying injury severity and informing subsequent management strategies. 3.5 Illustrative Case To illustrate the procedural and operator-related risk factors identified in the reviewed literature, we present a representative case of colonic injury following percutaneous nephrolithotomy from our institution. Additional clinical details of the illustrative case are provided in Supplementary Appendix 1. Preoperative CT did not demonstrate a retro renal colonic position or other overt anatomical variants predisposing to colonic injury (Fig. 1 A). Accordingly, procedural risk appeared to arise predominantly during the access creation phase rather than from pre-existing anatomical vulnerability. The patient was placed in the prone position, and percutaneous renal access was attempted via a flank approach under ultrasound guidance. In this female patient, prominent flank adiposity with increased lateral abdominal wall soft-tissue thickness limited the acoustic window and compromised sonographic visualization. An out-of-plane ultrasound-guided needle insertion technique was used in accordance with the operator’s routine practice; however, under the prevailing imaging constraints, this approach inherently limited continuous visualization of the needle trajectory. As a result of restricted needle tip visibility, multiple puncture attempts were required during access creation. Repeated unsuccessful access attempts under suboptimal imaging conditions were associated with increased cognitive load and procedural stress for the operator, further narrowing the margin for precise needle control. This combination of technical difficulty, elevated psychological pressure, and reduced visual feedback increased the likelihood of deviation from the intended posterior calyceal access axis, thereby elevating the potential risk of adjacent organ injury despite the absence of predisposing anatomical abnormalities on preoperative imaging. Immediately after emergence from anesthesia, the patient developed severe abdominal pain accompanied by marked abdominal wall guarding, which responded poorly to routine postoperative analgesia. Given that the severity of symptoms was disproportionate to the expected postoperative course following PCNL, early contrast-enhanced CT was performed. Contrast-enhanced CT demonstrated traversal of the nephrostomy tract through the colonic wall, confirming the diagnosis of colonic injury (Fig. 1 B). The same examination further revealed a high intercostal access trajectory through the 10th intercostal space toward the anterior group of the middle calyx, with imaging findings indicating confinement of the injury to the retroperitoneal space and no evidence of intraperitoneal contamination or generalized peritonitis. Based on the radiological findings and the patient’s hemodynamic stability without generalized peritonitis, conservative management was initiated. This approach included bowel rest, broad-spectrum antibiotics, and controlled nephrostomy tube management with subsequent withdrawal. The patient’s clinical course was favorable, with progressive symptom resolution and no evidence of fistula formation or infectious complications on follow-up imaging. Surgical intervention was not required. 4. Discussion Colonic injury during percutaneous nephrolithotomy has most commonly been associated with unfavorable anatomical relationships between the colon and the kidney, particularly the presence of a retro renal or posterolateral colon. Imaging-based studies have demonstrated that these anatomical variants are more frequently encountered during left-sided PCNL and in the prone position, thereby increasing the risk of colonic traversal during renal access ( 4 , 11 , 12 ). Consequently, preoperative CT has been widely advocated to delineate colon–kidney relationships and identify high-risk anatomy prior to access planning. However, both the published literature and the present illustrative case demonstrate that colonic injury can occur even in the absence of recognized anatomical risk factors. This has been observed not only in isolated case reports but also in larger clinical series where no overt preoperative anatomical abnormalities were identified ( 4 , 5 , 15 , 16 ). These findings underscore that anatomical assessment alone is insufficient to fully mitigate the risk of bowel injury. Therefore, from a clinical perspective, preoperative anatomical evaluation should be regarded as a necessary but not sufficient component of risk stratification for colonic injury during PCNL. Beyond anatomical considerations, technical and operator-related factors play a central role in determining the risk of colonic injury during PCNL. High intercostal access, lateral puncture trajectories, and deviation from the posterior calyceal axis have all been implicated as contributors to adjacent organ injury ( 4 , 5 , 7 ). Access through upper intercostal spaces may increase the likelihood of encountering nonrenal structures, particularly when combined with anterior or nonpapillary calyceal targeting ( 26 ). Ultrasound-guided access, while advantageous in reducing radiation exposure, may be limited in patients with obesity or when acoustic windows are suboptimal. Under such conditions, continuous visualization of the needle trajectory can be compromised, increasing the likelihood of unintended deviation during puncture ( 18 ). Several reports have emphasized that repeated puncture attempts and needle redirection under limited visualization conditions may cumulatively elevate the risk of extrarenal injury ( 5 , 25 ). Operator experience further modulates these technical risks, particularly during the critical phase of renal access creation. Previous studies have demonstrated a clear learning curve for percutaneous renal access, with novice operators and those in the early stages of experience exhibiting higher rates of access-related complications ( 3 , 27 ). However, most existing analyses focus on cumulative experience metrics and do not adequately capture the dynamic intraoperative conditions under which access decisions are made. In challenging access scenarios, such as those involving limited acoustic windows, reduced needle tip visualization, and repeated unsuccessful puncture attempts, the impact of limited operator experience may be amplified. In the present case, repeated access failures under suboptimal imaging conditions occurred during an early phase of operator experience, contributing to increased cognitive load and procedural stress. These factors may plausibly adversely affect situational awareness and fine motor control, thereby increasing susceptibility to subtle deviations from the intended posterior calyceal access axis. Importantly, such deviations may arise not solely from technical inexperience, but from a multifactorial interaction between novice-level experience, constrained imaging feedback, and heightened psychological pressure during access creation ( 20 , 21 ). From a procedural safety perspective, the present illustrative case exemplifies how the convergence of technical difficulty and operator-related factors may result in colonic injury despite the absence of classical anatomical predisposition. Clinically, these observations support a low threshold for modifying the access strategy, changing imaging guidance, or aborting further puncture attempts when optimal visualization cannot be maintained. Despite the potentially serious nature of colonic injury during PCNL, accumulated evidence supports conservative management in carefully selected patients. The majority of reported injuries are retroperitoneal and can be successfully managed without surgical intervention when promptly recognized ( 5 , 23 – 25 ). Core elements of conservative treatment include bowel rest, broad-spectrum antibiotic therapy, urinary diversion, and controlled nephrostomy tube management ( 16 , 28 ). Early and accurate differentiation between retroperitoneal and intraperitoneal injury is critical, as the latter typically necessitates surgical exploration ( 5 , 22 ). In our case, early contrast-enhanced CT was instrumental in delineating a retroperitoneally confined injury and informing conservative management, similarly, prior series highlight CT-based classification as a key determinant of treatment selection ( 5 ). The favorable outcome observed in the present case is consistent with prior reports demonstrating successful nonoperative management following early diagnosis ( 23 , 24 , 28 – 30 ). Taken together, the available evidence indicates that colonic injury during PCNL is a multifactorial complication arising from the interaction of anatomical variation, technical execution, and operator-related factors. Effective prevention therefore requires an integrated approach that extends beyond anatomical risk assessment alone to include access planning, imaging optimization, and operator judgment during access creation. Notwithstanding these overarching patterns, the interpretation of the available evidence is subject to several important limitations. This review is limited by the predominance of case reports and small retrospective series, which precludes quantitative analysis and limits causal inference. Heterogeneity in patient characteristics, access techniques, and reporting standards across studies further restricts direct comparison. In addition, operator-related factors were rarely explicitly reported in the existing literature and therefore could not be systematically evaluated. 5. Conclusions Colonic injury during PCNL is an uncommon but multifactorial complication that arises from the interplay of anatomical variation, technical execution, imaging conditions, and operator-related factors, rather than anatomical predisposition alone. While thorough preoperative imaging remains essential for risk assessment and planning, intraoperative technical conditions, access strategy, imaging quality, and operator judgment collectively determine procedural safety during access creation. Prompt recognition and accurate differentiation between retroperitoneal and intraperitoneal injury patterns enable appropriate management, with conservative treatment feasible in most retroperitoneal injuries, whereas intraperitoneal contamination generally necessitates surgical intervention. Abbreviations PCNL Percutaneous nephrolithotomy CT Computed tomography BMI Body mass index Declarations Ethics approval and consent to participate Ethical approval for this study was obtained from the institutional review board of the authors’ institution. Written informed consent was obtained from the patient for participation in this study. Clinical trial registration Clinical trial number: not applicable. Consent for publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. All identifying information has been removed to protect patient privacy. Availability of data and materials All data generated or analyzed during this study are included in this published article and its supplementary information files. Competing interests The authors declare that they have no competing interests. Funding This work was supported by the Medical Science and Technology Project of Zhejiang Province (Grant No. 2024638739). Authors' Contributions B.Y. conceived the study, collected and interpreted the clinical data, performed the literature review, and drafted the manuscript. C.W. provided interdisciplinary discussion and contributed to the interpretation of relevant findings. N.Z. contributed to perioperative patient care and follow-up and assisted in data collection and clinical documentation. M.Y. supervised the study, critically revised the manuscript for important intellectual content, and approved the final version for submission. All authors read and approved the final manuscript. Acknowledgements Not applicable. References Skolarikos A, Geraghty R, Somani B, Tailly T, Jung H, Neisius A, et al. European Association of Urology Guidelines on the Diagnosis and Treatment of Urolithiasis. Eur Urol. 2025;88(1):64–75. Lee WJ, Smith AD, Cubelli V, Badlani GH, Lewin B, Vernace F, et al. Complications of percutaneous nephrolithotomy. AJR Am J Roentgenol. 1987;148(1):177–80. Skolarikos A, de la Rosette J. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8357872","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":570818093,"identity":"3da2fba4-3059-4e39-8825-b9c5d91bf7f9","order_by":0,"name":"Botao Yu","email":"","orcid":"","institution":"Ningbo Medical Center Lihuili Hospital","correspondingAuthor":false,"prefix":"","firstName":"Botao","middleName":"","lastName":"Yu","suffix":""},{"id":570818094,"identity":"e7b36ed5-35a4-4fba-9c53-37c153cb4611","order_by":1,"name":"Chunling Wang","email":"","orcid":"","institution":"Ningbo Medical Center Lihuili 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Hospital","correspondingAuthor":true,"prefix":"","firstName":"Min","middleName":"","lastName":"Yin","suffix":""}],"badges":[],"createdAt":"2025-12-14 12:23:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8357872/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8357872/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":100007717,"identity":"465a3884-18a1-4e4a-abd3-f1839f3ce1f3","added_by":"auto","created_at":"2026-01-12 05:50:56","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":178244,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.docx","url":"https://assets-eu.researchsquare.com/files/rs-8357872/v1/8cf6c8cfe1c771edbc046ba4.docx"},{"id":100007719,"identity":"c8c3f63c-3358-4b84-87c7-fef59e028689","added_by":"auto","created_at":"2026-01-12 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05:50:57","extension":"png","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":104850,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8357872/v1/3b63bdd4fe22fc2c3278bf1b.png"},{"id":100007734,"identity":"3e1a6697-bbfd-465f-ab20-9505999011e4","added_by":"auto","created_at":"2026-01-12 05:50:57","extension":"xml","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":97756,"visible":true,"origin":"","legend":"","description":"","filename":"ad88bbc8704d4f64868aff768b379b3d1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8357872/v1/74eaab91c1ae60deeaae2600.xml"},{"id":100007723,"identity":"c2a5200f-a856-41c7-bf3f-7b063ebfd938","added_by":"auto","created_at":"2026-01-12 05:50:57","extension":"html","order_by":18,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":105255,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8357872/v1/18a2ab1082c354ab8e94f925.html"},{"id":100007714,"identity":"859c35f6-9db2-450a-bbe7-53180c6d18f3","added_by":"auto","created_at":"2026-01-12 05:50:56","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":945854,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative and immediate postoperative CT findings. (A) Preoperative non–contrast-enhanced abdominal CT (axial view) demonstrating a calculus located at the left ureteropelvic junction (white arrow). (B) Axial non-contrast phase of contrast-enhanced abdominal CT obtained on postoperative day 0, showing the nephrostomy tube traversing the descending colon before entering the anterior group of the middle calyx, with associated perirenal fluid and gas collections. The white arrow indicates the site where the nephrostomy tract passes through the descending colon.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8357872/v1/e0bce41817886563f868e00f.jpg"},{"id":100380934,"identity":"732229ea-8bbf-4825-98a3-d0af7d8c5fe0","added_by":"auto","created_at":"2026-01-16 10:36:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1651830,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8357872/v1/0721b1c0-d25e-4cb7-8a66-8e8385c69d8c.pdf"},{"id":100361631,"identity":"973b4153-d425-4113-b117-37325b5c2f1f","added_by":"auto","created_at":"2026-01-16 07:45:25","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":912397,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryAppendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8357872/v1/7980f8a6ac5cfdb9b4645213.docx"},{"id":100007721,"identity":"22e2cc99-32a6-4006-aeea-3dd41fb95cf5","added_by":"auto","created_at":"2026-01-12 05:50:57","extension":"jpg","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":859188,"visible":true,"origin":"","legend":"","description":"","filename":"FigureS1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8357872/v1/bfe694a3529522fb9353a590.jpg"},{"id":100007720,"identity":"4c96caa7-4f78-49e1-ac1c-38dfd13d3a29","added_by":"auto","created_at":"2026-01-12 05:50:57","extension":"jpg","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":2024361,"visible":true,"origin":"","legend":"","description":"","filename":"FigureS2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8357872/v1/d18ee6ec4269b413cc7ad4f8.jpg"},{"id":100007728,"identity":"b3308d73-3ed5-4bc5-b650-550469516419","added_by":"auto","created_at":"2026-01-12 05:50:57","extension":"jpg","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":1593727,"visible":true,"origin":"","legend":"","description":"","filename":"FigureS3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8357872/v1/367aa27830d99603599546e2.jpg"},{"id":100007725,"identity":"f74a600e-5be8-4414-9fd1-41a217abbb35","added_by":"auto","created_at":"2026-01-12 05:50:57","extension":"mp4","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":7944044,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryVideoS1.mp4","url":"https://assets-eu.researchsquare.com/files/rs-8357872/v1/06ae1a2d7ea42c3d2f81e08c.mp4"},{"id":100007744,"identity":"6826d25a-5211-4288-a606-24139c4220d5","added_by":"auto","created_at":"2026-01-12 05:50:58","extension":"mp4","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":43627919,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryVideoS2.mp4","url":"https://assets-eu.researchsquare.com/files/rs-8357872/v1/802e1ff9fda7f413a96b91d3.mp4"},{"id":100361696,"identity":"7c559bde-c137-4ba7-9b13-1a7c70a6a6de","added_by":"auto","created_at":"2026-01-16 07:45:31","extension":"mp4","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":9016704,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryVideoS3.mp4","url":"https://assets-eu.researchsquare.com/files/rs-8357872/v1/7da80378c06dda450ef91583.mp4"},{"id":100007741,"identity":"9a125e13-74c2-4b00-bac6-08e267825b0e","added_by":"auto","created_at":"2026-01-12 05:50:57","extension":"mp4","order_by":8,"title":"","display":"","copyAsset":false,"role":"supplement","size":8571652,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryVideoS4.mp4","url":"https://assets-eu.researchsquare.com/files/rs-8357872/v1/c4d0ac9d625c359ac6543e4d.mp4"}],"financialInterests":"No competing interests reported.","formattedTitle":"Colonic Injury During Percutaneous Nephrolithotomy: A Case- Illustrated Review of Risk Factors, Diagnosis, and Management Strategies","fulltext":[{"header":"1. Background","content":"\u003cp\u003ePercutaneous nephrolithotomy (PCNL) is widely established as the standard treatment for large and complex renal calculi (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Although most complications associated with PCNL are minor, injury to adjacent organs represents a rare but potentially serious event (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Among these complications, colonic injury is particularly concerning because of its variable clinical presentation, diagnostic challenges, and the potential for significant morbidity if not promptly recognized (\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe reported incidence of colonic injury during PCNL is low, generally ranging from approximately 0.2% to 0.8%, which limits the feasibility of prospective investigation and has resulted in a predominance of case-based evidence in the literature (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Consequently, current understanding of this complication is largely derived from individual case reports, small case series, and retrospective analyses. While these reports have traditionally emphasized anatomical risk factors, most notably the presence of a retro renal or posterolateral colon, this explanation alone does not fully account for all documented cases (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eComputed tomography (CT) based anatomical studies have demonstrated that the spatial relationship between the colon and kidney is highly variable and influenced by patient positioning, body habitus, and laterality (\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Preoperative imaging has therefore been advocated as a key preventive measure for identifying patients at increased risk. However, colonic injury has also been reported in patients without overt anatomical predisposition on preoperative imaging, suggesting that factors beyond static anatomical relationships contribute to injury risk (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eProcedural characteristics related to renal access creation have emerged as additional contributors to colonic injury. High intercostal puncture, lateral access trajectories, deviation from the posterior calyceal axis, and limited visualization during ultrasound-guided puncture have all been implicated in reported cases (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). These risks may be amplified in patients with obesity or in technically challenging access scenarios, where visualization of the needle path is suboptimal and repeated puncture attempts are required (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn addition to anatomical and technical considerations, operator-related factors may theoretically influence the risk of colonic injury during PCNL, however, such factors have not been specifically analyzed in PCNL-related studies and are instead inferred from broader surgical literature (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The interaction between anatomical context, procedural strategy, and operator performance likely underlies the multifactorial nature of colonic injury during PCNL.\u003c/p\u003e \u003cp\u003eManagement strategies for colonic injury range from conservative treatment to surgical intervention, depending largely on the extent of injury and the presence of intraperitoneal contamination (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Accumulated evidence suggests that early diagnosis, particularly through cross-sectional imaging, facilitates successful nonoperative management in the majority of retroperitoneal injuries (\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Nonetheless, the absence of integrated frameworks linking risk assessment, diagnosis, and management continues to pose challenges for clinical decision making.\u003c/p\u003e \u003cp\u003eIn this context, we present a case-illustrated review of colonic injury associated with PCNL. By synthesizing published evidence on anatomical, procedural, and operator-related risk factors, diagnostic pathways, and management strategies, and contextualizing these findings with a representative clinical case, we aim to offer a clinically oriented synthesis to aid risk awareness, early recognition, and management of this uncommon but clinically significant complication.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Literature Review Strategy\u003c/h2\u003e \u003cp\u003eA targeted narrative review of the literature was performed to identify published reports describing colonic injury associated with PCNL between January 1985 and March 2025. PubMed was searched using combinations of procedure-related terms (\u0026ldquo;percutaneous nephrolithotomy\u0026rdquo; OR \u0026ldquo;PCNL\u0026rdquo;) and complication-related terms (\u0026ldquo;colonic injury,\u0026rdquo; \u0026ldquo;colon perforation,\u0026rdquo; OR \u0026ldquo;bowel injury\u0026rdquo;).\u003c/p\u003e \u003cp\u003eThe search was limited to human studies published in English. In addition, reference lists of relevant articles were manually reviewed to identify additional publications of relevance that may not have been captured by the initial search.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Study Selection and Data Synthesis\u003c/h2\u003e \u003cp\u003ePublications were considered eligible if they reported clinical cases, case series, retrospective analyses, or narrative or systematic reviews describing colonic injury associated with PCNL. Only studies in which colonic injury was explicitly documented and discussed were included.\u003c/p\u003e \u003cp\u003eStudies focusing exclusively on PCNL techniques, anesthesia, or overall surgical outcomes without specific reference to colonic or bowel injury were excluded. Reports describing gastrointestinal injuries unrelated to PCNL, as well as studies addressing non-colonic bowel injuries (e.g., jejunal or duodenal injury), were excluded unless colonic involvement was specifically described.\u003c/p\u003e \u003cp\u003eFrom each included publication, key information was extracted, including publication year, study design, number of reported cases, anatomical and procedural context, diagnostic timing and imaging findings, management strategies, and clinical outcomes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Illustrative Case\u003c/h2\u003e \u003cp\u003eTo complement the narrative synthesis of the literature, a representative clinical case from our institution is presented to illustrate practical diagnostic challenges and conservative management principles described in the reviewed reports. This case is included for illustrative purpose only and was not incorporated into the literature synthesis.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Literature Identification and Overview of Included Evidence\u003c/h2\u003e \u003cp\u003eA focused PubMed search was performed to identify publications describing colonic injury in the context of PCNL. The body of literature informing this review consisted predominantly of case reports, small case series, retrospective analyses, and narrative or systematic reviews documenting PCNL-related colonic injury. The included evidence spans publications from 1988 to 2025. Key characteristics of the included studies, including publication year, number of reported cases, identified risk factors, management strategies, and clinical outcomes, are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eReported Colonic Injuries Associated with Percutaneous Nephrolithotomy (1988\u0026ndash;2025)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthor (Year)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCases (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eKey Risk Factors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eManagement Strategy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRodrigues Netto \u003csup\u003e(31)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(1988)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePosteriorly located colon; close colon\u0026ndash;kidney relationship; minimal retroperitoneal fat; lateral renal puncture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSurgical management (exploratory laparotomy with colostomy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFull recovery after surgical repair\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGoswami \u003csup\u003e(23)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(2001)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHorseshoe kidney; retro renal colon; upper calyceal puncture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eConservative management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFull recovery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNoor Buchholz \u003csup\u003e(8)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(2004)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRetro renal colon; extremely lateral access\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSurgical repair (hemicolectomy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSevere postoperative complications; eventual recovery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEl-Nahas \u003csup\u003e(4)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(2006)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAdvanced age; horseshoe kidney; lower calyceal puncture; left-sided access; multiple tracts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eConservative management in most cases; temporary colostomy in selected patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOverall favorable outcomes; recovery in all patients\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJuan \u003csup\u003e(24)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(2006)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLower calyceal puncture; retro renal colon; prone position\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eConservative management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFull recovery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChubak \u003csup\u003e(32)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(2014)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLower-pole access; subcostal lateral puncture; prone position; obesity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSurgical repair with diverting colostomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFull recovery after surgery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAslZare \u003csup\u003e(33)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(2014)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLower calyceal puncture; prior ipsilateral renal or abdominal surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eConservative management in most cases; temporary colostomy in selected patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFavorable outcomes with recovery in all patients\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026Ouml;zt\u0026uuml;rk \u003csup\u003e(7)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(2015)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale sex; lateral puncture trajectory in the absence of retro renal colon\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eConservative management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFull recovery without fistula formation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAkbulut \u003csup\u003e(5)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(2015)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLower calyceal puncture; retro renal colon; previous ipsilateral renal surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eConservative management for extraperitoneal perforation; open surgical repair or colostomy for intraperitoneal perforation or failed conservative treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAll patients recovered; colostomies were successfully closed without mortality\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBalasar \u003csup\u003e(11)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(2015)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAbsence of preoperative CT imaging; lower pole renal access\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNot reported\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElghoneimy \u003csup\u003e(28)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(2016)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLow BMI; supracostal or relatively lateral puncture; absence of classic retro renal colon on CT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eConservative management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFull recovery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaghsoudi \u003csup\u003e(28)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(2017)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLower-pole access; retro renal colon; prone position\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimarily conservative; surgery reserved for complicated cases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFavorable in all patients; no long-term bowel or urinary sequelae; no mortality\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRai \u003csup\u003e(29)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(2020)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eComplex renal anatomy; lower-pole or nonstandard access\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eConservative management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFavorable outcomes in all patients\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eG\u0026uuml;ler \u003csup\u003e(30)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(2020)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eReverse rotation anomalous kidney; posterior axillary line access; thin body habitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eConservative management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFull recovery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBoutros \u003csup\u003e(22)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(2024)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMalrotated pelvic kidney; lower-pole access\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEmergent surgical repair with hemicolectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSurvival after surgical intervention\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eSummary of published reports describing colonic injury associated with percutaneous nephrolithotomy (1988\u0026ndash;2025), including case reports and case series. Key risk factors, management approaches, and clinical outcomes are summarized based on available literature.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Reported Risk Factors for Colonic Injury during PCNL\u003c/h2\u003e \u003cp\u003eAcross the studies summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, colonic injury during PCNL was consistently associated with a convergence of anatomical vulnerability and procedural characteristics rather than a single isolated cause. From an anatomical perspective, an abnormal colon\u0026ndash;kidney relationship was the most frequently reported predisposing factor, most commonly described as a retro renal or posterolateral colon. Importantly, however, several reports documented colonic injury even in the absence of classic retro renal anatomy, indicating that normal preoperative imaging does not fully exclude bowel injury risk.\u003c/p\u003e \u003cp\u003eBeyond colon position alone, additional patient-specific anatomical factors reflecting individual heterogeneity were identified. These included complex or anomalous renal configurations such as horseshoe kidney, renal malrotation, and ectopic or pelvic kidneys, all of which may distort renal orientation and alter the expected spatial relationship between the kidney and adjacent bowel. In some cases, a paucity of retroperitoneal fat or a low body mass index was also noted, potentially reducing the protective buffer between the colon and the access tract.\u003c/p\u003e \u003cp\u003eProcedural characteristics repeatedly associated with colonic injury included left-sided renal access, lower-pole or nonstandard calyceal puncture trajectories, and relatively lateral or posterior axillary line entry points. Several reports emphasized that tract dilation proceeded without abnormal resistance or warning signs, underscoring that tactile feedback during access creation may be unreliable for excluding inadvertent colonic traversal. Additional contributory factors reported in case series included multiple access tracts, prior ipsilateral renal or abdominal surgery, and the absence of preoperative cross-sectional imaging, each of which may further compound injury risk through altered anatomy or limited procedural planning.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Diagnostic Timing and Imaging Findings\u003c/h2\u003e \u003cp\u003eAs summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, colonic injury associated with PCNL was more frequently diagnosed in the postoperative period than identified intraoperatively. Across reported cases, intraoperative warning signs were often absent, and tract dilation commonly proceeded without abnormal resistance, limiting real-time recognition of bowel involvement. Postoperative clinical presentation was variable and frequently atypical, including unexpected nephrostomy output, disproportionate inflammatory responses, or nonspecific abdominal or flank discomfort following an initially unremarkable procedure. In several reports, early symptoms were mild or subtle, contributing to delayed clinical suspicion and postponed diagnostic evaluation.\u003c/p\u003e \u003cp\u003eCross-sectional imaging, most notably computed tomography, emerged as the principal diagnostic modality across the included studies. CT enabled direct assessment of the nephrostomy tract in relation to the colon and was critical for distinguishing retroperitoneal from intraperitoneal perforation patterns. In cases with delayed presentation, imaging findings played a decisive role not only in confirming the diagnosis but also in stratifying injury severity and informing subsequent management strategies.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Illustrative Case\u003c/h2\u003e \u003cp\u003eTo illustrate the procedural and operator-related risk factors identified in the reviewed literature, we present a representative case of colonic injury following percutaneous nephrolithotomy from our institution. Additional clinical details of the illustrative case are provided in Supplementary Appendix 1.\u003c/p\u003e \u003cp\u003ePreoperative CT did not demonstrate a retro renal colonic position or other overt anatomical variants predisposing to colonic injury (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA). Accordingly, procedural risk appeared to arise predominantly during the access creation phase rather than from pre-existing anatomical vulnerability. The patient was placed in the prone position, and percutaneous renal access was attempted via a flank approach under ultrasound guidance. In this female patient, prominent flank adiposity with increased lateral abdominal wall soft-tissue thickness limited the acoustic window and compromised sonographic visualization.\u003c/p\u003e \u003cp\u003eAn out-of-plane ultrasound-guided needle insertion technique was used in accordance with the operator\u0026rsquo;s routine practice; however, under the prevailing imaging constraints, this approach inherently limited continuous visualization of the needle trajectory. As a result of restricted needle tip visibility, multiple puncture attempts were required during access creation. Repeated unsuccessful access attempts under suboptimal imaging conditions were associated with increased cognitive load and procedural stress for the operator, further narrowing the margin for precise needle control. This combination of technical difficulty, elevated psychological pressure, and reduced visual feedback increased the likelihood of deviation from the intended posterior calyceal access axis, thereby elevating the potential risk of adjacent organ injury despite the absence of predisposing anatomical abnormalities on preoperative imaging.\u003c/p\u003e \u003cp\u003eImmediately after emergence from anesthesia, the patient developed severe abdominal pain accompanied by marked abdominal wall guarding, which responded poorly to routine postoperative analgesia. Given that the severity of symptoms was disproportionate to the expected postoperative course following PCNL, early contrast-enhanced CT was performed. Contrast-enhanced CT demonstrated traversal of the nephrostomy tract through the colonic wall, confirming the diagnosis of colonic injury (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). The same examination further revealed a high intercostal access trajectory through the 10th intercostal space toward the anterior group of the middle calyx, with imaging findings indicating confinement of the injury to the retroperitoneal space and no evidence of intraperitoneal contamination or generalized peritonitis.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eBased on the radiological findings and the patient\u0026rsquo;s hemodynamic stability without generalized peritonitis, conservative management was initiated. This approach included bowel rest, broad-spectrum antibiotics, and controlled nephrostomy tube management with subsequent withdrawal. The patient\u0026rsquo;s clinical course was favorable, with progressive symptom resolution and no evidence of fistula formation or infectious complications on follow-up imaging. Surgical intervention was not required.\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eColonic injury during percutaneous nephrolithotomy has most commonly been associated with unfavorable anatomical relationships between the colon and the kidney, particularly the presence of a retro renal or posterolateral colon. Imaging-based studies have demonstrated that these anatomical variants are more frequently encountered during left-sided PCNL and in the prone position, thereby increasing the risk of colonic traversal during renal access (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Consequently, preoperative CT has been widely advocated to delineate colon\u0026ndash;kidney relationships and identify high-risk anatomy prior to access planning.\u003c/p\u003e \u003cp\u003eHowever, both the published literature and the present illustrative case demonstrate that colonic injury can occur even in the absence of recognized anatomical risk factors. This has been observed not only in isolated case reports but also in larger clinical series where no overt preoperative anatomical abnormalities were identified (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). These findings underscore that anatomical assessment alone is insufficient to fully mitigate the risk of bowel injury. Therefore, from a clinical perspective, preoperative anatomical evaluation should be regarded as a necessary but not sufficient component of risk stratification for colonic injury during PCNL.\u003c/p\u003e \u003cp\u003eBeyond anatomical considerations, technical and operator-related factors play a central role in determining the risk of colonic injury during PCNL. High intercostal access, lateral puncture trajectories, and deviation from the posterior calyceal axis have all been implicated as contributors to adjacent organ injury (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Access through upper intercostal spaces may increase the likelihood of encountering nonrenal structures, particularly when combined with anterior or nonpapillary calyceal targeting (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUltrasound-guided access, while advantageous in reducing radiation exposure, may be limited in patients with obesity or when acoustic windows are suboptimal. Under such conditions, continuous visualization of the needle trajectory can be compromised, increasing the likelihood of unintended deviation during puncture (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Several reports have emphasized that repeated puncture attempts and needle redirection under limited visualization conditions may cumulatively elevate the risk of extrarenal injury (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOperator experience further modulates these technical risks, particularly during the critical phase of renal access creation. Previous studies have demonstrated a clear learning curve for percutaneous renal access, with novice operators and those in the early stages of experience exhibiting higher rates of access-related complications (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). However, most existing analyses focus on cumulative experience metrics and do not adequately capture the dynamic intraoperative conditions under which access decisions are made.\u003c/p\u003e \u003cp\u003eIn challenging access scenarios, such as those involving limited acoustic windows, reduced needle tip visualization, and repeated unsuccessful puncture attempts, the impact of limited operator experience may be amplified. In the present case, repeated access failures under suboptimal imaging conditions occurred during an early phase of operator experience, contributing to increased cognitive load and procedural stress. These factors may plausibly adversely affect situational awareness and fine motor control, thereby increasing susceptibility to subtle deviations from the intended posterior calyceal access axis. Importantly, such deviations may arise not solely from technical inexperience, but from a multifactorial interaction between novice-level experience, constrained imaging feedback, and heightened psychological pressure during access creation (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFrom a procedural safety perspective, the present illustrative case exemplifies how the convergence of technical difficulty and operator-related factors may result in colonic injury despite the absence of classical anatomical predisposition. Clinically, these observations support a low threshold for modifying the access strategy, changing imaging guidance, or aborting further puncture attempts when optimal visualization cannot be maintained.\u003c/p\u003e \u003cp\u003eDespite the potentially serious nature of colonic injury during PCNL, accumulated evidence supports conservative management in carefully selected patients. The majority of reported injuries are retroperitoneal and can be successfully managed without surgical intervention when promptly recognized (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Core elements of conservative treatment include bowel rest, broad-spectrum antibiotic therapy, urinary diversion, and controlled nephrostomy tube management (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEarly and accurate differentiation between retroperitoneal and intraperitoneal injury is critical, as the latter typically necessitates surgical exploration (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). In our case, early contrast-enhanced CT was instrumental in delineating a retroperitoneally confined injury and informing conservative management, similarly, prior series highlight CT-based classification as a key determinant of treatment selection (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The favorable outcome observed in the present case is consistent with prior reports demonstrating successful nonoperative management following early diagnosis (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTaken together, the available evidence indicates that colonic injury during PCNL is a multifactorial complication arising from the interaction of anatomical variation, technical execution, and operator-related factors. Effective prevention therefore requires an integrated approach that extends beyond anatomical risk assessment alone to include access planning, imaging optimization, and operator judgment during access creation.\u003c/p\u003e \u003cp\u003eNotwithstanding these overarching patterns, the interpretation of the available evidence is subject to several important limitations. This review is limited by the predominance of case reports and small retrospective series, which precludes quantitative analysis and limits causal inference. Heterogeneity in patient characteristics, access techniques, and reporting standards across studies further restricts direct comparison. In addition, operator-related factors were rarely explicitly reported in the existing literature and therefore could not be systematically evaluated.\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eColonic injury during PCNL is an uncommon but multifactorial complication that arises from the interplay of anatomical variation, technical execution, imaging conditions, and operator-related factors, rather than anatomical predisposition alone. While thorough preoperative imaging remains essential for risk assessment and planning, intraoperative technical conditions, access strategy, imaging quality, and operator judgment collectively determine procedural safety during access creation. Prompt recognition and accurate differentiation between retroperitoneal and intraperitoneal injury patterns enable appropriate management, with conservative treatment feasible in most retroperitoneal injuries, whereas intraperitoneal contamination generally necessitates surgical intervention.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePCNL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePercutaneous nephrolithotomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eComputed tomography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBMI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eBody mass index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the institutional review board of the authors’ institution. Written informed consent was obtained from the patient for participation in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images.\u0026nbsp;All identifying information has been removed to protect patient privacy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article and its supplementary information files.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Medical Science and Technology Project of Zhejiang Province (Grant No. 2024638739).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eB.Y. conceived the study, collected and interpreted the clinical data, performed the literature review, and drafted the manuscript. C.W. provided interdisciplinary discussion and contributed to the interpretation of relevant findings. N.Z. contributed to perioperative patient care and follow-up and assisted in data collection and clinical documentation. M.Y. supervised the study, critically revised the manuscript for important intellectual content, and approved the final version for submission. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSkolarikos A, Geraghty R, Somani B, Tailly T, Jung H, Neisius A, et al. European Association of Urology Guidelines on the Diagnosis and Treatment of Urolithiasis. Eur Urol. 2025;88(1):64\u0026ndash;75.\u003c/li\u003e\n\u003cli\u003eLee WJ, Smith AD, Cubelli V, Badlani GH, Lewin B, Vernace F, et al. Complications of percutaneous nephrolithotomy. AJR Am J Roentgenol. 1987;148(1):177\u0026ndash;80.\u003c/li\u003e\n\u003cli\u003eSkolarikos A, de la Rosette J. Prevention and treatment of complications following percutaneous nephrolithotomy. Curr Opin Urol. 2008;18(2):229\u0026ndash;34.\u003c/li\u003e\n\u003cli\u003eEl-Nahas AR, Shokeir AA, El-Assmy AM, Shoma AM, Eraky I, El-Kenawy MR, et al. Colonic perforation during percutaneous nephrolithotomy: study of risk factors. Urology. 2006;67(5):937\u0026ndash;41.\u003c/li\u003e\n\u003cli\u003eAkbulut F, Tok A, Penbegul N, Daggulli M, Eryildirim B, Adanur S, et al. Colon perforation related to percutaneous nephrolithotomy: from diagnosis to treatment. Urolithiasis. 2015;43(6):521\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eMichel MS, Trojan L, Rassweiler JJ. Complications in percutaneous nephrolithotomy. European urology. 2007;51(4):899\u0026ndash;906.\u003c/li\u003e\n\u003cli\u003eOzturk H. Gastrointestinal system complications in percutaneous nephrolithotomy: a systematic review. J Endourol. 2014;28(11):1256\u0026ndash;67.\u003c/li\u003e\n\u003cli\u003eNoor Buchholz NP. Colon perforation after percutaneous nephrolithotomy revisited. Urol Int. 2004;72(1):88\u0026ndash;90.\u003c/li\u003e\n\u003cli\u003ede la Rosette JJ, Tsakiris P, Ferrandino MN, Elsakka AM, Rioja J, Preminger GM. Beyond prone position in percutaneous nephrolithotomy: a comprehensive review. European urology. 2008;54(6):1262\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eTefekli A, Karadag MA, Tepeler K, Sari E, Berberoglu Y, Baykal M, et al. Classification of percutaneous nephrolithotomy complications using the modified clavien grading system: looking for a standard. European urology. 2008;53(1):184\u0026ndash;90.\u003c/li\u003e\n\u003cli\u003eBalasar M, Kandemir A, Poyraz N, Unal Y, Ozturk A. Incidence of retrorenal colon during percutaneous nephrolithotomy. Int Braz J Urol. 2015;41(2):274\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eHur KJ, Moon HW, Kang SM, Kim KS, Choi YS, Cho H. Incidence of posterolateral and retrorenal colon in supine and prone position in percutaneous nephrolithotomy. Urolithiasis. 2021;49(6):585\u0026ndash;90.\u003c/li\u003e\n\u003cli\u003eHopper KD, Sherman JL, Luethke JM, Ghaed N. The retrorenal colon in the supine and prone patient. Radiology. 1987;162(2):443\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eChalasani V, Bissoon D, Bhuvanagiri AK, Mizzi A, Dunn IB. Should PCNL patients have a CT in the prone position preoperatively? Canadian Journal of Urology. 2010;17(2):5082.\u003c/li\u003e\n\u003cli\u003eTaylor E, Miller J, Chi T, Stoller ML. Complications associated with percutaneous nephrolithotomy. Translational andrology and urology. 2012;1(4):223.\u003c/li\u003e\n\u003cli\u003eGerspach JM, Bellman GC, Stoller ML, Fugelso P. Conservative management of colon injury following percutaneous renal surgery. Urology. 1997;49(6):831\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eMourmouris P, Mperdempes M, Daglas G, Skolarikos A. Bowel perforation during percutaneous urological procedures. Hellenic Urology. 2018;29(1).\u003c/li\u003e\n\u003cli\u003eKashi AH, Nouralizadeh A, Sotoudeh M, Hamidi Madani M, Narouie B, Dadpour M, et al. Ultrasound-guided percutaneous nephrolithotomy in patients with retrorenal colon: a single-center experience. World J Urol. 2023;41(1):211\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eXiao B, Zeng X, Ji C, Zhang G, Hu W, Jin S, et al. Percutaneous Nephrolithotomy With X-Ray Free Technique in Morbidlyobese Patients: Outcomes and Skills From A Large High-Volume Stone Management Center. Clin Surg 2021; 6. 2021;3368.\u003c/li\u003e\n\u003cli\u003eBirkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. New England Journal of Medicine. 2003;349(22):2117\u0026ndash;27.\u003c/li\u003e\n\u003cli\u003eArora S, Sevdalis N, Nestel D, Woloshynowych M, Darzi A, Kneebone R. The impact of stress on surgical performance: a systematic review of the literature. Surgery. 2010;147(3):318\u0026ndash;30. e6.\u003c/li\u003e\n\u003cli\u003eBoutros CS, Loftus AW, Bassiri A, Davis LE, Vince R, Sinopoli J, et al. A Rare Cause of Colon Perforation After Percutaneous Nephrolithotomy-A Case Report and Review of the Literature. Case Rep Surg. 2024;2024:4475216.\u003c/li\u003e\n\u003cli\u003eGoswami AK, Shrivastava P, Mukherjee A, Sharma SK. Management of colonic perforation during percutaneous nephrolithotomy in horseshoe kidney. J Endourol. 2001;15(10):989\u0026ndash;91.\u003c/li\u003e\n\u003cli\u003eJuan YS, Huang CH, Chuang SM, Shen JT, Li CC, Wang CJ, et al. Colon perforation: a rare complication during percutaneous nephrolithotomy. Kaohsiung J Med Sci. 2006;22(2):99\u0026ndash;102.\u003c/li\u003e\n\u003cli\u003eMaghsoudi R, Etemadian M, Kashi AH, Mehravaran K. Management of Colon Perforation During Percutaneous Nephrolithotomy: 12 Years of Experience in a Referral Center. J Endourol. 2017;31(10):1032\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003ePapanicolaou N, editor Renal anatomy relevant to percutaneous interventions. Seminars in interventional radiology; 1995: Copyright\u0026copy; 1995 by Thieme Medical Publishers, Inc.\u003c/li\u003e\n\u003cli\u003eMousavi-Bahar SH, Mehrabi S, Moslemi MK. Percutaneous nephrolithotomy complications in 671 consecutive patients: a single-center experience. Urol J. 2011;8(4):271\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eElghoneimy M, Abdel-Rassoul M, Elfayoumy H, Mosharafa A. Conservative management of colonic injury during percutaneous nephrolithotomy. African Journal of Urology. 2016;22(2):101\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eRai A, Kozel Z, Hsieh A, Aro T, Smith A, Hoenig D, et al. Management of Colon Perforation During Percutaneous Nephrolithotomy in Patients with Complex Anatomy: A Case Series. J Endourol Case Rep. 2020;6(4):416\u0026ndash;20.\u003c/li\u003e\n\u003cli\u003eGuler Y. Colon perforation after PCNL in reverse rotation anomalous kidney: A very rare case report and literature review. Urol Case Rep. 2020;29:101081.\u003c/li\u003e\n\u003cli\u003eRodrigues Netto N, Jr., Lemos GC, Fiuza JL. Colon perforation following percutaneous nephrolithotomy. Urology. 1988;32(3):223\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eChubak B, Stern JM. An unusual presentation of colon perforation following percutaneous nephrolithotomy. Can Urol Assoc J. 2014;8(11-12):E862\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eAslZare M, Darabi MR, Shakiba B, Gholami-Mahtaj L. Colonic perforation during percutaneous nephrolithotomy: An 18-year experience. Can Urol Assoc J. 2014;8(5-6):E323\u0026ndash;6.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Percutaneous nephrolithotomy, Colonic injury, Renal access, Risk factors, Computed tomography, Conservative management","lastPublishedDoi":"10.21203/rs.3.rs-8357872/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8357872/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eColonic injury is a rare but potentially serious complication of percutaneous nephrolithotomy (PCNL). Owing to its low incidence and heterogeneous clinical presentation, current evidence regarding risk factors, diagnostic pathways, and optimal management remains fragmented and largely case based.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA structured literature review was conducted to identify published reports of colonic injury associated with PCNL from 1985 to 2025. Data on anatomical context, procedural characteristics, diagnostic timing, management strategies, and outcomes were qualitatively synthesized. A representative clinical case from our institution is presented to illustrate key diagnostic challenges and management principles identified in the literature.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePublished evidence indicates that colonic injury during PCNL occurs in approximately 0.2%\u0026ndash;0.8% of procedures. Frequently reported risk factors include unfavorable colon\u0026ndash;kidney anatomy (particularly retro renal or posterolateral colon), left-sided access, prone positioning, high intercostal or lateral puncture trajectories, and limited visualization during access creation. Most injuries are retroperitoneal and are diagnosed postoperatively, often prompted by symptoms disproportionate to the expected recovery course. Contrast-enhanced computed tomography (CT) plays a central role in diagnosis and in distinguishing retroperitoneal from intraperitoneal injury patterns. When recognized early, most retroperitoneal injuries can be successfully managed conservatively, whereas intraperitoneal contamination or clinical deterioration necessitates surgical intervention.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eColonic injury during PCNL is a rare but multifactorial complication arising from the interplay of anatomical, technical, and operator-related factors rather than anatomical predisposition alone. Early recognition and appropriate stratification allow conservative management in most retroperitoneal injuries, whereas intraperitoneal involvement generally necessitates surgical intervention.\u003c/p\u003e","manuscriptTitle":"Colonic Injury During Percutaneous Nephrolithotomy: A Case- Illustrated Review of Risk Factors, Diagnosis, and Management Strategies","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-12 05:50:47","doi":"10.21203/rs.3.rs-8357872/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-02-01T04:36:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-28T18:27:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-22T16:58:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"57848114477264673372855755641192214672","date":"2026-01-19T19:51:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-19T12:05:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"36771168502723752220833239634710623644","date":"2026-01-19T11:55:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-17T23:37:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-15T12:51:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-13T10:39:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"170380258020457291893488183709718390767","date":"2026-01-11T13:32:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180449254807191381213397647175194878889","date":"2026-01-10T02:26:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"294328695190525980097835725615490712870","date":"2026-01-07T11:47:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"183936931471457807610195281685968627071","date":"2026-01-07T04:58:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"36446283246551297551650668157571135934","date":"2026-01-07T04:11:56+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-07T03:39:04+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-17T10:11:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-16T01:01:08+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-16T01:00:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Urology","date":"2025-12-14T12:05:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1ca5dae3-dd26-43e9-ae4a-dc240bdc32a2","owner":[],"postedDate":"January 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-12T05:50:47+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-12 05:50:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8357872","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8357872","identity":"rs-8357872","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}