PCNL - Percutaneous Nephrolithotomy:
Urology And Urosurgery
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Percutaneous nephrolithotomy (PCNL) Key hole surgery for kidney stones
Percutaneous nephrolithotripsy (PCNL or PNL) is a minimally invasive endoscopic treatment for removing large kidney stones called staghorn stones or large or multiple stones impacted at the upper ureter.
What does the procedure involve?
Disintegration & extraction of kidney stones with a telescope placed into the kidney (see below) through a small puncture in the back. This usually includes cystoscopy and x-ray screening.
Who is a candidate for PCNL?
While PCNL can be used to treat stones in any location and of any size, it is often reserved for the largest and most complex stones:
- Kidney stones treated with PCNL are usually larger than 1.5 cm or cannot be effectively treated with ESWL or ureteroscopy.
- On occasion, smaller stones may be treated by PCNL if there is a history of serious infection or if the kidney is malformed.
- If a nephrostomy tube has already been inserted for emergency drainage, it may be used to complete PCNL treatment
What should I expect before the procedure?
If you are taking Aspirin or Clopidogrel on a regular basis, you must discuss this with your urologist because these drugs can cause increased bleeding after surgery. There may be a balance of risk where stopping them will reduce the chances of bleeding but this can result in increased clotting, which may also carry a risk to your health. This will, therefore, need careful discussion with regard to risks and benefits.
You will usually be admitted on the same day as your surgery. You will normally receive an appointment for pre-assessment, approximately 14 days before your admission, to assess your general fitness, to screen for the carriage of MRSA and to perform some baseline investigations. After admission, you will be seen by members of the medical team which may include the Consultant, Specialist Registrar, House Officer and your named nurse. An X-ray may be taken in advance of surgery to confirm the position of your stone(s).
You will be asked not to eat or drink for 6 hours before surgery and, immediately before the operation, you may be given a pre-medication by the anaesthetist which will make you dry-mouthed and pleasantly sleepy.
If you are admitted on the day before surgery, you will normally be given antibiotics into a vein to prevent any infection at the time surgery.
Please be sure to inform your Urologist in advance of your surgery if you have any of the following:
- An artificial heart valve
- A coronary artery stent
- A heart pacemaker or defibrillator
- An artificial joint
- An artificial blood vessel graft
- A neurosurgical shunt
- Any other implanted foreign body
- A prescription for warfarin, aspirin or clopidogrel (plavix®)
- A previous or current mrsa infection
What happens during the procedure?
Normally, a full general anaesthetic will be used and you will be asleep throughout the procedure.
You will usually be given injectable antibiotics before the procedure, after checking for any allergies.
The operation is usually carried out in a single stage. First, a small tube is inserted up the ureter into the kidney by means of a telescope passed into the bladder. You are then turned on to your face and a puncture track into the kidney is established, using X-ray guidance. Finally, a telescope is passed into the kidney and the stone(s) extracted or disintegrated with ultrasound (see below). A catheter is usually left in the bladder at the end of the procedure together with a drainage tube in the kidney.
It may be necessary to puncture the kidney at more than one site if you have many stones scattered throughout the kidney.
What happens immediately after the procedure?
On the day after surgery, a further X-ray is normally performed to assess stone clearance. Occasionally, it may be necessary to perform an X-ray down the kidney drainage tube using contrast medium. If the X-ray is satisfactory, the tube in your kidney and the bladder catheter will be removed. There is often some leakage from the kidney tube site for 24-48 hours and you will be only discharged once this leakage has resolved.
The average hospital stay is 4-5 days.
The advantages of PNL or PCNL is:
- It avoids the large skin incision of pervious kidney surgery for stones.
- It avoids any large incision on the kidney or renal pelvis.
- Hospital stay is shorter.
- Recovery and healing is faster.
What are the potential risks and complications?
- Problems relating to the anaesthetic: such as a chest infection; deep vein thrombosis or DVT (blood clot in the legs); a pulmonary embolus (blood clot in the lung); stroke; or heart attack.
- Bleeding: in or around the kidney. Some bleeding is normal; only rarely (1%) is it heavy, needing further treatment. You will notice this bleeding as you will pass blood in your urine.
- Retained fragments: sometimes not all the stones are removed and these may need further treatment. Rarely, a temporary internal drainage tube called a stent is inserted during the procedure and left in place. This small tube runs from the kidney down to the bladder to make sure that the kidney is able to drain urine while any small fragments of stone are passed. If it is has a string attached, it is removed within 24 – 48 hrs, if it does not have a string attached it can be removed within six weeks. An x-ray is taken before removing the stent to find out if the fragments have passed with the urine.
- Infection: because some stones have bacteria trapped within them, we give you antibiotics routinely to prevent infection after the operation. A raised temperature is common after this procedure, but this is usually temporary. There is a 0.5% risk of sepsis.
- Injury to the lung cavity: there is a small chance of air or fluids pockets forming around a lung if the access channel is made toward the upper portion of the kidney. These pockets are treated with a chest tube, which allows the fluid to drain from around the lung.
- Bowel perforation: there is a possibility of damaging the bowel during the operation, although this is rare.
- Fluid build-up: sometimes urine can leak from the kidney, resulting in a small
collection of fluid inside the abdomen. If this becomes a large collection, it may need drainin
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