Percutaneous Nephrolithotomy (PCNL)

PCNL is a procedure that is performed to remove kidney stones or stones present in the upper ureter (the tube connecting the kidney to the bladder).

Kidney stones are formed due to solidification of certain chemical compounds present in the urine. If the stones are too large or cannot be removed by other treatment approaches, like ureteroscopy or SWL, doctors use the PCNL technique for stone removal. PCNL is generally performed by a urologist or a urologist-radiologist team.

In the past, open surgery with large incisions was required to remove large stones. However, the procedure for PCNL requires a very small incision and therefore reduces blood loss, pain and hospitalisation period. It is also highly successful in removing all the stones in a single procedure compared to other techniques for kidney stone removal that require several procedures.

A urologist may recommend this procedure if you have any of the following symptoms suggestive of kidney stones:

• Sharp pain in your side, lower abdomen, back or groin
• Pain while urinating
• Constant urge to urinate
• Inability to urinate
• Urinating only in small amounts
• Cloudy urine
• Bad-smelling urine
• Red, brown or pink urine
• Other symptoms like nausea, vomiting, fever or chills

PCNL is recommended:

• To remove kidney stones of size greater than 2 cm
• As an alternative to retrograde intrarenal surgery (RIRS) for kidney stones of size 1-2 cm. In RIRS, kidneys are accesed through the ureter 
• Together with RIRS for lower pole (the bottom portion of the kidney) kidney stones of size less than 1 cm
• To remove lower pole kidney stones of size 1-2 cm when factors are unfavourable for SWL
• For kidney stones that cannot be treated by SWL

Your urologist may not recommend this surgery if you:

• Are pregnant
• Have untreated urinary tract infection
• Are undergoing anticoagulant therapy (treatment to slow blood clotting)
• Have a tumour in the urinary tract
• Have kidney cancer

Before the surgery, inform your urologist if you:

• Are pregnant
• Have been consuming excess alcohol
• Have had an allergic reaction to the dye used for x-rays

Once your surgery has been scheduled, the urologist may ask you to get the following medical tests done:

• Physical exam
• Complete blood count
• Comprehensive metabolic panel
• Electrocardiogram
• Blood coagulation profile
• Urinalysis

Share with your urologist the list of all the medicines that you take, including vitamins, supplements and over-the-counter medicines. Your doctor may ask you to discontinue medicines containing the following components one week before the surgery:

• Aspirin
• Ibuprofen
• Warfarin
• Vitamin E
• Ticlopidine
• Enoxaparin
• Celecoxib
• Diclofenac
• Rofecoxib
• Clopidogrel

You also need to ensure that you don’t get a urinary tract infection before surgery. Therefore, inform your urologist if you experience any of the following symptoms:

• Burning sensation while urinating
• Sudden and intense urge to urinate 
• Need to urinate often
• Fever
• Blood in urine

Your doctor will perform necessary tests and start appropriate treatment if urinary tract infection is detected.

You are not supposed to drink/eat anything for a minimum of six hours before the surgery. Your urologist may prescribe some medicines on the day of surgery, which you can take with a small sip of water.

You will be asked to sign a consent form before the surgery and change into an operation theatre gown.

PCNL surgery consists of the following steps:

• A urologist or medical staff will make you lie face down on the operating table. He/she will give you general anaesthesia so that you sleep through the procedure and feel no pain.
• The urologist will insert a cystoscope (a thin camera) through your urethra (the tube that carries urine out of the body) into your bladder.
• A tube will then be passed through your ureter into your kidney to inject x-ray dye. This allows the urologist to find the precise location of the stone using x-rays.
• The urologist will then puncture the skin on your back with a fine needle and direct it towards the stone within the kidney under x-ray guidance.
• A 1.5-cm incision will be made on your back, and the path of the needle to the kidney will be stretched to pass a tube into the kidney.
• The urologist will then insert a telescope along with a stone fragmentation tool through the tube to look at the stone, break it into pieces and remove them from the kidney.
• A small stent (tube) may be placed in the ureter after removing the stones to ensure good drainage of urine. Another tube, called a nephrostomy tube, may also be inserted through the incision made in your back to drain the contents of your kidney into an external collection bag.
• The whole procedure may last for three to four hours.

A Foley catheter, which is a soft rubber tube, may be placed in your bladder while you are unconscious during the surgery to monitor your urine output. It will be removed before you are discharged from the hospital.

After the surgery

You will be shifted to a recovery room immediately after the surgery and once your vitals are stable and you regain consciousness you will be shifted to a hospital room. You may be hospitalised for one to two days after the surgery. During postoperative hospitalisation, You may require an IV catheter for up to two days to inject necessary fluids and medicines through your vein. You will be fed with a liquid diet initially and then advanced to solid food during your stay at the hospital.

You can expect the following:

• Tiredness and pain for a few days. The medical staff will give you pain medication by injection or via an intravenous (IV) catheter. 
• Nausea for a day or two, mostly because of the anaesthesia. You may be given medicines if the nausea persists.
• Slow or no bowel movements for a few days following the surgery. Stool softeners and mineral oil can help you give relief from constipation.

It is essential that you walk soon as you can after the surgery - under the supervision of medical staff - to prevent the formation of blood clots in your legs. You may need to wear tight stockings along with sequential compression devices (SCDs) to prevent blood clots. SCDs are sleeves wrapped around each leg. The sleeves inflate with air one leg at a time to mimic walking.

The medical staff will recommend you to do some specific breathing exercises using a device called incentive spirometer to prevent respiratory problems such as pneumonia.

After discharge from the hospital:

• You may observe blood in urine for up to two weeks after the surgery. Drink at least two litres of water or take enough liquids daily to help with this.
• Avoid soaking the incision for too long. Do not take tub baths, instead opt for showers. You can wet the site of incision, though make sure to dry it properly with a pad.
• Avoid straining and lifting heavy weights for at least four weeks.
• You may feel soreness around the operated area for several weeks. Your doctor would have prescribed some pain medicines which you can take as directed.
• Avoid lying down for extended periods since it may increase your chances of developing blood clots in legs or pneumonia.
• You can go for daily walks but avoid climbing stairs when you can or go slow on stairs.
• Start driving again only after at least two weeks or when your doctor says so.
• Usually, you can return to work one to two weeks after surgery. However, consult your doctor first.
• If the surgeon has discharged you with a nephrostomy tube, you need to take care of the following things to make sure that urine flows freely through the tube:
  • Tape the tube to your skin to keep it from being pulled.
  • Check the tube daily to ensure that there are no bends.
  • Make sure the stopcock of the tube (if present) is in open position.
  • Clean the area around the tube insertion daily with mild soap and water when you shower and pat the area dry. Clean directly around the site with hydrogen peroxide using a cotton tip applicator and apply a sterile dressing over the area.
  • Ensure that the urine collection bag is always kept below the level of kidneys.
  • If you notice a leakage around the tube or if the tube stops draining contact the doctor immediately, especially if you experience pain and fever.

PCNL is the most effective procedure to remove kidney stones completely. It almost always gives relief from the symptoms of kidney stones. In addition, PCNL has the following advantages over open stone surgery:

• Shorter period of hospitalisation
• Earlier return to normal routine and work
• Less postoperative pain

When to see the doctor?

You must immediately contact the hospital if you experience any of the following symptoms:

• Nausea or vomiting
• Fever greater than 101^oF
• Chest pain or difficulty breathing
• Numerous blood clots in the urine, causing difficulty in emptying your bladder
• Worsening pain in your lower ribs, lower abdomen and back

This surgery is generally safe. However, the safety and complications rates of this surgery are comparable to those of open surgery. The complications that may occur with a PCNL surgery are:

• Surgical wound infections are a common risk after surgeries. However, to prevent this, your doctor may give antibiotics. Contact your surgeon if you experience any of the following symptoms of infection: 
  • Need to urinate frequently
  • Discharge from the site of incision
  • Fever
  • Pain
  • Minimal blood loss may occur with this surgery. However, blood transfusion is rarely required.
• Injury to adjacent organs - like the bowel, liver, spleen and pancreas may rarely occur. Kidney function may be affected in rare cases. Scar tissue formation in the kidney or ureter may require further surgery.
• In some cases, the surgeon may fail to remove the stones completely due to its size or location, which may warrant further treatment.
• If the surgeon faces difficulties during the procedure, you may require a standard open surgery, which is associated with a larger incision and longer recovery period.

If a ureteral stent and/or a nephrostomy tube has been placed during the surgery, you may need to visit the urologist after one to two weeks for their removal. You may also have a follow-up about two months after the surgery to look at your kidneys and bladder using x-rays.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.