Percutaneous Nephrolithotomy (PCNL)

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About Percutaneous Nephrolithotomy (PCNL)

Percutaneous removal of kidney stones (PCNL) is basically a keyhole surgery. Under general anaesthetic the stone is eliminated by passing a small telescope through your side directly into the kidney. The stone is broken up and the fragments are removed.

Kidney stones are formed in the urinary tract due to crystallization of chemical compounds in the urine. PCNL is a technique used to remove certain stones in the kidney or upper ureter (the tube that drains urine from the kidney to the bladder) that are too large for other forms of stone treatment (e.g. shock wave lithotripsy, ureteroscopy).

The Procedure

This procedure has been performed on many patients over the last several years and is accepted standard of care for patients with kidney stones that are large, very firm, or resistant to other forms of stone treatment. As such it has replaced open operations for kidney stones in the vast majority of patients.

Generally, the length of the surgery is 3-4 hours. The surgery is performed by making a small 1 cm incision in the patient's flank area (Figure 1). A tube is placed through the incision into the kidney under x-ray guidance. A small telescope is then passed through the tube in order to visualize the stone, break it up and remove it from the body. If necessary a laser or other device called a lithotripter may be used to break up the stone before it can be removed. This procedure has resulted in significantly less post-operative pain, a shorter hospital stay, and earlier return to work and daily activities when compared to open stone surgery.

This technique also has a higher success rate for clearing all stones in one setting than other techniques such as extracorporeal shock wave lithotripsy (ESWL), which often require several attempts.

Possible Risks

Even minimally invasive surgeries, such as percutaneous nephrolithotomy or nephrolithotripsy, carry risks of infection, bleeding, and other complications. The procedure creates a hole in the kidney that usually heals without other treatment. Operations on the abdomen carry a small risk of injury to other nearby organs, such as the bowel, the ureter, the liver or the bladder.

Advantages & Disadvantages

One advantage of this surgery is that it is the most effective technique for making sure a patient is stone-free. Most patients leave the hospital stone free. Occasionally, though, another procedure will be needed to remove a stone.

Even though it involves an incision, it is less invasive than a full open surgery to treat the kidney stone. Because it is among the more difficult surgeries, it is performed by surgeons with specialized training. Urologists and radiologists may work together on these surgeries.

Percutaneous nephrolithotomy (PCNL) is an established, minimally invasive procedure for removal of renal calculi more than 2 centimetres in size. In 1976, Fernstorm and Johansson reported the removal of renal calculus through a nephrostomy tract for the first time [1]; since then PCNL has become the most common procedure performed for the management of renal stones. It facilitates a direct approach to the calculus while the kidney and surrounding structures are subjected to lesser trauma as compared to the open approach, and hence a great deal of surgical expertise is required for percutaneous access to the kidney and stone removal. Many changes and modifications have been done to minimise morbidity, analgesic requirements, and duration of hospitalization, including use of regional blocks, single step dilatation, “Mini-Perc” technique, tubeless PCNL, and sandwich therapy.

Though the entire surgical team shoulders the responsibility for the outcome, the role of the anesthesiologist is not less. They not only help in providing optimal working conditions for the surgeon, but also recognise and deal with the complications related to anesthesia and the procedure as a whole.

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