What is PCNL?

Kidney stones occur when you have less fluid in your urine than the minerals. These stones occur in your kidneys, where your body produces urine. Depending on the type and size of your kidney stones, the urologist recommends different treatments, including surgery. Percutaneous nephrolithotomy (PCNL) is one of the surgical methods used when the kidney stone blocks the urinary tract or has a bigger size. 

What are the Benefits of PCNL?

1. Less post-operative pain 
2. Fewer complications 
3. Small incision as it is a minimally invasive surgery
4. Quicker recovery
5. Better rates at which stones pass out post-procedure for larger and more complex stones
6. As PCNL is tubeless, there is no urine leakage and no discomfort is caused from an external drainage tube 

Who needs PCNL?

Kidney stones are small and hard deposits in your kidneys, which can pass from the kidneys to the ureters (the tube that carries urine from the kidneys to the urinary bladder). Our urine contains several waste products, and when too much waste is accumulated in a small amount of urine, crystals form. These crystals attract other elements and grow in size and form a solid. The stone-forming elements are oxalic acid, uric acid, calcium, cystine, phosphate, and xanthine.

The symptoms that you have to differ according to the size of the kidney stones. You can experience symptoms like:

1. Severe pain in the lower side or back, which can travel down to your genital area
2. Pain in your abdominal area that does not go away
3. An intense need to urinate
4. Pain while passing urine
5. Blood in the urine
6. Nausea and vomiting
7. High body temperature and chills
8. Urine with a cloudy appearance or foul odour

Many kidney stones are relatively smaller and do not require any treatment. However, larger stones may take a longer time to pass through your ureter and cause severe pain and other symptoms. For such stones, a surgical procedure is required.

Percutaneous Nephrolithotomy or stone extraction is a procedure that is performed when kidney and ureteral stones are numerous, dense, or large (usually larger than two centimetres) to be treated by other surgeries. Your endourologist may suggest PCNL when:

1. The kidney stones are very painful and do not pass on their own.
2. You have cystine kidney stones (stones formed due to the accumulation of a natural substance called cystine in the urine) that are resistant to alternative treatments, like extracorporeal shock wave lithotripsy.
3. Other surgical approaches to remove kidney stones have failed or are not possible
4. As an alternative method to large instruments used in the conventional method as they can cause postoperative pain, blood loss, and potential kidney damage.
5. You have staghorn kidney stones, a kidney stone with extensive branching.
6. Endourologists recommend PCNL because it is a minimally invasive (one cm skin incision) procedure used to remove these stones. In addition, it reduces pain, blood loss, blood transfusions, and hospitalisation time.

How is PCNL done?

During PCNL, your endourologist will:

1. Make an incision (cut) of one cm in your flank (the area between the upper abdomen and the lower back)
2. Insert a tube with a small diameter will into your kidney by using X-ray guidance
3. Insert a small telescope inside the kidney to visualise the stone and a lithotripter device into the tube to break the stone into smaller fragments
4. Extract stone fragments through the tube
5. Close the incision with non-absorbable sutures (stitches) and an adhesive strapping.
6. Place a drainage catheter inside your kidney to restore the urine flow, which was previously blocked due to the presence of stones. This procedure is called a nephrostomy. The urine is collected into a small bag.
7. Also, place a ureteral stent inside the kidney to promote the drainage of urine from your kidneys to the bladder
8. Your operating surgeon will take three to four hours to complete this surgery.

What to Expect Before Surgery?

Before undergoing PCNL, you will have a pre-surgical check-up with your operating surgeon and anesthesiologist. During this check-up, your surgeon will:

1. Check your physical condition and medical history
2. Recommend several tests based on your age, medical history, and surgical risk, such as:
   1. Urinalysis (an examination of urine)
   2. EKG (electrocardiogram)
   3. PT / PTT (blood coagulation profile)
   4. Physical exam
   5. CBC (complete blood count)
   6. Comprehensive Metabolic Panel (blood chemistry profile)

To undergo PCNL, you should not have any active urinary infections as it can increase the risk of sepsis (the body’s reaction to infection leads to injury to its tissues) during surgery. If any infections are found, your surgeon will recommend antibiotics to clear the infection before the surgery.

Based on the pre-anaesthesia check-up, your anesthesiologist can recommend general or spinal anaesthesia.

What to Ask and Tell Your Doctor?

You must ask the surgeon questions about the surgery or recovery process at your pre-surgical appointment. For example, you can ask questions like:

1. Why do I need PCNL?
2. What is the benefit of surgery?
3. What are the risks and complications of PCNL?
4. How will my recovery process be?
5. How will you perform the surgery?
6. When can I go back to my everyday activities after surgery?

Also, your surgeon must have complete information about you to perform the surgery smoothly. During your pre-surgical appointment, inform your operating surgeon if you:

1. Are currently using any prescription, non-prescription, supplements, or blood-thinning medications (e.g., aspirin and ibuprofen)
2. Have any allergies to medicines or foods
3. Suffer from severe lung and heart conditions
4. Have unstoppable bleeding tendencies
5. Have symptoms of urinary tract infection, such as fever, burning sensation while urinating, blood in the urine or urgency to urinate

Based on the pre-anaesthesia check-up, your anesthesiologist can recommend general or spinal anaesthesia

What to Expect During Surgery?

Patient position:

After the administration of spinal anaesthesia, you will be placed in the prone position (lying on your abdomen).

Draping:

1. A warm-air blanket will be placed over your head and shoulders to maintain your body temperature intraoperatively.
2. Next, you will be draped with sterile covers and prepped for the procedure.

What is Recovery and Post Op. Care after PCNL?

At hospital:

1. After the first two days of surgery, your diet will be gradually increased from clear liquids to solid foods as tolerated.
2. Your endourologist will continuously monitor your vital signs, food and drink consumption, pain levels and surgery site until you are discharged from the hospital.
3. A few hours after surgery, you will be recommended to get up and walk under the supervision of a caregiver to prevent blood clots in your legs.
4. You will be allowed to go home one or two days after the surgery.

At home:

Bathing:

1. You can shower with your nephrostomy tube in place; however, the site should be patted dry immediately afterwards. 
2. Clean the site of the nephrostomy with soap and water while showering. It should be patted dry, and clean gauze should be applied over the area.
3. Avoid bathtubs or hot tubs while your nephrostomy tube is in place.

Activity:

1. Increase the duration of walking after getting discharged from the hospital.
2. Avoid heavy lifting and intense exercise for two to four weeks after the surgery. Deep breathing exercises are suggested by experts and are beneficial in preventing respiratory diseases such as pneumonia.
3. Avoid driving for seven days.
4. You can return to work after seven to 14 days post-surgery.

First Follow up Appointment

Your surgeon will schedule a follow-up four to six weeks after surgery.[6] During the follow-up, your surgeon will:

1. Perform an ultrasound or X-ray to check if:
   1. Pieces of stone are still left in your kidney
   2. The passage of urine from your kidneys to the bladder is proper
2. Check the laboratory results along with blood and urine reports to:
   1. Determine if you are at high risk for recurrence of stones
   2. Check possible causes of kidney stones and recommend further tests, medications, or preventive measures to prevent stone recurrence.
3. Remove the nephrostomy tube and the ureteral stent placed inside the kidney (one to two weeks post-surgery)

What are Risks and Complications after PCNL?

Compared to other minimally invasive lithotripsy techniques, PCNL is usually considered a safer approach, and it offers the highest stone-free rates following the first treatment. Common side effects experienced after the surgery include:

1. Postoperative pain in your flank area
2. Nausea for one or two days after surgery 
3. Fatigue (can last for a few weeks to a month)

Significant problems mentioned below may arise after the surgery, though they are uncommon: 

1. Infection or sepsis
2. Systemic inflammatory response syndrome and postoperative fever. The risk for a postoperative fever depends on:
   1. Your gender (more common if you are a female
   2. Size of the stone
   3. A positive preoperative urine culture
   4. Time required for the surgery
3. Renal haemorrhage (loss of blood)
4. Injuries to the colon, lung, liver, pleura, duodenum, and spleen 
5. Collection of urine outside the urinary system (urinoma). This is a rare complication and develops due to trauma and obstruction caused by the surgery.
6. Damage to the pelvicalyceal system (renal pelvis and major and minor calyces) during tract dilatation or manipulation with the rigid nephroscope
7. Failure to remove the stone entirely.

You must see an endourologist if:

1. Pain is not relieved by the pain medications
2. You experience fever and chills
3. You notice significant bleeding (particularly blood clots) in your urine