Percutaneous nephrolithotomy

Overview

Percutaneous nephrolithotomy (PCNL) is a surgical procedure used to remove kidney stones that are too large to pass on their own. When less-invasive treatments are ineffective or not feasible, this method is typically recommended by healthcare providers. It involves creating a small passageway through the skin on the back to access the kidney and remove the stones.

During the procedure, a surgeon inserts specialized instruments through a tiny tube into the kidney to locate and extract the stones. This direct approach is often chosen for larger stones that can’t be removed through less invasive techniques. By creating a targeted passageway, the surgeon can efficiently reach and remove the problematic stones.

Although PCNL is considered a minimally invasive surgery, it is still a significant operation. It offers a faster recovery and fewer complications than open surgery, making it a preferred option in many cases. However, it remains a major surgical intervention, and careful consideration is given to its necessity based on the patient’s specific condition.

Reasons for undergoing the procedure

Most kidney stones pass naturally without the need for surgery. However, percutaneous nephrolithotomy may be recommended for patients with stones that are too large to be treated by other methods or when passing the stone naturally is not possible, particularly in the following cases:

• Kidney stones are larger than 0.8 inches (2 cm) in diameter.
• Large stones are lodged in the ureter.
• Staghorn kidney stones obstruct several branches of the kidney’s collecting system.

Risk

Although percutaneous nephrolithotomy is a minimally invasive procedure, it still carries several risks, including:

• Anesthesia-related complications
• Kidney damage
• Bleeding
• Infection
• Blood clots
• Sepsis or a severe urinary tract infection
• Incomplete removal of the kidney stone
• Damage to surrounding organs
• Seroma, or fluid accumulation at the surgical site

Before the procedure

Before the procedure, a comprehensive health assessment will be scheduled, which will include checking vital signs such as temperature, pulse, and blood pressure. To obtain a clearer view of the kidney stone, the healthcare provider may request imaging tests such as a computed tomography (CT) scan, ultrasound, or X-ray prior to surgery. Urine and blood tests may also be required to check for infections or other issues.

It is crucial to inform the healthcare provider about the following:

• All medications being taken, including prescription drugs, over-the-counter medications, and herbal supplements, as certain substances, such as aspirin, anti-inflammatory drugs, and blood thinners, can increase the risk of bleeding.
• Plans to discontinue any medications.
• Any known allergies, including those to medications, skin cleansers (such as iodine or isopropyl alcohol), latex, and foods.

The healthcare provider may also recommend the following before the procedure:

• Antibiotics to reduce the risk of infection after the procedure.
• Refraining from eating and drinking after midnight on the night before the procedure.

During the procedure

Percutaneous nephrolithotomy is typically performed in a hospital setting under general anesthesia, ensuring the patient is not awake and feels no pain. One usually lies on their stomach, though they may be positioned on their back with or without a cushion.

The procedure is done as follows:

• To create a pathway, a specialized needle is inserted into a urine-collecting chamber of the kidney.
• X-ray, CT, or ultrasound images is used to guide the needle into the correct position.
• A tube, known as catheter, may be inserted through the urethra to the kidney to help with imaging or through the use of a camera.
• A tube or sheath is placed along the needle’s path, allowing the healthcare provider to break up and remove the kidney stones.
• A nephrostomy tube is placed to drain urine from the kidney into an external bag during recovery, and to allow further access if needed.
• The healthcare provider will cover the patient’s stitches with bandages, and the kidney stone may be sent to a lab for analysis, helping to prevent future stones.

After the procedure

As the anesthesia wears off, one will regain consciousness but may feel groggy. In the recovery room, healthcare providers will monitor the patient, manage their pain, and ensure they are recovering properly.

It is normal for the patient to have a small amount of blood in their urine for one to two weeks after the surgery. However, those with drainage tubes left in the kidney should monitor for any signs of bleeding. Seek medical attention if any of the following is experienced:

• Fever
• Chills
• Pain not alleviated by medication
• Blood clots or thick, ketchup-like blood appear in the urine or drainage tube

Typically, the patient will stay in the hospital for a day for observation. Heavy lifting or strenuous activities for 2 to 4 weeks should be avoided. They may be able to return to work after about a week.

Outcome

After undergoing percutaneous nephrolithotomy, patients may need blood tests to identify the cause of the kidney stones and discuss strategies for preventing future stones. A follow-up visit with the surgeon is typically scheduled 4 to 6 weeks after the surgery, or sooner if a nephrostomy tube is in place. If a nephrostomy tube is present, it will be removed by the healthcare provider using local anesthesia. During this follow-up visit, imaging tests such as ultrasound, X-ray, or CT scan may also be performed to ensure that no stones remain, and that urine is draining properly.