Percutaneous Nephrolithotripsy (PNL): Meaning, Procedure, and Cost

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What is Percutaneous Nephrolithotripsy?

Percutaneous nephrolithotripsy is an inpatient invasive procedure in which the surgeon breaks and removes the kidney stone(s) through a small incision in the skin. Generally, this procedure is used to remove stones larger than 2 cm or irregularly shaped stones. This procedure is usually performed when less invasive procedures are not feasible or have failed to provide the desired outcome.

The cost of this procedure ranges between Rs.75,000 to Rs.1,10,000 depending on the clinical presentation. It is performed under general anaesthesia and takes about 2-3 hours to complete.

How is Percutaneous Nephrolithotripsy performed?

The process of Percutaneous Lithotripsy involves the following steps:

  1. At the outset, the anaesthetist administers the required dosage of general anaesthesia.
  2. Once the anaesthesia takes effect, the urologist inserts a cystoscope (a telescope-like instrument which is a thin tube with a camera and light on the end) to inspect the urinary bladder.
  3. He inserts a tube (catheter) into the ureter to your kidney and injects a special dye through the tube which travels to the kidneys. This radio-opaque dye highlights the kidney stones on an X-ray.
  4. Once the stone is located by X-ray, the urologist makes a 1.5 cm incision on your back, and through it, he accesses the kidney with an x-ray guided fine needle.
  5. With the help of a guide wire, the urologist serially inserts increasing sizes of dilators up to 1 cm to create an access passage to your kidney.
  6. Once the passage is created, the urologist inserts a hollow tube through which a nephroscope targeting the stones is inserted.
  7. Through the nephroscope, he inserts an ultrasonic lithotripter probe and positions it over the stone. The ultrasonic lithotripter probe produces ultrasonic energy targeted towards the stone and the stone breaks into fine granules.
  8. Finally, the urologist removes the stone fragments from your body using suction. Alternatively, the doctor may also use a grasper to retrieve the stone fragments.
  9. For multiple stones in the kidney, this procedure may be repeated through other access sites, if required, until all the stones are removed.


Please Note: If the stones are small and do not require to be fragmented and instead are suctioned out through the nephroscope, then the procedure is called Percutaneous Nephrolithotomy

Post the operation, a soft tube or catheter is left through the incision for a couple of days to drain the urine directly from the kidney into a drainage bag. Your recovery will be monitored closely until the catheter is removed.

Am I eligible for Percutaneous Nephrolithotripsy?

You are eligible for percutaneous lithotripsy if:

  • your kidney stones are larger than 2 cms in diameter
  • according to your doctor, you will not benefit by undergoing laser lithotripsy, ESWL, or ureterolithotomy.
  • you have a malformed kidney


You are not eligible for percutaneous lithotripsy if:


  • the stone has already damaged your kidney
  • the stone is less than 1 cm in diameter
  • you are severely obese
  • you take blood thinners
  • Ongoing urinary infection


Please Note: Eligibility criteria for various medical procedures differs from patient to patient and depends on their general health, medical history, and medical conditions. Please consult a doctor to know more about your eligibility or ineligibility for any medical procedure. 

What risks will I face while undergoing the Percutaneous Nephrolithotripsy procedure?

There are a number of risks associated with Percutaneous Nephrolithotripsy procedure which include:

  • inability to create a large enough tract with the needle and dilator to insert the nephroscope, in which case the procedure will be converted into an open kidney stone removal surgery.
  • bleeding, which may result from injury to blood vessels within the kidney.
  • in cases of very large stones, the procedure may be converted into percutaneous lithotripsy, where the stones will be broken and then removed. In very rare cases, a repeat procedure might be required.
  • formation of an arteriovenous fistula (a connection between an artery and a vein in which blood flows directly from the artery into the vein)
  • in rare cases, there may be an injury to the surrounding organs such as the spleen, liver, lung, pancreas, or gallbladder.

How will I benefit after undergoing a Percutaneous Nephrolithotripsy procedure?

For most patients with very large kidney stones the benefits of the PCNL procedure outweigh the risks:

  • It is a minimally invasive procedure, which means fewer complications as opposed to an open surgery.
  • Multiple stones can be removed.
  • Larger stones can be easily broken down into small pieces and removed from the body.
  • The procedure has a post-procedure stone-free rate which is greater than 97%.
  • The patient experiences less post-operative pain as compared to an open surgery.
  • The patient can return to his daily activities sooner when compared to an open surgery.

What are my alternatives to Percutaneous Nephrolithotripsy?

The alternatives to percutaneous lithotripsy include:

What are the pre-operative guidelines I should follow for Percutaneous Nephrolithotripsy? 

The pre-operative guidelines which are followed prior to a PCL procedure are:

  • A complete physical examination by your doctor to ensure you are in good health before undergoing the procedure. The doctor will also ask for your medical history prior to the procedure.
  • You may have to undergo blood tests or other diagnostic tests. The tests performed may include:
    • blood tests
    • an electrocardiogram (ECG)
    • a comprehensive set of metabolic tests
    • a urine test
    • tests that measure the speed of blood clotting.
  • Tests are done to determine the number, location, and size of the stone(s). These may include:
    • X-ray
    • Ultrasound
    • Intravenous pyelogram (IVP)
  • Sign a consent form expressing your consent for the procedure by taking responsibility for the risks related to it. You will be made aware of any risks related to the procedure by your doctor.
  • You may be asked to drink only clear fluids (chicken broth, clear fruit juices, or water) for 24 hours prior to surgery, with nothing taken orally after midnight before the day of the procedure.
  • Depending on the type of anaesthetic or sedation to be used, your doctor may instruct you to fast before the procedure.
  • Your surgeon may ask you to take a laxative the day before surgery to minimize the risk of constipation during the first few days of recovery.
  • You need to inform your doctor if you have a known sensitivity or allergy to any medications, latex, tape, or anesthetic agents (local and general).
  • You need to inform the doctor if you are pregnant or suffer from any heart disease.
  • Let your doctor know all the medications you take (prescription and over-the-counter).
  • Especially if you take any anticoagulant (blood-thinning) medications, aspirin, or any other medication that affects blood clotting. Your doctor may ask you to stop taking the medicines 7 to 10 days prior to the procedure.
  • Notify your doctor if you have a history of bleeding disorders.
  • Based on your medical condition, your doctor may request other specific preparations.
  • If you smoke, you will be advised by the doctor to stop smoking at least a week or two prior to the procedure.
  • Follow the instructions of your doctor.

What are the complications of Percutaneous Nephrolithotripsy?

The complications of PCL include:

  • Nausea
  • Fatigue
  • Constipation
  • Infection
  • Bleeding necessitating transfusion
  • Tissue injury or injury to organs surrounding the kidney such as spleen, liver, bowel, or colon, which may require emergency open surgery or further surgery.

 What are post-operative guidelines I need to follow after undergoing a Percutaneous Nephrolithotripsy procedure?

  • Promptly take all medication as prescribed by your doctor after the surgery.
  • You can expect to have a small tube called a catheter attached to your back to allow urine to drain directly from the kidney into a drainage bag. The catheter typically remains in place for one to two days. If deemed necessary by your surgeon, you may be discharged from the hospital with the catheter and will have to continue wearing it for a few days.
  • You will be advised to drink extra fluids to maintain good kidney health. It will help to dilute your urine. Drinking plenty of water will also reduce the chances of recurrence of kidney stones. So, make water your most frequent drink.
  • You may observe blood in the urine after your open surgery procedure. This is a temporary condition which clears up after a few days.
  • Post the procedure, you will be directed to do some very simple breathing exercises which will help prevent respiratory infections by using an incentive spirometry device (these exercises will be explained to you during your hospital stay).
    The exercises involve coughing and deep breathing and help prevent pneumonia and other pulmonary complications.
  • On the day after your surgery, it is very important to get out of bed and begin walking with the supervision of your nurse or family member to help prevent blood clots in your legs.
  • You may experience constipation for several days or weeks following the surgery. Stool softeners prescribed by the doctor can help with this problem.
  • You will be advised by the doctor to refrain from smoking and drinking alcohol for several weeks. Smoking and drinking alcohol can impede the healing process.

What is the recovery period after undergoing a Percutaneous Nephrolithotripsy procedure? 

Most patients usually resume work 1 to 4 weeks after the procedure, depending upon the severity of their condition. Complete recovery can take up to 6 weeks.

Are the results of Percutaneous Nephrolithotripsy permanent? 

The results of PCL are more or less permanent. New kidney stones may form until the underlying cause is rectified. The procedure required for the removal of the newly formed stones will be determined by your treating urologist.

How do I know if the Percutaneous Nephrolithotripsy procedure I underwent is a success? 

Medical imaging is performed immediately following the surgery to assess stone clearance. If there are no signs of stones, the procedure will be determined as a success.

More Topics On Kidney Stone Removal 

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References

1. Zengin K, Tanik S, Karakoyunlu N et al. Retrograde Intrarenal Surgery versus Percutaneous Lithotripsy to Treat Renal Stones 2-3 cm in Diameter. 2018. Available at: https://www.hindawi.com/journals/bmri/2015/914231/. Accessed March 5, 2018.

2. Fathelbab T, Abd EL Hamid A, Galal E. Percutaneous nephrolithotripsy under assisted local anaesthesia for high-risk patients: Is it effective?. 2018. Available at: https://www.sciencedirect.com/science/article/pii/S111057041300057X. Accessed March 5, 2018.

3. Usha N. Air embolism—a complication of percutaneous nephrolithotripsy. 2018. Available at: https://academic.oup.com/bja/article/91/5/760/254446. Accessed March 5, 2018.

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