Definition

It’s a minimally-invasive procedure to breakdown and remove medium sized and larger kidney stones using a telescope introduced into the kidney through a small puncture wound in the back or side of the patient. This usually involves a cystoscopy (telescope examination of the bladder) along with the use of X-rays and or Ultrasound.

Technique

PCNL is performed under general anaesthesia with the patient positioned lying down on their back or face down on their abdomen. Manchester Urology Consultants has adopted the newer innovation of performing most PCNLs with the patient lying on their which is quicker and associated with certain safety advantages. Once anaesthesia is administered, your surgeon will perform cystoscopy (telescopic examination of your bladder) and pass a soft catheter up into the collecting system of the kidney with stones. X-ray dye is instilled into the kidney through the small catheter placed up through the ureter or drainage tube of the affected kidney to “map” the branches of the collecting system. This allows your surgeon and or Radiologist to precisely locate the stone within the kidney and place a small needle through the skin under xray guidance to directly access the stone.

This needle tract is dilated to approximately 0.5-1cm to allow placement of a access sheath and telescope to directly visualize the stone. Using an ultrasonic, mechanical or laser lithotripsy device, the stone is fragmented into small pieces and extracted out of the body through the sheath. On occasions, more than one tract may be required to access and attempts removal of all stones.

A small ureteric stent or catheter may be left draining the kidney to the bladder in addition to or instead of a nephrostomy tube draining the kidney to an external drainage bag at the end of the operation. The length of the surgery is generally 1.5-3 hours.

Manchester Urology Consultants were the first in the North-west of England (and among the first in the UK) to introduce the following innovations:

1. PCNL in the supine position
2. ‘Mini-PCNL’ which is the performance of PCNL with bespoke miniaturised equipment

Potential Risks and Complications

As with any surgical procedure there are risks and potential complications that are associated with PCNL. These include: 

• Bleeding: Blood loss during PCNL is generally minimal, and risk of blood transfusion ranges from 2-12%, depending on stone size, location, and number of tracts dilated. Manchester Urology risk of blood transfusion following PCNL is consistently ≤5%
• Infection: Also ≤5%. Broad-spectrum antibiotics are administered at the start of the operation to minimize the risk of a urinary infection.
• Adjacent Tissue and Organ Injury: ≤1% Rarely organs surrounding the kidney such as bowel, colon, blood vessels, spleen, and liver may be injured during surgery requiring emergent open surgery or further surgery. The chest cavity is in close proximity to the upper pole of the kidney and can be accidentally entered when accessing an upper pole kidney stone resulting in a pneumothorax (or air surrounding the lung). This may require that a small chest tube be placed temporarily to drain air and fluid from around the lung. 
• Failure to Remove the Stone:  Despite placement of one or more tracts into the kidney to remove stones, there is a small chance that PCNL may not be able to successfully remove all stones as a result of either size, number or location of the stone within the collecting system. Additional treatment may be required.

Alternatives to PCNL

The alternatives to this procedure include extra-corporeal shock-wave lithotripsy (ESWL), Retrograde Uretero-renoscopy, “open” surgical removal of stones and observation. These could be discussed at the time of your consultation

What to Expect After Surgery

During your hospitalisation

Following your surgery you will be transferred to the recovery room and then to your hospital room once you are fully awake.

Post-operative pain

Following surgery, pain in the flank area overlying your kidney is common for the first few days, but well controlled with intravenous or oral pain medication provided to you on request by your nurse.

Nephrostomy Tube

A nephrostomy tube drains urine directly from your kidney into a drainage bag. It is routinely placed to tamponade bleeding from the tract between the skin and the kidney. Urine from the kidney is often blood-tinged and will clear over the ensuing days following surgery. There is a possibility that you will be discharged from the hospital with the nephrostomy tube as deemed necessary by your surgeon. The nephrostomy tube could then be removed in the office at the bedside generally 1-2 weeks following surgery or could be used for access at repeat surgery.

Ureteric Stent

A ureteric stent is a small flexible plastic internal tube that is placed to promote drainage of your kidney down to the bladder. This is typically removed  typically 1-2 weeks following surgery.

Nausea

Often patients experience transient nausea the first day or two following surgery under general anaesthesia. Medication is available to treat persistent nausea.

Urinary Catheter

A bladder catheter is placed in the operating theatre while you are asleep and left in place for typically 1-2 days after the surgery. This allows your surgical team to continuously monitor your urine output. It is not uncommon to have blood-tinged urine for a several days after surgery.  The catheter is usually removed prior to discharge.

Diet

Your diet will be advanced slowly from clear liquids to solid foods as tolerated over the first two days following surgery. In addition, intravenous fluids will be administered to keep your body well hydrated following surgery. Most patients, however, will not regain their appetite until they are discharged and at home.

Fatigue

Fatigue is common and should start to subside in a few weeks to a month following surgery.

Physical Activity

On the evening of or latest morning after surgery it is very important to get out of bed and begin walking with the supervision of your nurse or family member to help prevent blood clots from forming in your legs. During and after your hospital stay it is advised that you keep walking - The more walking you can tolerate the better.

Hospital Stay

The average length of hospital stay for most patients is approximately 2 days.

Secondary Procedures

On occasions, a second PCNL procedure may be required as a “second look” procedure through the original nephrostomy tract to retrieve any retained stone fragments. This procedure may be performed during your hospitalization or at a second surgery date as determined by your surgeo