PCNL

During PCNL, your endourologist will:

1. Make an incision (cut) of one cm in your flank (the area between the upper abdomen and the lower back)
2. Insert a tube with a small diameter will into your kidney by using X-ray guidance
3. Insert a small telescope inside the kidney to visualise the stone and a lithotripter device into the tube to break the stone into smaller fragments
4. Extract stone fragments through the tube
5. Close the incision with non-absorbable sutures (stitches) and an adhesive strapping.
6. Place a drainage catheter inside your kidney to restore the urine flow, which was previously blocked due to the presence of stones. This procedure is called a nephrostomy. The urine is collected into a small bag.
7. Also, place a ureteral stent inside the kidney to promote the drainage of urine from your kidneys to the bladder
8. Your operating surgeon will take three to four hours to complete this surgery.

Before undergoing PCNL, you will have a pre-surgical check-up with your operating surgeon and anesthesiologist. During this check-up, your surgeon will:

1. Check your physical condition and medical history
2. Recommend several tests based on your age, medical history, and surgical risk, such as:
   1. Urinalysis (an examination of urine)
   2. EKG (electrocardiogram)
   3. PT / PTT (blood coagulation profile)
   4. Physical exam
   5. CBC (complete blood count)
   6. Comprehensive Metabolic Panel (blood chemistry profile)

To undergo PCNL, you should not have any active urinary infections as it can increase the risk of sepsis (the body’s reaction to infection leads to injury to its tissues) during surgery. If any infections are found, your surgeon will recommend antibiotics to clear the infection before the surgery.

Based on the pre-anaesthesia check-up, your anesthesiologist can recommend general or spinal anaesthesia.

What to Ask and Tell Your Doctor?

You must ask the surgeon questions about the surgery or recovery process at your pre-surgical appointment. For example, you can ask questions like:

1. Why do I need PCNL?
2. What is the benefit of surgery?
3. What are the risks and complications of PCNL?
4. How will my recovery process be?
5. How will you perform the surgery?
6. When can I go back to my everyday activities after surgery?

Also, your surgeon must have complete information about you to perform the surgery smoothly. During your pre-surgical appointment, inform your operating surgeon if you:

1. Are currently using any prescription, non-prescription, supplements, or blood-thinning medications (e.g., aspirin and ibuprofen)
2. Have any allergies to medicines or foods
3. Suffer from severe lung and heart conditions
4. Have unstoppable bleeding tendencies
5. Have symptoms of urinary tract infection, such as fever, burning sensation while urinating, blood in the urine or urgency to urinate

Based on the pre-anaesthesia check-up, your anesthesiologist can recommend general or spinal anaesthesia

Patient position:

After the administration of spinal anaesthesia, you will be placed in the prone position (lying on your abdomen).

Draping:

1. A warm-air blanket will be placed over your head and shoulders to maintain your body temperature intraoperatively.
2. Next, you will be draped with sterile covers and prepped for the procedure.

At hospital:

1. After the first two days of surgery, your diet will be gradually increased from clear liquids to solid foods as tolerated.
2. Your endourologist will continuously monitor your vital signs, food and drink consumption, pain levels and surgery site until you are discharged from the hospital.
3. A few hours after surgery, you will be recommended to get up and walk under the supervision of a caregiver to prevent blood clots in your legs.
4. You will be allowed to go home one or two days after the surgery.

At home:

Bathing:

1. You can shower with your nephrostomy tube in place; however, the site should be patted dry immediately afterwards. 
2. Clean the site of the nephrostomy with soap and water while showering. It should be patted dry, and clean gauze should be applied over the area.
3. Avoid bathtubs or hot tubs while your nephrostomy tube is in place.

Activity:

1. Increase the duration of walking after getting discharged from the hospital.
2. Avoid heavy lifting and intense exercise for two to four weeks after the surgery. Deep breathing exercises are suggested by experts and are beneficial in preventing respiratory diseases such as pneumonia.
3. Avoid driving for seven days.
4. You can return to work after seven to 14 days post-surgery.

First Follow up Appointment

Your surgeon will schedule a follow-up four to six weeks after surgery.[6] During the follow-up, your surgeon will:

1. Perform an ultrasound or X-ray to check if:
   1. Pieces of stone are still left in your kidney
   2. The passage of urine from your kidneys to the bladder is proper
2. Check the laboratory results along with blood and urine reports to:
   1. Determine if you are at high risk for recurrence of stones
   2. Check possible causes of kidney stones and recommend further tests, medications, or preventive measures to prevent stone recurrence.
3. Remove the nephrostomy tube and the ureteral stent placed inside the kidney (one to two weeks post-surgery)

Compared to other minimally invasive lithotripsy techniques, PCNL is usually considered a safer approach, and it offers the highest stone-free rates following the first treatment. Common side effects experienced after the surgery include:

1. Postoperative pain in your flank area
2. Nausea for one or two days after surgery 
3. Fatigue (can last for a few weeks to a month)

Significant problems mentioned below may arise after the surgery, though they are uncommon: 

1. Infection or sepsis
2. Systemic inflammatory response syndrome and postoperative fever. The risk for a postoperative fever depends on:
   1. Your gender (more common if you are a female
   2. Size of the stone
   3. A positive preoperative urine culture
   4. Time required for the surgery
3. Renal haemorrhage (loss of blood)
4. Injuries to the colon, lung, liver, pleura, duodenum, and spleen 
5. Collection of urine outside the urinary system (urinoma). This is a rare complication and develops due to trauma and obstruction caused by the surgery.
6. Damage to the pelvicalyceal system (renal pelvis and major and minor calyces) during tract dilatation or manipulation with the rigid nephroscope
7. Failure to remove the stone entirely.

You must see an endourologist if:

1. Pain is not relieved by the pain medications
2. You experience fever and chills
3. You notice significant bleeding (particularly blood clots) in your urine