Tract Location Predicts Angiographic Outcomes in Severe Post-Percutaneous Nephrolithotomy Bleeding: A Multicenter Cohort Study

Purpose: Severe bleeding following percutaneous nephrolithotomy (PCNL) is uncommon but potentially life-threatening, and the criterion for performing renal arteriography (RA) remains unclear. This study aimed to identify predictors of angiographic outcomes and optimize clinical decision-making in patients with severe post-PCNL bleeding. Methods: We retrospectively analyzed 75 patients with severe post-PCNL bleeding across multiple centers (2015–2025). Severe bleeding was defined as hemodynamic instability, hemoglobin decrease >35 g/L, or persistent gross hematuria. Patients were categorized as continued conservative treatment (CCT), negative RA with conservative recovery (RAN), or positive RA requiring transcatheter arterial embolization (TAE). Univariable and multivariable logistic regression analyses identified predictors of TAE, and receiver operating characteristic (ROC) analysis assessed discriminative performance. Results: Among 75 patients (65 men, 10 women; mean age 52.7 years), 8 (10.7%) were treated with CCT, 15 (20.0%) had negative RA (RAN), and 52 (69.3%) underwent effective TAE. Baseline demographic and perioperative parameters were comparable among groups, except for tract location, which was significantly associated with embolization ( p < 0.001). Nonpapillary tracts were more frequent in the TAE group. In binary logistic regression (TAE vs non-TAE), tract location remained the sole independent predictor of embolization. ROC analysis demonstrated good discrimination (area under the curve = 0.778; 95% confidence interval 0.663–0.893; p < 0.001), with 73.1% sensitivity and 82.6% specificity. Conclusion: Nonpapillary tract location independently predicts positive angiography and the need for embolization in severe post-PCNL bleeding. Routine intraoperative documentation of tract site may enhance RA yield, expedite hemostasis, and avoid unnecessary angiography.