Percutaneous Nephrolithotomy (PCNL) Surgery in Delhi, India

Percutaneous Nephrolithotomy (PCNL) is a minimally invasive surgical procedure used to remove kidney stones that are too large to pass naturally through the urinary tract. In this procedure, a surgeon makes a small incision in the back and creates a narrow tunnel directly into the kidney. Through this tunnel, specialised instruments are inserted to break up the kidney stones, which are then removed through the tunnel.

PCNL is typically recommended for individuals with large kidney stones or those who have stones that have not responded to other treatments like medications or lithotripsy (a procedure that uses shock waves to break up stones). It's considered when the size or location of the kidney stone makes it difficult or impossible to pass naturally through the urinary tract.

The procedure is done to relieve symptoms associated with kidney stones, such as severe pain, and to prevent complications like urinary tract infections, kidney damage, or obstruction of urine flow. By removing the stones, PCNL aims to improve kidney function and alleviate discomfort caused by the presence of the stones.

Here's an overview of preparation, procedure, and post-operative care for percutaneous nephrolithotomy (PCNL):

Preparing for Percutaneous Nephrolithotomy

Before undergoing a percutaneous nephrolithotomy (PCNL), doctors discuss a patient's medical history and perform a physical examination.

• Medical evaluation: The patient undergoes a thorough medical evaluation by their healthcare provider to assess their overall health and any pre-existing conditions that may affect the procedure.
• Imaging tests: Imaging tests such as CT scans or X-rays are performed to locate the kidney stones and determine their size and location.
• Medication review: The patient may be instructed to discontinue certain medications, such as blood thinners, before the procedure.
• Fasting: Patients are typically instructed not to eat or drink anything for a certain period before the surgery, usually starting at midnight the night before.

During Percutaneous Nephrolithotomy

The procedure is typically performed in a hospital operating room under general anaesthesia, to ensure they are asleep and experience no pain. Here's a general outline of the steps involved:

• Anaesthesia: The patient is administered anaesthesia to ensure they are comfortable and pain-free during the procedure. This may include general anaesthesia or regional anaesthesia, depending on the patient's specific case.
• Incision: A small incision is made in the patient's back to access the kidney.
• Guidewire insertion: A thin, flexible guidewire is inserted through the incision and into the kidney to guide the placement of other instruments.
• Stone removal: Specialised instruments, such as a nephroscope or lithotripter, are inserted through the incision to locate and remove the kidney stones. In some cases, the stones may be broken into smaller pieces using laser or ultrasound energy before removal.
• Closure: Once the stones have been removed, the incision may be closed with sutures or covered with a sterile dressing.

Post-Percutaneous Nephrolithotomy Care

Following PCNL, the patient typically stays in the hospital for a day or two for observation. Here's what to expect:

• Observation: The patient is monitored closely in a recovery area until they wake up from anaesthesia and their vital signs are stable.
• Pain management: Patients may experience some discomfort or pain after the procedure, which can be managed with pain medications prescribed by their doctor.
• Fluid intake: Drinking plenty of fluids is important to help flush out any remaining stone fragments and prevent dehydration.
• Activity restrictions: Patients may be advised to avoid strenuous activities or heavy lifting for a period of time after the procedure to allow for proper healing.
• Follow-up: Patients are scheduled for follow-up appointments to monitor their recovery, review imaging studies, and discuss any further treatment or preventive measures.

PCNL offers several advantages over other stone removal methods. Here are some of the key benefits of percutaneous nephrolithotomy:

• High success rate: PCNL boasts a high success rate, often nearing 100%, in removing even large or complex kidney stones in a single procedure.
• Suitable for complex stones: Unlike other stone removal methods, PCNL can effectively address large stones (over 2 cm), staghorn calculi (branching stones resembling antlers), or stones in unfavourable locations within the kidney.
• Minimally invasive: Compared to traditional open surgery, PCNL is minimally invasive. It involves a smaller incision and generally leads to faster healing and recovery with less postoperative pain.
• Outpatient possibility: In some cases, depending on the complexity of the procedure and your recovery, PCNL may allow for same-day discharge or a shorter hospital stay.

While PCNL offers significant advantages for treating complex stones, it's important to be aware of the potential risks involved. Here's a breakdown of the possible risks associated with PCNL:

• Bleeding: Although uncommon, bleeding can occur during or after the procedure.
• Infection: There's a risk of infection developing in the kidney or urinary tract following surgery.
• Kidney damage: There's a slight possibility of damage to surrounding organs like the intestines, colon, or blood vessels during instrument insertion.
• Urinary leakage: Leakage of urine around the kidney may occur temporarily after surgery.
• Incomplete stone removal: In some cases, it might not be possible to remove all stone fragments during the procedure.
• Anaesthesia risks: As with any surgery using general anaesthesia, there are potential risks associated with the medication itself.

It's important to know that these are just potential risks, and the likelihood of experiencing them is relatively low.

What are other treatment options available for large kidney stones?

For smaller stones, shock wave lithotripsy (ESWL) or ureteroscopy may be suitable options. However, for large or complex stones, PCNL is often the most effective treatment.

What dietary or lifestyle changes can I make to prevent future kidney stones?

Drinking plenty of fluids, reducing your sodium intake, and following a healthy diet low in animal protein and oxalates can help prevent future kidney stones. Your doctor can provide specific dietary recommendations based on your individual risk factors.

Does PCNL increase the risk of future kidney stones?

PCNL itself doesn't necessarily increase your risk of future stones. However, the underlying factors that led to the initial stones are still present and can increase your chance of developing new stones. Following a preventive diet and staying well-hydrated are crucial to minimise this risk.

How long will it take to recover from PCNL?

A typical recovery timeline after PCNL involves a hospital stay of 1-2 days. Full recovery can take around a week, depending on the complexity of the surgery and your individual healing process. Your doctor will provide specific guidance on activity restrictions and returning to work.

What restrictions will I have on activity after surgery?

Strenuous activity should be avoided for several weeks after PCNL to allow for proper healing. Your doctor will advise you on a gradual return to exercise and physical activity.

What should I do if I experience pain or discomfort after the stent is removed?

Some pain or discomfort is normal after stent removal. Over-the-counter pain medication can usually help manage these symptoms. However, if you experience severe pain, chills, fever, or difficulty urinating, contact your doctor right away.

What are the signs of infection after PCNL?

Signs of infection after PCNL can include fever, chills, pain around the incision site, cloudy or bloody urine, and burning with urination. If you experience any of these symptoms, see your doctor promptly.

What can be done to minimise the risk of bleeding during PCNL?

Your doctor will likely ask you to stop taking certain medications, such as blood thinners, before surgery. Additionally, advanced imaging techniques help guide instrument placement during surgery, minimising the risk of injury to blood vessels.

What happens if there is leakage of urine around the kidney after surgery?

Leakage of urine around the kidney (urinoma) is a potential but uncommon complication after PCNL. A drainage tube may be placed to help manage the leakage, and it usually resolves on its own within a few days.

Can PCNL be performed if I have other medical conditions?

Generally, PCNL can be performed safely for most people. However, if you have certain medical conditions, your doctor will carefully assess the risks and benefits to determine if PCNL is the right option for you. Be sure to discuss any pre-existing health conditions with your urologist before surgery.

Will I need to take any medications after PCNL?

You may be prescribed pain medication to manage discomfort after surgery. Your doctor may also recommend antibiotics to help prevent infection.

When can I return to work after PCNL?

The timeframe for returning to work depends on your job and recovery progress. For most office jobs, you might return within a week after surgery. However, if your work involves strenuous activity, you may need to wait for a couple of weeks.Discuss this with your doctor for specific guidance.

What should I expect during a follow-up appointment after PCNL?

Your doctor will likely want to see you within a week or two after surgery to check the key hole incision site, monitor your recovery, and potentially remove the stent. Follow-up appointments may also be scheduled to check

Reviewed by Dr. Vimal Dassi - Director - Urology, Uro-oncology, Kidney Transplant, Robotic Surgery on 1 July 2024.