What are Closed Kidney Stone Surgery, Percutaneous Kidney Stone Surgery, and Percutaneous Nephrolithotomy-PNL, and How are They Performed?

Closed Kidney Stone Surgery, Percutaneous Kidney Stone Surgery, Percutaneous Nephrolithotomy-PNL; refers to the surgical procedure of breaking up and removing kidney stones, usually larger than 2 centimeters, that are numerous or too large to be treated with extracorporeal shock wave fusion (ESWL) or ureteroscopy (URS). In the past, large kidney and ureter stones were removed through open surgery requiring a large incision. Percutaneous nephrolithotomy is performed through a 1 cm skin incision, minimizing incision size, pain, blood loss, and blood transfusions, and shortening hospital stays. This technique also has a higher success rate in removing all stones in a single session compared to other techniques such as ESWL, which usually require several procedures.

During the initial clinical examination before surgery, all X-ray images and reports, such as CT scans, intravenous pyelography or IVP, sonogram, or MRI, are obtained and carefully reviewed by the surgical team. If necessary, blood and urine tests are ordered, the medical history is reviewed, and a physical examination may be performed. The decision is made to perform ureteroscopy, or laser kidney stone removal. After this, surgical preparation begins. A pre-operative anesthesia consultation is conducted. For anesthesia preparation, the anesthesia team will perform a physical examination, ECG, blood count, blood clotting status (INR, PT, PTT), biochemical blood tests, and urinalysis.

Closed kidney stone surgery, or ureteroscopy, is the only minimally invasive stone surgery that can be performed even while taking active blood-thinning medication. However, even with this option, it is most preferable to discontinue all blood-thinning medications before surgery, if medically possible.

What are the necessary steps before percutaneous nephrolithotomy (PNL) surgery?

During the initial pre-operative consultation, it is extremely important to review all images and reports of the patient's X-ray films, including ultrasound, urography, CT scan, and MRI. Then, your medical history will be reviewed, and a brief physical examination will be performed. A urinalysis will be mandatory during your first visit. All treatment options for the stone(s), including the risks and advantages of each treatment, will be discussed. If Percutaneous Nephrolithotomy (PNL) is decided upon, after your surgery date is set, you will have the opportunity to discuss the available types of anesthesia and their risks/benefits with the anesthesia team. Some tests will be performed for anesthesia: ECG, complete blood count, PT/PTT (blood clotting profile), Comprehensive Metabolic Panel (blood chemistry profile), urinalysis, and urine culture.

There are medications that need to be stopped or changed at least 5-7 days before surgery. Many of these medications can alter platelet function, or your body's clotting function, and therefore cause unwanted bleeding during surgery. It is important to be informed about and have a list of these blood-thinning medications and others in place.

It is crucial that the urine is free of infection before percutaneous nephrolithotomy (PNL) surgery. Therefore, if you suspect you have a urinary tract infection (burning during urination, blood in urine, frequent and urgent urination, fever), it is important to inform the surgical team immediately so that appropriate culture and treatment can be performed.

How is Percutaneous Nephrolithotomy (PNL) Surgery Performed?

PNL (Percutaneous Nephrolithotomy) is performed under general anesthesia, with the patient lying either prone or supine. After anesthesia, a camera with a light is inserted into the bladder, the bladder is examined, a hollow catheter is placed in the affected renal tract (ureter), and a contrast agent is injected to visualize the renal and ureteral lumens. Using this visualization, the patient can pinpoint the stone within the kidney and, under X-ray guidance, access the stone through a small needle inserted through the skin. Once the needle's position is confirmed, a wire guide is sent through the needle, and the needle is withdrawn. Then, using special instruments, the path accessed through the wire guide is widened to allow the telescope to pass through, and a rigid plastic sheath is inserted. Using an ultrasonic, mechanical, or laser lithotripsy device, the stone(s) are broken into small pieces by laser through this sheath and removed from the body. In some cases, it may be necessary to access multiple channels and ensure the removal of all stones.

At the end of the surgery, a small ureteral stent may be left in place to drain the kidney into the bladder, or a nephrostomy tube may be left in place to drain the kidney into an external drainage bag. The surgery generally lasts 3-4 hours.

You can watch an animation of this type of stone removal surgery and all the surgical stages by clicking the link:https://www.youtube.com/watch?v=NKXTEm_rh7o

What are the possible adverse complications during and after percutaneous nephrolithotomy (PNL) surgery?

August:During percutaneous nephrolithotomy (PNL) surgery, blood loss is generally minimal, and the risk of needing a blood transfusion ranges from 5-7%, depending on the size and location of the stone and the number of pathways involved.

Infection:Bacteria can sometimes multiply inside stones, and therefore can cause urinary tract infections during stone removal surgery, and rarely, spread to the body and cause sepsis. Consequently, urinary tract infections need to be treated before surgery, and broad-spectrum antibiotics are administered at the beginning of surgery to minimize the risk of urinary tract infection.

Injury to Adjacent Tissues and Organs:Occasionally, complications requiring open surgery or further surgery may occur, albeit rarely. During surgery, organs surrounding the kidney, such as the intestines, colon, blood vessels, spleen, and liver, may be injured. The chest cavity is very close to the upper pole of the kidney, and kidney stones at the upper pole can sometimes cause lung injury, resulting in pneumothorax (or air surrounding the lung). This may require the temporary placement of a small chest tube to drain the air and fluid surrounding the lung. Permanent kidney damage and loss during percutaneous nephrolithotomy (PNL) is extremely rare. Damage and perforation of the ureter draining the kidney can occur, albeit rarely.

The stone could not be completely cleaned:Although one or more pathways are created in the kidney to remove the stones, it is a small possibility that not all stones may be successfully removed during Percutaneous Nephrolithotomy (PNL) surgery due to the size, number, or location of the stones within the kidney.
What is the process like after percutaneous nephrolithotomy (PNL) surgery?

Following your surgery, you will be transferred to the recovery room and then, once you are fully awake, to your hospital room.

Postoperative pain:Following surgery, pain in the area where your kidney is located is common for the first few days, but it is usually well controlled with intravenous or oral pain medication.

Nephrostomy Tube:The nephrostomy tube, placed at the end of surgery, drains urine directly from the kidney into a drainage bag. It is routinely placed to tamponade bleeding in the pathway between your skin and kidney. The urine from the kidney is often blood-colored and is expected to become clear in the days following surgery. If necessary, you may be discharged from the hospital with the nephrostomy tube in place. The nephrostomy tube is then usually removed 2-3 days after surgery.

Ureteral Stent:A ureteral stent is a small, flexible plastic inner tube placed to support the drainage of your kidney to the bladder. It is usually easily removed within 1-2 weeks following surgery.

Nausea:Patients usually experience temporary nausea within the first one or two days following surgery performed under general anesthesia. Nausea can be controlled with medication.

Urinary Catheter:A bladder catheter, called a Foley catheter, is inserted in the operating room while you sleep and left in place for about a day after surgery. This allows for continuous monitoring of your urine output. It is not uncommon for your urine to be bloody for a few days after surgery. The urinary catheter will be removed before you are discharged.

Diet:During the first two days after surgery, your diet will gradually progress from liquids to solids, as tolerated. You will also receive intravenous fluids to maintain your body's fluid balance after the surgery.

Fatigue:Fatigue after percutaneous nephrolithotomy (PNL) surgery is a common complaint and is expected to resolve within a few weeks.

Breathing exercises:Deep breathing exercises are important in reducing the incidence of lung complications such as pneumonia. These exercises can be performed using blowing devices or balloons.

Physical Activity:It is very important to get out of bed and start walking under the supervision of your nurse or family member the evening after your Percutaneous Nephrolithotomy (PNL) surgery. This is to prevent blood clots from forming in your legs. Wearing compression stockings is also recommended to prevent blood clots from forming in your legs. During your hospital stay, it is recommended that you walk in the corridors at least 4-6 times a day to minimize the risk of clots. The more walking you tolerate, the better.

Hospital Stay Duration:Most patients stay in the hospital for about 1-3 days.

Second Session Percutaneous Nephrolithotomy-PNL Surgery:In some cases, a secondary PNL procedure may be necessary through the existing nephrostomy canal to remove any remaining stone fragments. This procedure can be performed during your hospital stay or on a second surgery date determined by your surgeon.

What should the recovery process be like after discharge from the hospital following percutaneous nephrolithotomy (PNL) surgery?

Pain Control:Mild pain at the nephrostomy tube site may require pain medication, but patients are advised not to overuse pain medication to avoid constipation and excessive drowsiness that may result from it.

Taking a shower:You are allowed to shower while your nephrostomy tube is in place; however, the area should be gently dried immediately after showering. Bathtub baths or hot tubs should be avoided while your nephrostomy tube is in place.

Time for physical activity, driving, and returning to work:To minimize the risk of blood clots forming in your legs, a condition called deep vein thrombosis, daily walks are recommended. Avoid sitting or lying in bed for long periods. Climbing stairs is possible, but done slowly. Avoid driving for at least 1-2 weeks after surgery. After this time, activity can be resumed as tolerated. You can return to work 1-2 weeks after surgery or as directed by your doctor.

Care of the Nephrostomy Site:Nephrostomy tube care is critical to ensuring your kidney heals properly. It's important that urine flows freely through the tube and is always kept below your kidney level. You need to ensure your nephrostomy tube isn't twisted, pulled, or dislodged from its correct position. You should contact your doctor immediately if you experience any changes in pain, fever, chills, pus at the insertion site, failure of the catheter to drain, or leakage around the tube.

Stent Removal and Follow-up:A slight fullness on the side associated with the stent and an urgent need to urinate may frequently occur. These symptoms usually disappear over time as the body adjusts to the stent. The ureteral stent is generally easily removed within 1-2 weeks after surgery. Long-term, permanent ureteral stents can develop calcification and crusting. Because this can lead to potential kidney loss due to infection and obstruction, it is critical for patients to return for ureteral stent removal as instructed by their surgeon.

When should you call your doctor?Although adverse events after PNL are rare, it is important for patients to recognize these events and know when to contact their surgeon. Worsening pain in the days following Percutaneous Nephrolithotomy (PNL) surgery, even with oral pain medication, may indicate a blockage in the ureter due to a large stone, a hematoma around the kidney, or a kidney infection. Fever above 38 degrees Celsius may indicate a serious urinary tract infection. Nausea and vomiting, chest pain, or difficulty breathing are also reasons to seek medical attention.

Frequently Asked Questions About Percutaneous Nephrolithotomy (PNL) Surgery?

1. What are the advantages of percutaneous nephrolithotomy (PNL) compared to other stone treatments?

The primary advantage of percutaneous nephrolithotomy (PNL) over other treatments such as ESWL or ureteroscopy is that it provides a minimally invasive approach for treating and removing large stone loads in a single procedure.

2. What are the disadvantages of percutaneous nephrolithotomy (PNL) compared to other treatments?

While ESWL and ureteroscopy can be performed under intravenous sedation, Percutaneous Nephrolithotomy (PNL) requires general anesthesia. Some patients may not tolerate general anesthesia due to their medical conditions. Compared to other stone treatments, PNL is somewhat more invasive and carries a slightly higher risk. However, for most patients with large stone burdens, multiple stones, or stones resistant to other treatments, the advantages of Percutaneous Nephrolithotomy (PNL) outweigh the risks.

3. Which patients are good candidates for Percutaneous Nephrolithotomy (PNL) surgery?

Percutaneous nephrolithotomy (PNL) surgery is an excellent option for patients with large kidney stones (typically > 2 cm), multiple large stones, or stones that have previously been resistant to treatment with ESWL or ureteroscopy.

4. Which patients are not good candidates for Percutaneous Nephrolithotomy (PNL) surgery?

Patients with serious heart or lung conditions, or those with an uncorrectable bleeding tendency, are not good candidates for PNL. Patients with active urinary tract infections are at a higher risk of sepsis during surgery and should therefore be treated with antibiotics to clear the urinary tract infection before PNL.

5. Can multiple stones be treated simultaneously with percutaneous nephrolithotomy (PNL) surgery?

Multiple stones can be treated with PNL. This is one of the advantages of this approach; however, sometimes, even with the use of flexible telescopes, it can be difficult to visualize all areas of the collection system, and therefore some stones may not be retrieved. This may necessitate the placement of a second access route to reach the remaining stones or a second PNL procedure at a later date.

6. Will I need a permanent ureteral stent after percutaneous nephrolithotomy (PNL) surgery?

In most cases, a permanent ureteral stent is placed to facilitate the drainage of urine from the kidney to the bladder.

7. What is the overall success rate of percutaneous nephrolithotomy (PNL) surgery?

The success of Percutaneous Nephrolithotomy (PNL) surgery depends on many factors, including stone composition, stone size, number of stones, location in the kidney, the patient's body type (obesity), and the anatomy of the kidney's collecting system. Our surgeons will carefully evaluate all of the above variables and discuss them with you to maximize success and determine if Percutaneous Nephrolithotomy (PNL) surgery is right for you. The overall stone-free success rate is approximately 80-90% following the initial PNL and 90-100% following a secondary surgical procedure.

8- How can I tell if my Percutaneous Nephrolithotomy (PNL) surgery was successful?

The success of the treatment will be determined based on a CT scan performed following percutaneous nephrolithotomy (PNL) surgery. If stone fragments remain in the urinary tract, it may take more time to allow them to pass spontaneously, which usually takes several weeks. Alternatively, repeat surgery with PNL, ESWL, or ureteroscopy may be recommended.

9. Can percutaneous nephrolithotomy (PNL) surgery be repeated?

Yes, it can be repeated, done multiple times. Often, due to stone density or size, or the complex anatomy of the renal system, fragments may remain in the urinary tract, requiring a secondary procedure to remove them. This is usually done a few days after your first surgery. Alternatively, this second procedure may be postponed to a later date, depending on your surgeon.

10- Is it possible to have Percutaneous Nephrolithotomy (PNL) surgery on both kidneys simultaneously?

If the patient has a large stone burden in both kidneys, bilateral percutaneous nephrolithotomy (PNL) can be performed in the same procedure, or alternatively, as two separate surgeries at a later date. Your surgeon will make this decision with you.