Name of the Procedure:

Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; over 2 cm.
Common Name(s): PCNL, Percutaneous Nephrolithotomy

Summary

Percutaneous nephrostolithotomy is a minimally invasive surgical procedure used to remove kidney stones that are larger than 2 cm. The procedure involves making a small incision in the skin and using specialized instruments to break up and extract the stones directly from the kidney.

Purpose

The procedure addresses kidney stones that are too large to pass naturally through the urinary tract. It aims to remove the stones, alleviate pain, prevent urinary tract infections, and avoid kidney damage caused by large stones.

Indications

• Kidney stones larger than 2 cm.
• Stones that haven't responded to other treatments like shock wave lithotripsy.
• Persistent pain, infection, or bleeding due to kidney stones.
• Obstruction of the urinary tract by stones.

Preparation

• Patients are usually advised to fast for 6-8 hours before the procedure.
• Certain medications may need to be adjusted or discontinued.
• Blood tests, urine tests, and imaging studies (e.g., CT scan, ultrasound) are typically conducted to assess the size and location of the stones.

Procedure Description

1. Under general anesthesia, a small incision is made in the patient's back.
2. A nephroscope (an endoscopic instrument) is inserted through the incision into the kidney.
3. Stones are located using imaging guidance.
4. Depending on the stone's size and composition, it may be broken up using laser lithotripsy or ultrasound lithotripsy.
5. The fragmented stones are then removed using specialized extraction tools like baskets or forceps.
6. A stent may be placed to ensure urine flow during recovery.
7. The incision is closed, and a nephrostomy tube might be left in place temporarily to drain urine.

Duration

The procedure typically takes between 1 to 3 hours, depending on the complexity and size of the stone.

Setting

The procedure is performed in a hospital operating room or a specialized surgical center.

Personnel

• Urologist or Endourologist (surgeon)
• Anesthesiologist
• Surgical Nurses
• Radiologist (for imaging guidance)

Risks and Complications

• Infection
• Bleeding
• Injury to surrounding organs
• Incomplete stone removal
• Urinary leakage
• Rarely, the need for an additional procedure.

Benefits

• Effective removal of large kidney stones.
• Relief from pain and symptoms caused by obstructive stones.
• Prevention of recurrent urinary tract infections and kidney damage.

Recovery

• Hospital stay typically ranges from 1 to 2 days.
• Instructions may include managing the nephrostomy tube, if placed, and avoiding strenuous activities.
• Pain management usually involves prescribed medications.
• Follow-up appointments are necessary to ensure proper healing and stent removal if placed.
• Full recovery can take several weeks.

Alternatives

• Extracorporeal Shock Wave Lithotripsy (ESWL): Less invasive but may be less effective for large stones.
• Ureteroscopy: Effective for stones in the ureter but not typically used for very large kidney stones.
• Medical management with medications: May help smaller stones pass but is often inadequate for large stones.

Patient Experience

During the procedure, patients are under general anesthesia and will not feel any pain. Post-surgery, there may be discomfort at the incision site, pain from the stent, or mild back pain. Pain is managed with medications, and most patients report significant relief from pre-surgical symptoms soon after the procedure.