Q1. What is percutaneous nephrolithotomy (PCNL)?
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Q2. What exactly is done?
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Q3. What is the main advantage of this approach?
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Q4. What are the pre-operative tests that are required?
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Q5. When would your doctor recommend this procedure?
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Q6. Does this procedure need anaesthesia?
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Q7. What is the success rate of clearance of stones with this procedure?
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Q8. What is the post-operative course like?
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Q9. What are the complications associated with this procedure?
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Q10. When can I get back to work?
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Q11. What are the contraindications to this procedure?
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Q12. When should I come back after the procedure?
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Q13. How do I prevent recurrence of these stones?
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| Q1. |
What is percutaneous nephrolithotomy (PCNL)? |
| A1. |
Percutaneous nephrolithotomy (PCNL) is a well-established procedure by which stones in the kidney or the upper ureter are removed by making a small incision in the flank. |
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| Q2. |
What exactly is done? |
| A2. |
Generally, an incision, that is 1 cm or less than 1 cm, is made in the flank. A guide wire is passed through this incision into the kidney. This is performed under fluoroscopy or x-ray control. A passage is then created around this guide wire by dilatation. Through this passage, a nephroscope is passed into the kidney in order to visualise the stone and remove it. Larger stones can be fragmented by different methods and removed. Stones are therefore cleared easily.
Once the procedure is complete, a tube is left through this tract as drainage for one or two days.
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| Q3. |
What is the main advantage of this approach? top |
| A3. |
Unlike traditional open surgery, only an incision of 1 cm is made in the flank. The stones can be visualised directly and removed. Unlike ESWL or ureteroscopy, the stones are removed in the same sitting and the kidney is cleared of calculi. The stay in the hospital is only for 3-4 days. |
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| Q4. |
What are the pre-operative tests that are required? |
| A4. |
Apart from the routine blood and urine investigations, you will also need an ultrasound scan of the abdomen. An intravenous urogram or IVU (special x-rays to image the urinary tract) will delineate the anatomy and function of the kidneys, helping to plan the appropriate treatment. Urine cultures are mandatory to detect and treat urinary infection, prior to the procedure. |
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| Q5. |
When would your doctor recommend this procedure? |
| A5. |
This surgery would be recommended as a treatment of choice if you have kidney stones larger than 2 cm, upper ureteric stones bigger than 1 cm, or at times for stones found in the lower pole of the kidney that cannot be effectively treated with either ureteroscopy or ESWL.
This procedure is also performed following failure of other modalities of treatment such as medical therapy, ESWL, etc., for renal and upper ureteric stones. |
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| Q6. |
Does this procedure need anaesthesia? |
| A6. |
Yes, it is commonly performed under general anaesthesia and therefore you also need to be admitted to the hospital for this procedure. In special circumstances, it can be performed under intravenous sedation, or under regional or local anaesthesia. |
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| Q7. |
What is the success rate of clearance of stones with this procedure? top |
| A7. |
It ranges between 90 to 95%. This actually depends upon the size, number and location of these stones. Sometimes, complete clearance may require a second procedure after a few days. |
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| Q8. |
What is the post-operative course like? |
| A8. |
Usually, you will need to stay in the hospital for 2 to 3 days after the procedure. You will also undergo additional x-rays or ultrasound studies, in order to determine if there are any residual stone fragments present.
A large amount of residue will require the urologist to look again with a nephroscope to remove it. The other alternative is to treat the remaining fragments with ESWL.
From the site of the puncture, you will have a drainage tube and a urethral catheter, for a day or two. Following the removal of the flank drainage tube, urine may leak for a day.
After your operation, your urologist will also encourage a high fluid intake, in order to keep the daily volume of urine produced to more than 2 litres a day. |
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| Q9. |
What are the complications associated with this procedure? |
| A9. |
By and large, this procedure is safe. Some risks that can be associated with all surgical procedures are the possibilities of bleeding (1%) and infection, sometimes requiring blood transfusion.
Some patients have a prolonged leakage of urine from the flank site, requiring ureteric stenting. Fever, if present, will require a change in antibiotic.
Rare complications in patients include persistent, uncontrolled bleeding due to arteriovenous malformations or pseudo-aneurysms (0.4%). These patients will need secondary procedures or even a nephrectomy to control the same.
When a supracostal puncture (above the 12th rib) is made, complications would then include pneumothorax (commonly called collapsed lung, which is caused due to the accumulation of air or gas in the space surrounding the lungs) or fluid accumulation in the thorax. Again the incidence of these is only 0-4%. |
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| Q10. |
When can I get back to work? top |
| A10. |
This would depend upon the magnitude of the stone burden and the number of tracts made. Most patients return to average activity levels within a week or so. A return to vigorous activity should probably take place after two weeks. |
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| Q11. |
What are the contraindications to this procedure? |
| A11. |
The contraindications to this procedure are bleeding disorders and pregnancy (due to the risk of radiation). The others are medical problems that make the patient unsuitable for anaesthesia. |
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| Q12. |
When should I come back after the procedure? |
| A12. |
Your first review would be at three weeks. If you have a ureteric stent (a tube in your ureter), it is usually removed at that time. You would also need a urine culture to check for any urinary tract infection. Further reviews will be advised by your doctor. |
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| Q13. |
How do I prevent recurrence of these stones? |
| A13. |
It is advisable to maintain a urine output of 2 to 2.5 litres per day. Your doctor may also advise dietary changes and medications, which will be tailored according to the requirements of your case. Generally, a high-fibre diet, with avoidance of high-calorie foods, is recommended.
Diagram Illustrating How PCNL is Performed
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