PCNL (Percutaneous Nephrolithotomy) for kidney and upper ureteric stones
Percutaneous nephrolithotomy (PCNL) is a minimally-invasive procedure to remove stones from the kidney by a small puncture wound (up to about 1 cm) through the skin of your back. It is most suitable to remove stones of more than 2 cm in size and which are present near the pelvic region of the kidney and within the kidney.
After removal of the stone, a tube known as a nephrostomy is inserted into the kidney which drains from your back into a drainage bag and kept there for 3-5 days to allow the tube to tamponade bleeding from the puncture tract between the skin and the kidney. Urine from the kidney is often blood-tinged and will clear over the ensuing days following surgery.
On occasions, a second PCNL procedure may be required as a “second look” procedure through the original nephrostomy tract to retrieve any retained stone fragments. This procedure may be performed within 3-5 days during your hospitalization or at a second surgery date as determined by your surgeon.
PCNL, minimally invasive operation done via a small puncture in the kidney. Pic from Health Travelers Worldwide
Prior to PCNL
What to expect during you preoperative consultation:
Prior to your initial consultation, it is important for patients to obtain all Xray films (e.g. KUB, CT scan, MRI, sonogram) and reports to bring to your surgeon for review. Your surgeon will review your medical history and perform a brief physical examination. A urinalysis will also be performed at your initial visit. All options for treatment of your stone(s) will be discussed at this time as well as the risks and benefits of each treatment. If your surgeon determines that you are a candidate for PCNL, he will then arrange for the date of your operation.
What to expect prior to the surgery:
Once your surgery date is secured, the items listed below will be ordered as necessary based upon your age, medical history and risk for surgery. You will have the opportunity to speak to the anesthesia staff regarding the types of anesthesia available and the risks / benefits.
Physical exam
ECG (electrocardiogram)
CBC (complete blood count)
Comprehensive Metabolic Panel (blood chemistry profile)
Urinalysis and Urine Culture
Preparation for surgery
Medications to Avoid Prior to Surgery:
The following is a list of medications to avoid at least 7-10 days prior to surgery. Many of these medications can alter platelet function or your body’s ability to clot and therefore may contribute to unwanted bleeding during surgery. Please contact your surgeon’s office if you are unsure about which medications to stop prior to surgery. Do not stop any medication without contacting the prescribing doctor to get their approval.
Antiplatelets: Aspirin, Cardiprin, Plavix (Clopidogrel), Ticlid, Prasugrel, Ticagrelor (Brilinta), and any blood thinners
Anti-coagulants: Warfarin, Rivaroxaban (Xarelto), Dabigatran (Pradaxa), Apixaban (Eliquis), Edoxaban (Lixiana), etc
NSAIDs and COX2 inhibitors: Ibuprofen, Diclofenac (Voltaren), Mefenemic acid, Indomethacin, Celebrex, Vioxx, etc
Inform your doctor if you are taking herbal, traditional medicines or any unregistered medications
Signs and Treatment of Urinary Infections Prior to Surgery:
It is very important that your urine remain free of infection prior to PCNL. Therefore if you suspect that you may have a urinary tract infection (burning on urination, blood in the urine, urinary frequency and urgency, fevers), please notify your surgeon immediate so that proper cultures and treatment may be provided.
The Surgery
PCNL is performed under general anesthesia with the patient lying face down on their abdomen.
Once anesthesia is administered, your surgeon will perform cystoscopy (telescopic examination of your bladder) and instill x-ray dye into your kidney through a small catheter placed up through the ureter or drainage tube of the affected kidney to “map” the branches of the collecting system. This allows your surgeon to precisely locate the stone within the kidney and place a small needle through the skin under x-ray guidance to directly access the stone.
This needle tract is dilated to approximately 1-cm to allow placement of a plastic sheath and telescope to directly visualize the stone. Using an ultrasonic, mechanical or laser lithotripsy device, the stone is fragmented into small pieces and extracted out of the body through the sheath. On occasions, more than one tract may be required to access and attempts removal of all stones.
A small ureteral stent may be left draining the kidney to the bladder in addition to a nephrostomy tube draining the kidney to an external drainage bag at the end of the operation. The length of the surgery is generally 3-4 hours.
Potential Risks and Complications
As with any surgical procedure there are risks and potential complications that are associated with PCNL. Potential risks include:
Bleeding:
Blood loss during PCNL is generally minimal, and risk of blood transfusion ranges from 2-5%, depending on stone size, location, and number of tracts dilated.
Infection:
Bacteria can at times grow within stones and therefore cause a urinary infection and rarely sepsis during stone surgery. As a result, urinary infections should be treated before surgery and broad-spectrum antibiotics are administered at the start of the operation to minimize the risk of a urinary infection.
Adjacent Tissue and Organ Injury:
Rarely organs surrounding the kidney such as bowel, colon, blood vessels, spleen, and liver may be injured during surgery requiring emergent open surgery or further surgery.
The chest cavity is in close proximity to the upper pole of the kidney and can be accidentally entered when accessing an upper pole kidney stone resulting in a pneumothorax (or air surrounding the lung). This may require that a small chest tube be placed temporarily to drain air and fluid from around the lung.
Permanent damage to the kidney during PCNL resulting in loss of the kidney is extremely rare.
Damage and perforation to the ureter draining the kidney may result in scarring and obstruction requiring further surgery.
Failure to Remove the Stone:
Despite placement of one or more tracts into the kidney to remove stones, there is a small chance that PCNL may not be able to successfully remove all stones as a result of either size, number or location of the stone within the collecting system. Additional treatment may be required.
What to Expect After Surgery
Following your surgery you will be transferred to the recovery room and then to your hospital room once you are fully awake.
Post-operative pain:
Following surgery, pain in the flank area overlying your kidney is common for the first few days, but well controlled with intravenous or oral pain medication provided to you on request by your nurse.
Nephrostomy Tube:
A nephrostomy tube drains urine directly from your kidney into a drainage bag. It is routinely placed to tamponade bleeding from the tract between the skin and the kidney.
Urine from the kidney is often blood-tinged and will clear over the ensuing days following surgery.
There is a possibility that you will either get your nephrostomy tube removed within 3-5 days, or be discharged from the hospital with the nephrostomy tube as deemed necessary by your surgeon. The nephrostomy tube will then be removed in the office at the bedside generally 1-2 weeks following surgery.
Ureteral Stent:
A ureteral stent is a small flexible plastic (polyurethane) internal tube that is placed to promote drainage of your kidney down to the bladder. This will be removed in your surgeon’s office in typically 1-3 weeks following surgery.
Nausea:
Often patients experience transient nausea the first day or two following surgery under general anesthesia. Medication is available to treat persistent nausea.
Urinary Catheter:
A bladder catheter called a Foley is placed in the operating room while you are asleep and left in place for approximately one day after the surgery. This allows your surgical team to continuously monitor your urine output. It is not uncommon to have blood-tinged urine for a several days after surgery. The catheter will be removed prior to discharge.
Diet:
Your diet will be advanced slowly from clear liquids to solid foods as tolerated following surgery. In addition, intravenous fluids will be administered to keep your body well hydrated following surgery.
Fatigue:
Fatigue is common and should start to subside in a few weeks to a month following surgery.
Incentive Spirometry:
Deep breathing exercises are important in reducing the incidence of pulmonary complications such as pneumonia. These exercises will be performed with the use of an incentive spirometer, which your nurses and surgical team will explain how to use.
Physical Activity:
It is very important to get out of bed and begin walking with the supervision of your nurse or family member to help prevent blood clots from forming in your legs. You can also expect to have SCD’s (sequential compression devices), if you are high risk, to prevent blood clots from forming in your legs. During your hospital stay it is advised that you walk at least 4-6 times in the hallways per day to minimize risks of clots. The more walking you can tolerate the better.
Hospital Stay:
The length of hospital stay for most patients is approximately 3-5 days.
Secondary Procedures:
At times it may be difficult to visualize all areas of the collecting system despite the use of flexible telescopes and therefore some stones may not be retrievable.
On such occasions, a second PCNL procedure may be required as a “second look” procedure through the original nephrostomy tract to retrieve any retained stone fragments. This procedure may be performed during your hospitalization or at a second surgery date as determined by your surgeon.
If stone fragments remain within the urinary tract, more time may be required to allow for spontaneous passage, which often takes several weeks. Alternatively your surgeon may recommend further treatment with repeat PCNL, ESWL, or ureteroscopy.
What to Expect After Discharge from the Hospital
Pain Control:
Mild pain at the nephrostomy tube site may require pain medication.
Showering:
Showering with your nephrostomy tube in place is permissible; however, the site should be patted dry immediately after showering. Tub baths or hot tubs should be avoided while your nephrostomy tube is in place.
Activity:
Taking daily walks is advised to minimize blood clots, called a deep vein thrombosis, from forming in your legs. Prolonged sitting or lying in bed should be avoided. Climbing stairs is possible, however, should be taken slowly.
Driving should be avoided for at least 1-2 weeks after surgery and only after narcotic pain medications have been stopped. After this time, activity can begin as tolerated.
You can expect to return to work as soon as 1-2 weeks following surgery or as instructed by your physician.
Nephrostomy Site Care:
Caring for your nephrostomy tube is critical to ensure proper healing of your kidney. It is important that urine flow freely from the tube and into the drainage bag, which should be kept below the level of your kidney at all times.
Clean the area around the nephrostomy tube insertion site wound with mild soap and water each day when you shower. Pat the area dry after showering and clean directly around the insertion site. Apply a clean gauze dressing after cleaning the area.
If urine stops draining from your tube, this may result in obstruction of your kidney, increased pain and infection. Immediately check your nephrostomy tube to ensure that it is not kinked or has not been pulled or dislodged from proper position.
If you experience any change in pain, fever, chills, pus forming around the insertion site, the catheter not draining or leaking around the tube you must contact your doctor immediately.
Follow-up for Stent Removal:
The ureteral stent is generally removed within 1-3 weeks following surgery and will be determined by your surgeon. While your stent is in place, it is common to feel a slight amount of flank fullness and urgency to void as a result of the stent. These symptoms often improve over time as the body adjusts to the indwelling stent.
The stent is removed by cystoscopy during which time your surgeon will place a small flexible telescope into the urethra to visualize and grasp the terminal end of the stent that rests in your bladder. This generally takes less than a couple of minutes to perform.
NOTE: It is critical that patients return to have their ureteral stent removed as instructed by their surgeon as a prolonged indwelling ureteral stent can result in encrustation by stone debris, infection, and obstruction and potential loss of the kidney.
When to call your Doctor
Although serious adverse events are uncommon following PCNL, it is important for patients to recognize these events and know when to contact their surgeon. You should contact your surgeon or primary care doctor immediately if any of the following occur:
Worsening pain over the ensuing days following PCNL. If this pain continues to escalate despite the use of oral pain medication, this may indicate obstruction of the kidney from a large stone fragment lodged within the ureter, hematoma around the kidney or infection of the kidney.
Large amounts of blood clots in the urine that may lead to difficulty with voiding and fully emptying the bladder.
Fevers >101o F may indicate a serious infection within the urinary tract.
Nausea and vomiting
Chest pain or difficulty breathing
Frequently Asked Questions (FAQs)
What is the advantage of PCNL as compared to other stone treatments?
The primary advantage of PCNL over other treatments such as ESWL or ureteroscopy is that it provides a minimally invasive approach to treating and removing large stone burden in a single setting as compared to the need for multiple surgeries with the other therapies mentioned.
Are there disadvantages?
Whereas ESWL and ureteroscopy can be performed under intravenous sedation, PCNL requires a general anesthesia. Some patients may not be able to tolerate a general anesthesia due to their medical condition(s). As compared to other stone treatments, PCNL is slightly more invasive carrying with it a slightly higher risk. However, for most patients with large stone burdens, multiple stones or stones resistant to other forms of treatment, the benefits of PCNL outweigh the risks.
Which patients are good candidates for PCNL?
PCNL is an excellent option for patients with large kidney or ureteral stones (generally > 2 cm), multiple large stones, or stones resistant to prior treatment with ESWL or ureteroscopy.
What patients are not good candidates for PCNL?
Patients who have severe heart or lung conditions or have an uncorrectable bleeding propensity are not good candidates for PCNL. Patients with an active urinary infection are at a higher risk of sepsis during surgery and therefore should be treated with antibiotics to clear up the urinary infection prior to PCNL.
Can multiple stones be treated simultaneously with PCNL?
Multiple stones can be treated with PCNL. This is one of the advantages of this approach as a flexible telescope can be passed through the skin and directly into the kidney to attempt identification and removal of multiple stones in one setting. However, at times it may be difficult to visualize all areas of the collecting system despite the use of flexible telescopes and therefore some stones may not be retrievable. This may require placement of a second needle tract to access the remaining stones or a second PCNL procedure at a later date. Alternatively, PCNL can be used to remove the majority of the stone burden with ureteroscopy and ESWL left to clean up the remaining stone fragments.
Will I need placement of an indwelling ureteral stent following PCNL?
In most cases an indwelling ureteral stent is placed to promote drainage of urine from the kidney to the bladder.
What is the overall success rate with PCNL?
The success of PCNL is dependent on many factors such as stone composition, stone size, number of stones, location within the urinary tract, patient body habitus (obesity), and anatomy of the collecting system of the kidney. Your doctor will carefully consider all of the aforementioned variables and will discuss this with you in order to maximize success and determine if PCNL is right for you. Overall stone free success rate is approximately 80-90% following an initial PCNL and 90-100% following a “second look” procedure.
How do I know if PCNL was successful?
Following PCNL, your surgeon will determine whether the treatment was successful based upon an ultrasound, X-ray or CT scan that is performed during your hospitalization.
If stone fragments remain within the urinary tract, more time may be required to allow for spontaneous passage, which often takes several weeks. Alternatively your surgeon may recommend further treatment with repeat PCNL, ESWL, or ureteroscopy.
Can PCNL be repeated?
Yes. Often due to stone density or size or difficult anatomy of the collecting system, fragments may at times remain in the urinary tract that may require a “second look” procedure to attempt removal. This is usually performed a few days after your initial surgery. Alternatively this second procedure may be staged at a later date depending upon your surgeon.
Can PCNL be performed on both of my kidneys at the same time?
If patients present with large stone burdens in both kidneys, bilateral PCNL surgeries can be performed at the same setting or alternatively staged at a later date as two separate surgeries. This decision will be made with you by your surgeon.
