Mini Percutaneous Nephrolithotomy

Mini PCNL (mini percutaneous nephrolithotomy or stone extraction) is a minimally invasive approach to treating kidney and ureteral stones that are too big (often greater than 2 centimeters), too numerous, or too dense to be treated by extracorporeal shock wave lithotripsy (ESWL) or ureteroscopy. Large kidney and ureteral stones were traditionally removed with open surgery, necessitating a major flank incision. A 1-cm skin incision is used during percutaneous nephrolithotomy, which reduces the size of the incision, pain, blood loss, blood transfusions, and length of hospital stay. Additionally, compared to other techniques like ESWL, which frequently take multiple procedures, this technique has a greater success rate for eliminating all stones in a single session.

Percutaneous Nephrolithotomy

The minimally invasive surgery known as percutaneous nephrolithotomy (PCNL) involves making a small puncture wound through the skin (up to one centimeter) to remove kidney stones. The procedure is most suited to remove stones that are larger than 2 cm in diameter and located close to the pelvic area. Typically, either a spinal or general anesthetic is used during the procedure. These procedures are used to treat kidney stones in patients who have large or irregularly shaped stones, infections, stones that have not been sufficiently broken up by extracorporeal shockwave lithotripsy (ESWL), or patients who are not candidates for ureteroscopy, another widely used stone treatment. This process is necessary for stones larger than 2 cm (the diameter of a marble).

Percutaneous Nephrolithotomy Advantages and Disadvantages

In comparison to other therapies like ESWL or ureteroscopy, PCNL's main benefit is that it offers a minimally invasive method of treating and removing big stone burden in a single setting, whereas the other therapies require numerous procedures.

While ESWL and ureteroscopy can be carried out while sedated intravenously, PCNL necessitates general anesthesia. Due to their medical condition, some patients might not be able to sustain a general anesthetic. PCNL is significantly more invasive than other stone therapies, which has a modest increase in risk. The advantages of PCNL, however, exceed the dangers for the majority of patients with significant stone loads, many stones, or stones refractory to other forms of treatment.

Percutaneous Nephrolithotomy Indications

Patients with big kidney or ureteral stones (often > 2 cm), several large stones, or stones that have proven resistant to past ESWL or ureteroscopy treatment are suitable candidates for PCNL.

PCNL is not recommended for patients with serious heart or lung diseases or bleeding tendencies that cannot be corrected. Patients who have an active urinary infection should receive antibiotic treatment to get the infection under control before PCNL because they are more likely to develop sepsis after surgery.

Percutaneous Nephrolithotomy Preparation

Patients must obtain all x-ray films and reports (such as KUB, CT scan, MRI, and ultrasonography) before their initial consultation so that their surgeon can review them. In addition to reviewing your medical history, the surgeon will do a quick physical. At your initial appointment, a urinalysis will also be carried out. At this time, you will hear about all of your stone-treating alternatives as well as the advantages and disadvantages of each method. You will meet with a surgery scheduling coordinator to set the date of your procedure if your surgeon believes that you are a candidate for PCNL.

The items specified below will be ordered as necessary based on your age, medical history, and risk for surgery when one of the surgery scheduling coordinators has confirmed your surgery date. Preoperative anesthesia consultations for these will be scheduled for you at your initial appointment. You will have the chance to discuss the various types of anesthesia that are offered, as well as their advantages and disadvantages, with the anesthesia specialists during this consultation.

Physical exam
ECG (electrocardiogram)
CBC (complete blood count)
PTT and PT (blood coagulation profile)
Comprehensive Metabolic Panel (blood chemistry profile)
Urine culture and urinalysis

The list of medications to avoid before surgery is as follows (Ticlid, Coumadin, Lovenox, Celebrex, Voltaren, Plavix, Motrin, Ibuprofen, Advil, Alka Seltzer, Vitamin E), at least 7-10 days before the procedure. Many of these drugs may cause unintended bleeding during surgery because they affect platelet function or your body's capacity to clot. If you are unsure of which drugs to cease before surgery, get in touch with your surgeon's office. Without first requesting permission from the prescribing physician, never discontinue taking any prescription. You will be given a complete list of these medications, along with others, by your Surgeon.

Before PCNL, your urine must remain infection-free. Therefore, contact your surgeon right away if you think you might have a urinary tract infection (burning when urinating, blood in the urine, frequent and urgent urination, fevers, etc.) so that the appropriate cultures and treatment can be given.

Percutaneous Nephrolithotomy Procedure

To detect the kidney stone, a retrograde pyelogram is performed. The percutaneous nephrolithotomy (PCN) needle is inserted into the renal pelvis through a tiny 1-centimeter incision in the loin.
Fluoroscopy is used to confirm the needle's location.
The needle is inserted into the pelvis, followed by a guide wire. The guide wire is kept inside the pelvis while the needle is removed. The dilators are passed over the guide wire, and then a working sheath is introduced.
Small stones are then removed by passing a nephroscope within. If the stone is large, it could first need to be broken up using ultrasonic probes, and then the pieces need to be taken out.
Making the passage between the kidney and the flank skin is the trickiest part of the process. The antegrade approach, which is most frequently used to accomplish this, involves inserting a needle from the flank skin into the kidney.
A flexible ureteroscope is used to help with a retrograde technique, which involves passing a small wire from inside the kidney to outside the flank. This method might lower radiation exposure for both the patient and the urologist.
In both surgeries, a tiny incision in the back is used to access the kidney.
A nephroscope, a tiny fiberoptic camera, and other tiny instruments are put in through the hole once the urologist reaches the kidney. Nephrolithotomy is the term used when the stone is removed through the tube.
Nephrolithotripsy is the term used when the stone is fragmented before being removed. The urologist can utilize high-frequency sound waves to break up the stone while visualizing it, and a suction machine to vacuum up the dust.

Percutaneous Nephrolithotomy Recovery

After your procedure, you will be taken to the recovery area before being taken, after you are completely conscious, to your hospital room.

Postoperative discomfort. After surgery, pain in the flank region beneath your kidney is typical for the first few days, but it can be effectively managed with intravenous or oral pain medications, which your nurse will supply you with upon request.

Nephrostomy tube. Your kidney's urine is immediately drained into a drainage bag through a nephrostomy catheter. To stop bleeding from the passage between the skin and the kidney, it is frequently inserted there. Urine from the kidney is frequently stained with blood and will clear over the days that follow surgery. If your surgeon decides it's essential, you can be sent home from the hospital with a nephrostomy tube. 1-2 weeks after surgery, the nephrostomy tube will then be withdrawn in the office at the patient's bedside.

Ureteral stent. A ureteral stent is a tiny, flexible plastic tube inserted internally to help your kidneys flow more effectively into your bladder. This will normally be removed in your surgeon's office 1-2 weeks after surgery.

Nausea. Patients who have general anesthesia for surgery frequently experience brief nausea on the first or second day after the procedure. Persistent nausea can be treated with medication.

Urinary catheter. While you are unconscious during surgery, a bladder catheter known as a Foley is inserted and remains in place for roughly one day. Your surgical team can thereafter keep track of your urine output because of this. After surgery, it is usual to experience blood-tinged urine for a few days. Before discharge, the catheter will be taken out.

Diet. Over the first two days after surgery, your diet will be gradually transitioned from clear liquids to solid foods as tolerated. Additionally, intravenous fluids will be given to you after surgery to keep your body hydrated. However, the majority of patients won't start to feel like eating again until they are sent home.

Fatigue. Following surgery, fatigue is typical and should start to go away in a few weeks to a month.

Incentive spirometry. Exercises that improve deep breathing are crucial for lowering the risk of respiratory problems like pneumonia. Your nurses and the surgical team will demonstrate how to utilize an incentive spirometer as you carry out these exercises.

Physical activity. To assist prevent blood clots from forming in your legs, it is crucial to get out of bed the night before surgery and start walking under the guidance of your nurse or a family member. Additionally, SCDs (sequential compression devices) will likely be used to stop blood clots from forming in your legs. To reduce the risk of blood clots during your hospital stay, it is recommended that you walk at least 4-6 times daily in the hospital hallways. You should walk as much as you can tolerate.

Hospital stay. For the majority of patients, a hospital stay lasts between one and two days.

Secondary procedures. To retrieve any residual stone particles, a second PCNL surgery may occasionally be necessary as a second look procedure through the original nephrostomy tract. Your surgeon may decide to carry out this treatment while you are in the hospital or at a later surgical date.

What to Expect After Hospital Discharge

Pain management. Patients are advised to switch to extra-strength Tylenol as soon as possible to avoid constipation and oversedation that may come from taking narcotic painkillers for mild discomfort at the site of the nephrostomy tube.

Showering. Showering with a nephrostomy tube in place is acceptable, but the site needs to be patted dry right away afterward. While your nephrostomy tube is in situ, you should refrain from taking hot tubs or tub baths.

Activity. To reduce the risk of deep vein thrombosis, or blood clots, developing in your legs, it is recommended that you walk every day. Avoid spending too much time sitting or in bed. It is feasible to climb stairs, but you should go slowly. When surgery, driving should be avoided for at least one to two weeks, and then only after narcotic painkillers have been withdrawn. Activity can resume after this point as tolerated. After surgery, you can anticipate going back to work as soon as 1-2 weeks later, based on your doctor's instructions.

Nephrostomy site care. For your kidney to heal properly, you must take care of your nephrostomy tube. Urine should freely flow from the tube into the drainage bag, which should always be kept below the level of your kidney. When you take a shower every day, gently wash the region around the nephrostomy tube insertion site. After showering, pat the skin dry and use a cotton tip applicator to apply hydrogen peroxide to the region immediately surrounding the insertion site. After cleansing the wound, apply a fresh gauze dressing. The obstruction of your kidney, severe pain, and infection may occur if urine stops draining from your tube. Check your nephrostomy tube right away to make sure it is not kinked, pulled, or displaced from its appropriate position. Contact your doctor right away if you suffer any change in pain, a fever, chills, pus accumulating around the catheter implant site, the catheter not emptying, or the catheter leaking around the tube.

Follow-up after stent removal. Your surgeon will decide when to remove the ureteral stent, which is typically done one to two weeks after surgery. It is normal to experience mild flank fullness and a need to urinate urgently while your stent is in place. As the body becomes used to the indwelling stent, these symptoms frequently get better with time. A little flexible telescope will be inserted into the urethra during the cystoscopy procedure to allow your surgeon to see and hold the stent's terminal end, which is located in your bladder. Usually, this may be completed in under two minutes.

NOTE. Patients must follow their surgeon's instructions and go back to have their ureteral stent removed because leaving it in place for too long can cause infection, stenosis, stone encrustation, and even kidney loss.

Follow-up appointment. Your surgery team will arrange a follow-up visit before you are discharged from the hospital.

Percutaneous Nephrolithotomy Risks

There are risks and potential consequences with PCNL, just like with any surgical surgery. Despite being uncommon, possible risks include:

Bleeding. Depending on stone size, position, and the number of tracts dilated, blood transfusion risk during PCNL can range from 2-12%. Blood loss during PCNL is often modest. Patients may choose to donate blood at their nearby hospital around two months before surgery, however, it is not necessary.
Infection. During stone surgery, bacteria can occasionally grow within the stones and result in a urinary tract infection and, very rarely, sepsis. Therefore, to reduce the risk of a urinary infection, urinary infections should be managed before surgery, and broad-spectrum antibiotics are given at the beginning of the procedure.
Injury to nearby organs and tissues. Rarely, during surgery, the stomach, intestines, blood vessels, spleen, and liver may be damaged, necessitating urgent open surgery or additional surgery. The top pole of the kidney is adjacent to the chest cavity, which can be mistakenly entered when removing an upper pole kidney stone, leading to a pneumothorax (or air surrounding the lung). To temporarily drain the air and fluid from the area surrounding the lung, a tiny chest tube may be necessary. It is highly uncommon for PCNL to permanently harm the kidney, resulting in kidney loss. The ureter that empties the kidney may become injured or perforated, leading to scarring and obstruction that need additional surgery.
Not removing the stone. There is a slight possibility that PCNL may not be able to completely remove all stones due to the size, number, or location of the stones inside the collecting system, even after inserting one or more tracts into the kidney to remove stones. It might be necessary to receive more care.

Conclusion

The method of percutaneous nephrolithotomy is constantly changing. It has been demonstrated that lying on your back is a viable choice. To access their renal tracts, urologists need to undergo special training. For better outcomes, the miniperc PCNL still requires equipment modifications. The use of tubeless PCNL is growing, and various tract sealants have been researched. After PCNL, medical prevention should always be used because it is beneficial against stone recurrence. Urologists must keep developing new technology and refining their expertise despite the technique's evolution over the past 20 years if they want to provide patients with a growing number of safe and efficient options for treating large kidney stones.