Percutaneous Nephrostolithotomy (PCNL)

Percutaneous renal surgery is minimally invasive telescopic surgery performed under general anaesthetic for kidney stones, tumours and some other collecting system problems where it is impossible to gain access ureteroscopically. The kidney is visualized radiologically and an access sheath 1 cm in diameter is placed through the skin and muscles of the back, into the kidney. Percutaneous nephrolithotomy (PCNL) is the fragmentation and removal of stones down this access sheath.

Percutaneous surgery avoids some of the risks of open surgery and allows for a shorter hospital stay and rapid recovery of normal function. There is minimal injury to the kidney. Commonly, a kidney drainage tube is the left passing out along the track through the skin and a urethral catheter draining the bladder for one to two days after the surgery. Most patients go home once these tubes are removed, one or two days after the surgery.

Pre-operatively:

• urine sample to laboratory 1 week prior, repeat x-ray day before surgery
• discontinue aspirin 1 week prior, other medications may need to be stopped
• nil by mouth from midnight

Post-operatively – early:

• day 1: diet, reinstate usual medications, up and about, maintain a high fluid intake (2 litres daily) for 2 weeks
• day 1 - 2: remove urethral catheter, clamp nephrostomy tube and remove if no pain after 4 hours

Although most cases proceed without particular difficulty and have excellent outcomes, surgical complications occur overall in 5% of patients. The list below details complications recognised as common or serious, but this does not include the rare and extraordinary.

• Depending on the location and size of stones within the kidney, it may not be possible to clear all of the stone at one operation. Stone remnants may be left alone, cleared with subsequent repeat PCNL, or mopped up with ESWL (<20%).
• It may not be possible to gain access to the kidney or the access may be lost partway through the procedure and the operation may have to be abandoned.
• The kidney is very vascular and therefore bleeding may occur during the procedure, again such that the operation has to be abandoned. Blood transfusion may be necessary in 5% of patients. Such bleeding may start up to 2 weeks after the surgery, as the track heals. Rarely, embolisation of a renal vessel, performed radiologically may be required to stop the bleeding. One in 10,000 patients will require emergency nephrectomy if bleeding is catastrophic and cannot be controlled.
• Some kidney stones harbour infection, which is released with fragmentation during the operation, resulting in bacteraemia and septicaemia. This may require prolonged antibiotic treatment and on occasion, admission to intensive care unit (< 1%). Small stone fragments may be displaced down the ureter, resulting in later blockage and pain, and may have to be removed with another procedure.
• Injury may occur to adjacent organs including colon, with placement of the nephrostomy access sheath (< 1%). Generally, these will settle with conservative management but rarely will require conversion to an open operation.
• Numbness or tingling, usually temporary
• Death < 0.5%

This fact sheet complements the discussion during your consultation, which will apply your individual circumstances to the above facts.