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

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.