Essentially, a Percutaneous Nephrolithotomy (PCNL) involves the removal of a kidney stone or stones via a direct puncture into the kidney. This technique is employed when shock wave lithotripsy (SWL) is unlikely to succeed due to stone size or hardness. It is also used when other treatments, including SWL and laser lithotripsy have failed.
Please refer to the detailed instructions provided by the rooms. These instructions may also be downloaded from the website.
It is of vital importance that you bring all of your scans and X-rays with you to the hospital on the day of the procedure. Without these, the operation cannot be performed.
The actual procedure can take anywhere from 1-3 hours depending on stones (size, location and composition) as well as your anatomy. Once under general anaesthesia, you will be placed lying face down with cushions and supports. With help of an expert interventional radiologist, via a small cut in the back, we dilate (spread open) an access tract until we can fit our nephroscope (scope that goes into the kidney) inside. Using a combination of direct vision through the scope, as well as x-ray guidance, we advance the scope directly to the stone(s). Depending on the location, size, and consistency of the stone, we may elect to use one or a combination of technologies or instruments to break the stone and remove any significant fragments. When we are finished removing as much stone as is safely possible, we place a tube (which is attached to a small drainage bag) in the tract. In some cases, we may also elect to place a stent (small plastic tube that goes from the kidney all the way down to the bladder) in the ureter.
After the procedure, your back may be sore where we made the small hole for the scope and where you now have a tube. You may have a catheter in your bladder overnight. It is common to have a sense of urinary urgency (bladder spasms) from the catheter. Patients may have no blood in the urine, mild blood, or even what appears to be a significant amount of blood or small clots. The blood usually disappears within a few days.
After 1-3 days, depending on the recovery process, we will take an x-ray with dye injected into the tube in your back. If there is no evidence of kidney blockage, we will remove the drainage tube in your back and allow you to return home with detailed follow-up instructions. You will have a gauze dressing on your back that will need to be changed one or a few times over the next 24-48 hours. Urine may leak from this hole for a few days, and then should stop on its own. If a stent was placed in your procedure, you will be discharged with that tube inside your kidney and ureter. Arrangements will be made for this to be removed at a later date.
Expectations of Outcome
In the majority of cases, most or all of the stone will have been removed. Occasionally, this is not possible. If there is excessive bleeding, if stone fragments are pushed around the kidney by the water current used to assist the procedure, or if the stone is too hard to fragment, some of the stone may remain. If this is the case, a strategy for removing any residual stones will be discussed with you after discharge.
Possible Complications of the Procedure
Most patients do not experience any significant problems after the procedure. Aside from anaesthesia complications, it is important that every patient be made aware of all possible outcomes which may include, but are not limited to:
- Blood Loss / Transfusion
Because the scope and the stone traumatize small blood vessels, there is always minor to moderate blood loss expected. In some instances, blood loss is more severe and could possible necessitate a transfusion.
- Renal Infarction / Loss of Kidney
Sometimes the scope or stone instruments can traumatize an important blood vessel supplying a portion of the kidney. If this occurs, part of the kidney could lose function. If there is a major vascular injury, it could necessitate an emergent procedure by the interventional radiologists to clot off the vessel. In an extreme situation, an open operation to correct the problem or even remove the kidney entirely may be the only way to control the bleeding.
- Urine Leak
As described, this operation requires entering through a hole in the kidney. Typically, this hole closes almost immediately after the nephrostomy tube is removed. Sometimes, there may be a leak for a longer period. While the vast majority of these leaks stop within a few days, persistent leaks may require additional minimally-invasive procedures or repeat minor operations (ie. placement of a stent).
- Pneumothorax (Collapse of the Lung)
The kidneys lie close to the chest cavity. Using any of the three methods, it is possible to enter the lung cavity and cause collapse of the lung. It may be necessary to place a tube (lung cavity drain) in the side of the chest wall to allow the lung to re-inflate. The tube will usually be removed in a few days.
- Liver, Spleen of Bowel Injury
Whilst every possible precaution is taken to ensure direct puncture into the kidney, other nearby organs may very rarely be injured when gaining access to the kidney. This may occur even in the hands of the most experienced interventional radiology experts. If this occurs further surgery may be required to repair or remove portions of these organs.
- Urinary Tract Infection or Urosepsis (Bloodstream Infection)
Before this procedure can take place, it is essential that you have a urine test to prove that you do not have a urinary tract infection. You will also be given antibiotics at the time of the operation. Despite this, you may still develop a urinary tract infection which may make you quite unwell. This usually resolves with intravenous antibiotics.
Please contact the office within 3 days of discharge. You should make an appointment to see Dr Sved as directed in the hospital. You may see him in his offices at RPA, Bankstown or Strathfield Private Hospital. Do not hesitate to call at any time if you have any concerns.