Percutaneous Nephrolithotomy (PCNL)
Percutaneous nephrolithotomy (PCNL) is a minimally-invasive procedure to remove stones from the kidney by a small puncture wound (up to about 1 cm) through the skin. It is most suitable to remove stones of more than 2 cm in size and which are present near the pelvic region. It is usually done under general anesthesia.
Small needle is passed into the kidney. The position of the needle is confirmed by fluoroscopy. A guide wire is passed through the needle into the pelvis. The needle is then withdrawn with the guide wire still inside the pelvis. Over the guide wire the dilators are passed and a working sheath is introduced. A nephroscope is then passed inside and small stones taken out. In case the stone is big it may first have to be crushed using ultrasound probes and then the stone fragments removed.
What are the advantages?
Allows for large or complicated stones to be treated in a minimally invasive fashion, which in the past this would have necessitated a large incision, and longer hospital stay.
Hospital stay is now 1-3 days, and the out of hospital recovery time is significantly shorter than the traditional open surgical approaches.
Quicker return to work.
What are the disadvantages?
Compared to traditional techniques in dealing with large complex stones, there are no disadvantages.
Improvements in techniques and equipment have allowed this type of surgery to be carried out more safely amongst subspecialty trained surgeons.
What are the risks?
This form of surgery is low risk if performed by a urologist who is specifically trained in this technique, and aided by meticulous pre-operative planning. The specific risks are uncommon but include infection, excessive bleeding (necessitating blood transfusion 2-5%, angio-embolisation 0.5%, and adjacent organ injury (spleen, liver, bowel, lung, and diaphragm).
What to expect afterwards?
You may have a temporary catheter called a nephrostomy tube draining urine from the kidney, as well as a urethral catheter draining urine from your bladder. These catheters will be removed prior to your discharge from hospital. The urine may be bloodstained for up to a week after discharge and this should not alarm you provided it is not getting heavier. Medical imaging is performed immediately following surgery to assess stone clearance. Your hospital stay will be usually on average be 1-3 days. Occasionally, further follow-up day surgery is required using flexible pyeloscopy and laser to clear any remaining stones to achieve complete kidney stone clearance.
Surgery Scheduling
-Your physician will begin the scheduling process with the hospital.
-My administrative assistant Brandi (254)-724-7573 will verify your records and make an appointment for your pre-surgical evaluation.
-Your pre-surgical evaluation may either take place in person or by phone, depending on your physician's orders; we may require clearance from your primary care physician.
-Any pre-operative testing will be ordered during your evaluation.
-If you have not been reached by phone and your surgery is scheduled to occur within the next 48 hours, please call (254)-724-7573 between 7:30am and 5pm, Monday through Friday.
Medications
- Please take your prescribed preoperative antibiotics exactly as prescribed if you are prescribed one.
-Some medicine such as aspirin, aspirin containing compounds, Coumadin, Pradaxa or Plavix impair the body's ability to form a clot and stop bleeding. Based on your needs, specific details on these medications will be discussed at the time of your doctor visit, if there you are taking one of these medications and you didn't tell your doctor, please call the nurse line and let them know (254)-724-8277.
-If you are on any blood thinner or anticoagulants please let your doctor know, we will consult the Doctor who prescribed these medications in order to stop it.
-You will be instructed on what medicines you should and should not take in the days leading up to your surgery and on the morning of the surgery itself.
-Some vitamins and herbal medicine contain blood thinners, please be advised to stop any of these medications 1 week before the surgery
-If you have diabetes and take insulin or another diabetes medicine, instructions will be provided on how to adjust your medicine on the day of surgery when you will not be eating.
- You will spend the night in the hospital
The Day before Surgery
-Please contact your surgeon's office to validate your arrival time.
-Do not shave near your surgical site. Shaving can irritate your skin, which may lead to infection.
-Do not smoke on the day before surgery. This is irritating for your lungs.
-Do not eat any solid food or drink any liquids as instructed at the time of your interview, this includes water, candy, and chewing gum.
The Day of Surgery
-If you've been asked to take routine or other medicines on the morning of surgery, please take them with a very small sip of water.
-Wear loose and comfortable clothing and flat shoes.
-Leave jewelry and valuables at home. If you wear contact lenses, please bring your glasses with you. Please remove any body piercings.
-Please arrive at the hospital at the specified time.
-Because of urgent cases, there may be a delay in the start of your surgery or, your start time could be earlier than expected if last minute cancellations occur. If possible, bring something to read and arrive early.
-If you receive general anesthesia, you will be taken to the Recovery Room for approximately one hour after your procedure.
-If you are going to be discharged from the hospital after surgery, you will be allowed to go home when you are fully alert.
-A nurse will review your post-operative instructions and prepare you for discharges from the hospital.
-You will not be allowed to drive yourself home. Please make arrangements for someone to take you home.
Information for Patients Following Surgery for Stones
The physicians and staff of Baylor Scott and White hope that you have a smooth recovery from your surgery for kidney stones. Patients often have questions after surgery or need clarification about what has occurred! The following information will help you know what to expect. We welcome your calls with questions or concerns; please do not hesitate to contact us.
Hematuria (blood in the urine)
You might see blood in your urine for up to a couple of weeks after surgery. Although this may seem alarming, please know that it is unlikely that you are losing a significant quantity of blood, even though the urine may look VERY red! The general trend should be a decrease in bleeding over time. The bleeding may come and go; this is normal. You may see clots or dark strands in the urine; if large, they can cause difficulty with urination. They can be minimized by consuming lots of fluids (strive for at least 2 liters per day).
Stents
Your doctor may have placed a stent in the ureter during surgery to ensure drainage from the kidney. You may or may not see a string exiting the urethra; if you do have a string, try to avoid tugging or catching it in a zipper. The stent will need to be removed either days or weeks from the date of surgery. Your doctor will advise you or your family members to make an appointment for removal.
Some patients have no side effects while the stent is in place. Common stent symptoms include cramping pain or pressure in the kidney and bladder, urinary frequency, and pain on urinating. Please contact our office if these symptoms are severe or persist beyond a few postoperative days. Your doctor may be able to prescribe medication to help decrease those symptoms.
Nephrostomy
If you had your stones removed percutaneously, or through your back, you may be discharged with a urine collection bag adhered to your back. Beneath it lays a small incision, which will close on its own. Empty the bag periodically, or as it becomes full. The site may drain for a few days; when there has been no drainage for approximately 24 hours, you may remove the bag, and then cover the incision with a dry dressing or Band-Aid until incision is dry and scabbed. You may shower with the bag on and after its removal, but do not soak in a tub until incision is well healed (at least 2 weeks).
Follow up
Please call our office to make a follow up appointment approximately 6 weeks from the date of surgery.
Definition of Terms and anatomy of the urinary tract:
Kidney: Most patients have two! The kidneys filter wastes and fluid from the body, making urine.
Ureter: There is usually one ureter per kidney. The ureter is a tube that transports urine from the kidney to the bladder, where it is stored until expulsion through urination.
Bladder: Urine enters the bladder from the ureters and stores the urine until urination.
Urethra: The urethra carries urine from the bladder to the outside of the body, either through the penis in men, or through an outlet near the vagina in women.
Hydronephrosis: The condition resulting from the back up of urine in the kidney. This occurs when a stone or a narrowed area of the ureter is blocking the flow of urine. It is sometimes associated with pain, fever, nausea, vomiting, or infection.
Stent: A thin, hollow tube placed in the ureter during surgery to insure drainage from the kidney into the bladder. Side effects can include feelings of pain, pressure and a frequent need to urinate. Medication can help reduce these symptoms.
Foley Catheter: A tube placed in the urethra to drain urine from the bladder.
Nephrostomy: An opening through the skin of the back into the kidney. There may be a tube and/or bag draining urine from the kidney.
Description of Procedures:
Cystoscopy: The process of looking into the bladder through the urethra. Using a small camera and light, your surgeon can inspect the bladder and remove stones and some bladder tumors.
Ureteroscopy: The process of looking into the ureter and kidney through the bladder. No incision is required. It is can be used to inspect the ureter and kidney, and to remove stones or enlarge narrowed areas.
Lithotripsy: The process of breaking stones into tiny pieces so that they can exit the body. This can be accomplished with shock wave, ultrasound or with a laser.
Percutaneous Nephro-lithotripsy (PERC or PCNL): The process of removing stones through a small incision in the back.
WHEN TO CALL THE DOCTOR:
· If your temperature is 101° or higher, please call the office number. Have the telephone number of your pharmacy available.
· If you develop a rash (breaking out), stop your medicine and call the office number.
· If you feel like you need to urinate and are unable to.
· Severe dizziness or fainting
· Nausea and vomiting so severe and persistent that you cannot consume fluids
· Severe pain that is uncontrolled by prescribed medications
A doctor is on emergency call 24 hours a day, PLEASE ASK TO SPEAK WITH THE UROLOGY RESIDENT ON CALL, 7 days a week to assist you (including after office hours and weekends). Please call if you have urgent concerns.
You may use milk of magnesia or another mild laxative as needed to keep your bowels moving and soft. Do not allow yourself to strain.
Make an appointment to see the doctor who performed your surgery about six weeks from the time of hospital discharge.