Percutaneous Nephrolithotomy (PCNL)

Definition

Percutaneous = “through the skin”

Nephro = “kidney”

Lithotomy = “stone breakage and removal”

Essentially, a PCNL is just that…removing a kidney stone through a hole in your back. Before the invention of endoscopic (through a scope) procedures, very large kidney stones would be removed through an incision (open operation). While this is still sometimes performed, open operations for stones are now rarely necessary.

We attempt to remove most kidney stones with shock wave lithotripsy (SWL), which is anon-invasive procedure involving external shock waves. Other stones in the kidney or ureter(tube extending from the kidney to the bladder) can be successfully treated with ureteroscopy (a procedure in which a scope is passed from the urethra, into the bladder and up the ureter into the kidney). In this operation, no incisions are made in the skin.

When a stone is very large, moderately large and located in certain parts of the kidney, or have been unsuccessfully treated with the above mentioned procedures, a PCNL is commonly recommended.

Preparation

As with any procedure in which anesthesia is administered, you will be asked not to eat or drink anything after midnight on the evening prior to your surgery. You may brush your teeth in the morning but not swallow the water. If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if you are currently taking, or have recently taken any medication that may interfere with your ability to clot your blood (“blood thinners, aspirin, anti-inflammatory medicines, etc….”). The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter). Please refer to the attached list and tell us if you took any of these within the past 10 days. If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

Procedure

To review the basics of what we discussed in the office: Some urologists place the initial tube into your kidney at the time of the procedure. Other urologists ask the interventional radiology team (physician radiologists that perform minimally invasive procedures) to place the initial tube the day prior to or the day of your procedure.

This initial tube (the nephrostomy tube) is called the “access” because it is the tube that will allow us access to the center of your kidney. If your tube is being placed the day prior, you will be admitted to the hospital overnight, and the PCNL will be performed the following day.

The actual procedure can take anywhere from one to three hours depending on stones (size, location and composition) as well as on your anatomy. Once under general anesthesia, you will be placed lying face down with cushions and supports. We dilate (spread open) the access tract up to the size of a nickel until we can fit our nephroscope (scope that goes into the kidney) inside. Using a combination of direct vision through the scope, as well as x-ray guidance, we advance the scope directly to the stone(s). Depending on the location, size and consistency of the stone, the surgeon may elect to use one or a combination of technologies or instruments to break the stone and remove any significant fragments. When we are finished removing as much stone as is safely possible, we place a tube (which is attached to a small drainage bag) in the tract. In some cases, we may also elect to place a stent (small plastic tube that does from the kidney all the way down to the bladder) in the ureter.

Post Procedure

After the procedure, you will be in the recovery room until you are ready to be sent to your room. Your back may be sore where we made the small hole for the scope and where you now have a tube. You may have a catheter in your bladder overnight. It is common to have a sense of urinary urgency (bladder spasms) from the catheter. Patients may have no blood in the urine, mild blood, or even what appears to be a significant amount of blood or small clots. The blood usually disappears within a few days. You may also notice stone fragments in the urine. Because they are small, a patient typically does not feel them as they pass in the urine.

Although the stent is soft plastic, any degree of sensation from its presence is possible. Some patients have no feeling, while on the other extreme, some have bothersome symptoms. The symptoms can be any one or a combination of back or groin discomfort, urinary frequency, urgency or burning. The symptoms may last only one day or persist for the duration of the presence of the stent. Most patients, however, have very mild symptoms that are tolerable.
In the next day or two, we may take an x-ray with dye injected into the tube in your back. If everything looks acceptable, we will remove the drainage tube in your back and send you home with detailed follow-up instructions. You will have a gauze dressing on your back that will need to be changed one or a few times over the 24-48 hours. Urine may leak from this hole for a few days, and then should stop on its own. If a stent was placed in your procedure, you will be discharged with that tube inside your kidney and ureter. Sometimes, we may leave the tube in the kidney when you go home. It will be connected to a drainage bag or have a cap in the end of it. We will remove it in the office as an outpatient or we may leave it in if another procedure is planned for the near future.

Expectations of Outcome

It is important that you understand the possible outcomes of the procedure. While our intent is to fragment the stone into small pieces, this is not always possible. There are occasional instances in which the scope cannot be passed safely into the kidney despite what appeared to be adequate access. We would not force the scope in as this could cause significant injury to the kidney or surrounding organs. In this instance, we would terminate the procedure, and the next step would be discussed in a follow-up consultation.

Another obstacle may be that the composition of the stone is too hard to fragment. Alternatively, part or all of the stone may be situated in an area that is not readily or safely approachable. Sometimes, small fragments of the stone can be pushed down into the ureter by the water current (from the scope) or from the attempt to break it. If it cannot be safely accessed or adequately broken, a stent may be placed and a different type of procedure (ureteroscopy or shock wave lithotripsy) might be planned for another day. In this regard, treatment for large or complex stones is sometimes referred to as a “staged procedure” because it is done in different stages. Lastly, open surgery could be necessary to fully remove the stone.

Possible Complications of the Procedure

ALL surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes which may include, but are not limited to:

• Blood Loss/Transfusion: Because the scope and the stone traumatize small blood vessels, there is always minor to moderate blood loss expected. In some instances, blood loss is more severe and could possibly necessitate a transfusion.
• Renal Infarction/Loss of Kidney: Sometimes the scope or stone instruments can traumatize an important blood vessel supplying a portion of the kidney. If this occurs, part of the kidney could die. If there is a major vascular injury, it could necessitate an emergent procedure by the interventional radiologists to clot off the vessel. In an extreme situation, an open operation to correct the problem or even remove the kidney entirely may be the only way to control the bleeding.
• Urine Leak: As described, this operation requires entering through a hole in the kidney. The tube(s) placed at the end of the case are there to allow healing of the hole. Typically, this hole closes after 1-3 days. Sometimes, there may be a leak for a longer period. While the vast majority of these leaks stop within a few days, persistent leaks may require additional minimally-invasive procedures or repeat minor operations (i.e. placement of a stent). This complication can present immediately (while in the hospital)or even weeks later.
• Pneumothorax (Collapse of the Lung): The kidneys lie close to the chest cavity. Using any of the methods, it is possible to enter the lung cavity and cause collapse of the lung. It may be necessary to place a tube (lung cavity drain) in the side of the chest wall to allow the lung to re-inflate. The tube will usually be removed in a few days.
• Liver or Spleen Injury: Kidneys that have had infections (those associated with scarring and inflammation) can sometimes be directly adjacent to or even adherent to surrounding organs–on the right, the liver, and on the left, the spleen. During placement of the initial catheter or scope into the kidney, either organ can be injured. The injury may be small and easily repaired. A significant injury can increase the incidence of transfusion. It is extremely rare for part of all of an organ to necessitate removal. Open surgery may be necessary for these repairs, and a general surgeon might be called to assist with this problem.
• Injury to the Small Intestine or Colon: The kidneys lie in close proximity to portions of the small intestine and colon. If the scope inadvertently exits the kidney, it can cause injury to these structures. If immediately recognized, we would terminate the procedure immediately. An open abdominal operation (sometimes assisted by a general surgeon) would then be performed. A significant injury could necessitate a temporary colostomy.
• Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE): In any operation (especially longer operations or those in which your legs are in stirrups), you can develop a clot in a vein of your leg (DVT). Typically, this presents 2-7 days (or longer) after the procedure as pain, swelling, and tenderness to touch in the lower leg (calf). Your ankle and foot can become swollen. If you notice these signs, you should go directly to an emergency room and also call our office. Although less likely, this blood clot can move through the veins and block off part of the lung (PE). This would present as shortness of breath and possibly chest pain. We may sometimes ask the medical doctors to be involved with the management of either of these problems.
• Urinary Tract Infection or Urosepsis: Although we may give you antibiotics, it is still possible for you to get an infection. It may be a simple bladder infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. This will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you may feel very ill. This type of infection can present with both urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. You may require a short hospitalization for intravenous antibiotics, fluids, and observation. This scenario is more common in diabetics, patients on long-term steroids, or patients with any disorder of the immune system.
• *If you have symptoms suggesting any of the above after your discharge from the hospital, you must contact us immediately or go to the nearest emergency room.
• Pain: Chronic pain, although unusual, may develop from the treated kidney and/or access tract.
• Ureteral Injury: In an attempt to get the portion of the stone heading down the ureter, this delicate structure may be injured from the scope or from the instruments employed to break/remove your stone. The solution is typically to terminate the procedure, place a stent, and allow the tissue to heal itself over the next week or two. A complete separation of the ureter from the kidney (ureteral avulsion) is a very rare occurrence and requires open surgery through an incision to repair the injured organ. Strictures or scar tissue may develop, narrowing or completely blocking off the urine drainage through the ureter requiring treatment to allow adequate urine flow.

We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

UUANJ, P.C.