Percutaneous Nephrolithotomy (PCNL)
Figure 1: Percutaneous nephrolithotomy (PCNL) to remove large kidney stones
What are the indications for a PCNL?
PCNL is a technique used to remove certain stones in the kidney or upper ureter that are too large or in a place inaccessible for other forms of stone treatment such as shock wave lithotripsy or ureteroscopy. This is usually undertaken in stones larger than 1.5cm.
What pre-operative work up is needed?
Your urologist will organise any necessary urine and blood tests and imaging scans at your consultation prior to your procedure.
If you take any blood thinning medication such as aspirin, warfarin, plavix (clopidogrel) and anticoagulants, you should discuss with your urologist, as these need to be stopped temporarily before your procedure.
Please ensure you return any admission forms given to you to be filled out back to the hospital.
What happens on the day of the procedure?
You will be given fasting instructions prior to your admission (usually for 6 hours prior to the procedure). You should bring a list of your medications, any recent scans or reports with you to the hospital. After you are admitted from the admission lounge, your urologist will see you to discuss the surgery. An anaesthetist will see you to discuss the general anaesthetic before you are taken to the operation theatre. You may be provided with a pair of TED stockings to wear to prevent blood clots from developing and passing into your lungs.
What does this procedure involve?
After a general anaesthetic and an injection of antibiotics, a telescope is passed into your bladder, through your urethra (waterpipe). Through the telescope, a catheter is passed up into your kidney. The kidney is then punctured with a needle using X-ray guidance. A special balloon is passed through the puncture site and pumped up to create a passage into the kidney. A telescope is passed through this passage to see the stone(s) inside the kidney (pictured). The stones are broken up using a special machine or laser. We may insert a temporary drainage tube (a nephrostomy tube) into the kidney as well as a temporary drainage tube called a stent into your ureter at the end of the procedure to allow passage of blood and debris out of the system. The procedure takes 2 to 3 hours to perform.
Most patients will stay in hospital 1-2 days. The catheter in the bladder and the tube in the kidney are removed before discharge but the stent is left for a few weeks until confirmation of stone clearance is obtained.
If there are remaining fragments, a ureteroscopy may be performed later to completely treat the remaining stones. If this is the case, a stent will be left in your ureter until the second procedure.
Are there any risks or side-effects of a PCNL?
Mild burning on passing urine for a few days 60-70%
Blood in the urine for a few days after the procedure 60-70%
Discomfort in the kidney area for a few days 60-70%
Infection of the kidney requiring antibiotic treatment 5-10%
Remaining fragments in kidney needing secondary procedure 5-10%
Failed access to kidney requiring abandoning of procedure 2-3%
Significant bleeding needing transfusion, embolisation or removal of kidney 1-2%
Damage to the kidney, bowel, lung and other organs 1-2%
Major anaesthetic or cardiovascular problems 1-2%
What can I expect after discharge when I get home?
You should drink twice as much fluid as you would normally for the first 24 to 48 hours, to flush any blood and debris out of your system and reduce the risk of infection.
It will take you 5-7 days to recover from the procedure; you may return to light work after 2 weeks when you are comfortable enough and when your GP is satisfied with your progress. You should avoid any strenuous activity, heavy lifting or driving for at least 4 weeks. If you have had a stent put in, you may get blood stained urine, pain in your kidney area when you pass urine, or in your bladder; this usually settles quickly but may persist until the stent is removed in some patients.
If you feel unwell, develop a fever, get severe pain in the area of the affected kidney or on passing urine, get severe bleeding with clots in your urine or are unable to pass urine, you should go to your nearest emergency department.
What follow-up will I need?
Your urologist will generally see you in the clinic in the next 4-6 weeks with an X-ray and / or CT scan prior.