Percutaneous Nephrolithotomy (PCNL) Surgery for Kidney Stones in South Delhi

About Percutaneous nephrolithotomy (PCNL)

Percutaneous nephrolithotomy (PCNL) was first described by Fernström and Johansson in 1976 in a prone position. Since then, this surgical approach has become the gold standard for treatment of large stones and it has evolved over time resulting in decrease in invasiveness and morbidity and improvements in ergonomics and outcomes.

What is PCNL?

PCNL is a procedure designed to remove large or complex kidney stones while the patient lies on their back (supine position). This approach allows for direct access to the kidney through a small incision in the back, utilizing a nephroscope and specialized instruments to locate and extract the stones. The technique is particularly advantageous for patients with larger stones or those who have not responded to other treatments such as medication or lithotripsy

PCNL Procedure

1. Anesthesia

• The surgery is performed under general anesthesia, ensuring the patient is completely asleep and free from pain during the procedure.
• A breathing tube is inserted, and vital signs are continuously monitored by an anesthesiologist throughout the surgery.

2. Patient Positioning

• The patient is positioned on their back in a modified supine posture, often with a slight tilt or padding under the flank to optimize access to the kidney.
• This position allows easier airway management, better cardiovascular stability, and the possibility of performing simultaneous retrograde procedures if needed.

3. Access to the Kidney

• After sterilizing the area, a small 1–1.5 cm incision is made on the side or back, depending on the best angle for kidney access.
• A specialized needle is inserted into the renal collecting system (usually the renal pelvis) using real-time imaging guidance such as fluoroscopy or ultrasound to avoid injury to surrounding organs.

4. Tract Dilation

• Once the needle reaches the desired calyx, a guidewire is passed into the kidney.
• The skin and soft tissue tract is then gradually dilated using metallic or balloon dilators to create a channel wide enough (usually 22–30 Fr) to allow insertion of a nephroscope and other instruments.

5. Stone Visualization and Removal

• A nephroscope, a thin camera-equipped tube, is introduced through the tract into the kidney.
• The surgeon identifies the stones, which are then fragmented using laser, pneumatic, or ultrasonic lithotripsy.
• Stone fragments are suctioned out or retrieved using forceps or baskets, ensuring maximum stone clearance.

6. Drainage and Closure

• Depending on the intraoperative findings, a nephrostomy tube (to drain urine from the kidney) or a ureteral stent (to ensure free urine flow from the kidney to the bladder) may be placed.
• The skin incision is closed using absorbable sutures or surgical glue.
• The patient is transferred to the recovery room for monitoring.

Before PCNL Surgery

1. Evaluation

• A complete evaluation is done to assess stone size, location, number, and complexity:
  
  • CT scan is the gold standard imaging modality.
  • Ultrasound may also be used, especially in patients where radiation exposure is a concern.
• Blood tests are performed to check kidney function, hemoglobin levels, and blood clotting status.
• Urine tests help rule out active infection, which must be treated before surgery.

2. Medication Adjustments

• Blood-thinning medications (e.g., aspirin, clopidogrel, warfarin) are stopped 5–7 days before surgery to minimize bleeding risks, in consultation with your physician.
• If any infection is detected, antibiotics are prescribed ahead of surgery to avoid complications during the procedure.

3. Fasting Guidelines

• Patients are advised to avoid food and drinks for at least 6–8 hours prior to surgery.
• Clear instructions are given by the anesthesiology team during pre-operative counseling.

After PCNL Surgery

Immediate Post-Operative Care

• Upon awakening from anesthesia, the patient is observed in the recovery area to monitor:
  
  • Vital signs, urine output, and pain levels
  • Any signs of bleeding, fever, or urinary leakage
• IV fluids and painkillers are given as needed.
• The nephrostomy tube or stent (if placed) is monitored for proper drainage.

Hospital Stay

• The usual hospital stay ranges from 1 to 3 days, depending on the complexity of the case and how well the patient recovers.
• The nephrostomy tube, if present, is usually removed within 24–48 hours once urine drainage is satisfactory.
   

At-Home Recovery

• Most patients can resume light activities within 7–10 days, although full recovery may take a bit longer depending on overall health.
• Instructions include:
  
  • Avoid lifting heavy weights or strenuous activity for 2–3 weeks.
  • Maintain adequate hydration (2.5–3 liters per day) to prevent future stones.
  • Take all prescribed medications, including pain relievers, antibiotics, and urinary alkalizers if recommended.

Follow-Up Care

• A follow-up appointment is scheduled within 2–4 weeks post-surgery.
• A KUB X-ray or ultrasound is done to confirm that all stone fragments have been cleared.
• Stone analysis and metabolic evaluation may be advised to identify the cause of stone formation and guide prevention strategies.
• Lifestyle and dietary counseling are often part of the long-term plan.

Advantages of PCNL

The position offers several benefits compared to the traditional prone approach:

• Improved Access: The supine position allows better endoscopic access to the upper pole of the kidney through lower calyx puncture, increasing the likelihood of successful stone removal.
• Reduced Complications: There is a lower risk of complications such as nerve injuries and thromboembolism associated with prolonged prone positioning. Additionally, it minimizes fluid absorption risks during surgery.
• Ergonomics: Surgeons report less fatigue due to improved ergonomics during the procedure. This is crucial for maintaining focus and precision throughout surgery.
• Shorter Recovery Time: Patients often experience quicker recovery times and reduced postoperative discomfort, making it easier for them to return to normal activities sooner