Treatments

Percutaneous Nephrolithotomy /Nephrolithotripsy (PCNL)

PCNL is a minimally invasive technique to access the kidney to remove large stones (>2cm) or stones that are resistant to other treatments.

It involves entering the kidney through a small incision in the back. Once the surgeon gets to the kidney, a nephroscope (a miniature fiberoptic camera) and other small instruments are threaded in through the hole. lf the stone is removed through the tube, it is called nephrolithotomy. lf the stone is broken up and then removed, it is called nephrolithotripsy. The surgeon can see the stone, use high frequency sound waves to break up the stone, and “vacuum” up the dust using a suction machine.

What it means:

  • Percutaneous means through the skin
  • Nephrolithotomy is a combination of the word roots nephro- (kidney), litho-(stone) and -tomy (removal)
  • Nephrolithotripsy is a combination of the word roots nephro- (kidney), litho (stone), and -tripsy (crushed)

(Uncomplicated PCNL)

Hospital Stay: Hospital Stay: 5 days
Duration: Duration: 3-4 hrs
Cost Estimate: Cost Estimate: 1575 USD - 4078 USD

(Stag Horn Calculus PCNL)

Hospital Stay: Hospital Stay: 5 days
Duration: Duration: 3-4 hrs
Cost Estimate: Cost Estimate: 2250 USD - 5211 USD These are indicative prices in Indian Hospitals

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.

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 or carbon dioxide 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.

Typically, the length of the surgery is 3-4 hours. The surgery is performed by making a small 1 cm incision in the patient’s flank area. A tube is placed through the incision into the kidney under x-ray guidance. A small telescope is then passed through the tube in order to visualize the stone, break it up and remove it from the body. If necessary a laser or other device called a lithotripter may be used to break up the stone before it can be removed. This procedure has resulted in significantly less post-operative pain, a shorter hospital stay, and earlier return to work and daily activities when compared to open stone surgery.

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.

This technique also has a higher success rate for clearing all stones in one setting than other techniques such as extracorporeal shock wave lithotripsy (ESWL), which often require several attempts.

Risks and Complications

Although this procedure has proven to be very safe, as in any surgical procedure there are risks and potential complications. The safety and complication rates are similar when compared to the open surgery. Potential risks include:

  • Bleeding:
  • Infection:
  • Tissue / Organ Injury:
  • Conversion to open surgery.
  • Failure to Remove the Stone

What to expect after surgery:

During hospitalization

Immediately after the surgery you will be taken to the recovery room, then transferred to hospital room once you are fully awake and your vital signs are stable.

  • Post-operative pain: Pain medication can be controlled and delivered by the patient via an intravenous catheter or by injection (pain shot).
  • Nephrostomy Tube: You can expect to have a small tube called a nephrostomy tube coming out of your back to allow urine to drain from the kidney into a drainage bag. The nephrostomy tube typically remains in place for 1-2 days. There is a possibility that you will be discharged from the hospital with the nephrostomy tube as deemed necessary by your surgeon.
  • Stent: You may have an internal ureteral stent in place within the ureter, between the kidney to the bladder to promote drainage from the kidney. This will be removed in typically 1-2 weeks following surgery.
  • Nausea: You may experience some nausea related to the anaesthesia. Medication will be given to treat persistent nausea.
  • Urinary Catheter: You can expect to have a urinary catheter draining your bladder (which is placed in the operating room while the patient is asleep) for approximately one day after the surgery. It is not uncommon to have blood-tinged urine for a several days after surgery.
  • Diet: You can expect to have an intravenous catheter (IV) in for 1-2 days. Most patients are able to tolerate small sips of liquids on the day of the surgery and regular food the next day. Once on a regular diet, pain medication can be given by mouth instead of by IV or shot.
  • Fatigue is common and should subside in a few weeks following surgery.
  • Incentive Spirometry: You will be expected to do some very simple breathing exercises to help prevent respiratory infections through use of an incentive spirometry device (these exercises will be explained to you during your hospital stay). Coughing and deep breathing is an important part of your recuperation and helps prevent pneumonia and other pulmonary complications.
  • Ambulation: On the day after your surgery it is very important to get out of bed and begin walking with the supervision of nurse or family member to help prevent blood clots from forming in your legs. You can expect to have SCDs (sequential compression devices) along with tight white stockings on your legs to also aid in the prevention of blood clots.
  • Hospital Stay: The length of hospital stay for most patients is approximately 2 days.
  • Constipation: You may experience sluggish bowels for several days or several weeks following surgery. Suppositories and stool softeners can be taken to help with this problem.
  • Secondary Procedures: Some patients have stones that are very large or that cannot be safely removed at one setting. You may need a “second look” operation to remove any remaining stones, either during the hospitalization or at another visit.

What to expect after discharge from the hospital:

Pain Control: you can expect to have some pain that may require pain medication for a few days after discharge.
Showering: Tub baths can soak your incision and therefore are not recommended in the first 2 weeks after surgery.
Activity: Taking daily walks is advised. 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. 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.
Stent Follow-up: The length of time the stent remains in place is variable. Your doctor will probably request it to be removed within a 1-4 week period. 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. It is critical that patients return to have their stent removed as instructed by their physician as a prolonged indwelling ureteral stent can result in encrustation by stone debris, infection, and obstruction of the kidney.
Nephrostomy Site Care: If you are discharged home with a nephrostomy in place, it is important that urine flow freely through the tube. Check daily to make sure the tube is not kinked. Monitor the amount of drainage and color. Blood tinged urine is not uncommon. Keep the drainage bag below the level of the kidney at all times. It is important to clean the area around the insertion site. Pat the area dry after showering and clean directly around the insertion site with hydrogen peroxide using a cotton tip applicator. Apply a clean sterile dressing after cleaning the area. 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.

When to call your Doctor

Although adverse events are rare 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

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.

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.

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.

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.

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.

In most cases an indwelling ureteral stent is placed to promote drainage of urine from the kidney to the bladder.

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. Our surgeons 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.

Following PCNL, your surgeon will determine whether the treatment was successful based upon a CT scan that is performed during your hospitalization on the first postoperative day. 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.

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.

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.

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