Overview
Definition:
Percutaneous Nephrolithotomy (PCNL) is a minimally invasive surgical procedure used to remove large or complex kidney stones by creating a small incision in the flank, through which a nephroscope is inserted to access and break up or extract the stones
Perioperative care encompasses all aspects of management before, during, and after the procedure to ensure optimal patient outcomes and minimize complications.
Epidemiology:
Nephrolithiasis affects approximately 5-10% of the population globally, with stone recurrence rates being high
PCNL is indicated for staghorn calculi, large stones (>2 cm), or stones refractory to extracorporeal shock wave lithotripsy (ESWL) or ureteroscopy
Patient demographics vary with stone composition and etiology.
Clinical Significance:
Effective perioperative management of PCNL is crucial for patient safety and procedural success
It impacts pain control, fluid balance, infection prevention, and recovery time
For DNB and NEET SS aspirants, understanding these principles is vital for managing patients undergoing this common urological intervention and for answering exam questions related to stone disease management.
Indications And Contraindications
Indications:
Large (>2 cm) renal calculi
Staghorn calculi
Stones refractory to ESWL or ureteroscopy
Certain stone compositions requiring direct access
Co-existing renal pathology requiring intervention
Upper tract transitional cell carcinoma.
Contraindications:
Untreated urinary tract infection
Uncorrected bleeding diathesis
Pregnancy
Severe cardiopulmonary disease precluding general anesthesia
Active inflammatory bowel disease in the region of surgical access
Situs inversus
Renal anomaly making access impossible.
Preoperative Preparation
Patient Assessment:
Thorough medical history and physical examination
Assess for comorbidities (diabetes, hypertension, cardiac/pulmonary disease)
Review previous stone history and imaging
Evaluate for urinary tract infection with urinalysis and culture.
Investigations:
Complete blood count (CBC), coagulation profile (PT/INR, aPTT)
Serum electrolytes, BUN, creatinine to assess renal function
Urine culture and sensitivity
Imaging: CT KUB (gold standard) for stone burden, location, and anatomy
ultrasonography
IVU if renal function is borderline or in specific cases.
Medications And Prophylaxis:
Antibiotic prophylaxis (e.g., quinolone or cephalosporin) administered 30-60 minutes before incision
Anticoagulation review and management: stop antiplatelets/anticoagulants as per guidelines
Optimal hydration
Pain management
Bowel preparation if indicated by surgical team.
Patient Counseling And Consent:
Detailed discussion of the procedure, risks (bleeding, infection, injury to adjacent organs, residual stone fragments, need for further procedures), benefits, and alternatives
Obtain informed consent after addressing all patient concerns.
Intraoperative Management
Anesthesia And Positioning:
Typically general anesthesia
Patient positioned prone on a specialized flank support table to create a distinct costo-iliac angle for optimal access
Careful padding of pressure points.
Access And Tract Creation:
A small skin incision (0.5-1 cm) is made in the costo-iliac angle
A Veress needle or a guidewire is advanced into the pelvicalyceal system under fluoroscopic or ultrasound guidance
A tract is created using serial dilators or a balloon dilator to achieve the desired working channel size (e.g., 24-30 Fr).
Stone Fragmentation And Extraction:
Once access is established, a nephroscope is introduced
Stones are fragmented using ultrasonic, pneumatic, or electrohydraulic lithotripters
Fragments are removed with graspers, baskets, or suction
Complete stone clearance is assessed visually and often confirmed with intraoperative imaging.
Hemostasis And Drainage:
Meticulous attention to hemostasis during tract creation and stone removal
If significant bleeding occurs, pressure can be applied, electrocoagulation used, or balloon tamponade
A nephrostomy tube (e.g., 16-20 Fr) or a drainage catheter is typically placed in the renal pelvis for drainage and access
A small flank drain may also be placed.
Postoperative Care
Monitoring And Vital Signs:
Close monitoring of vital signs (BP, HR, RR, SpO2, temperature) for signs of bleeding, sepsis, or respiratory compromise
Monitor urine output and characteristics (color, presence of clots)
Assess for flank pain and administer analgesics as needed.
Fluid Management And Hydration:
Intravenous fluid resuscitation to maintain adequate hydration and renal perfusion
Monitor intake and output
Avoid overhydration, especially in patients with impaired renal function or cardiac issues.
Pain Management:
Effective analgesia is crucial
Options include IV narcotics, NSAIDs, and patient-controlled analgesia (PCA)
Consider scheduled analgesics for better pain control
Non-pharmacological methods like repositioning can also help.
Antibiotics And Infection Prevention:
Continue antibiotic prophylaxis for 24-48 hours postoperatively or as guided by urine culture results and clinical status
Monitor for signs and symptoms of urinary tract infection or sepsis (fever, chills, dysuria, flank pain, elevated WBC count).
Nephrostomy Tube Care And Removal:
The nephrostomy tube provides drainage and allows for repeat access if needed
Keep the tube patent by flushing periodically
The tube is typically removed 1-3 days postoperatively after a check imaging (e.g., plain X-ray KUB or non-contrast CT) confirms adequate drainage and no significant residual stones or extravasation
Urine output from the tube should be monitored, and the stoma site inspected for leakage or signs of infection.
Complications
Early Complications:
Bleeding requiring blood transfusion or reoperation (most common)
Injury to adjacent organs (colon, spleen, lung – pleural effusion/pneumothorax)
Urinary tract infection and sepsis
Perinephric hematoma
Residual stone fragments
Incomplete stone removal
Acute urine leak
Hemorrhage
Pain.
Late Complications:
Nephrocutaneous fistula
Stricture formation at the tract site
Chronic pain
Hydronephrosis secondary to obstruction
Stone recurrence
Sepsis
Injury to colon or spleen
Erosion of nephrostomy tube into adjacent organs.
Prevention Strategies:
Careful patient selection and optimization
Meticulous surgical technique with good hemostasis
Judicious use of dilators and instruments
Adequate antibiotic prophylaxis
Prompt recognition and management of bleeding
Postoperative imaging to confirm clearance
Careful nephrostomy tube management.
Key Points
Exam Focus:
PCNL is the gold standard for large (>2cm) and staghorn calculi
Perioperative care is multidisciplinary, involving urologists, anesthesiologists, and nurses
Complications like bleeding and infection are critical to identify and manage
Nephrostomy tube management is a key aspect of postoperative care.
Clinical Pearls:
Always perform a post-PCNL KUB X-ray or CT to assess stone clearance
residual fragments often require further intervention
Prone positioning requires meticulous padding to prevent pressure sores
Monitor urine output from the nephrostomy tube closely
significant leak may require tube repositioning or drainage management
Hemorrhage is the most common complication
have transfusion protocols ready.
Common Mistakes:
Inadequate preoperative workup (e.g., missing UTI)
Aggressive tract dilation leading to increased bleeding
Incomplete stone removal due to poor visualization or inadequate fragmentation
Neglecting postoperative fever as a sign of sepsis
Inappropriate management of residual stone fragments
Delayed recognition of organ injury.