Treating Kidney Stones:
Percutaneous Nephrolithotomy (PNL)
PNL is the treatment of choice for large stones located within the kidney that will not be effectively treated with either ESWL(extracorporeal shock wave lithotripsy) or URS (ureteroscopy). General anesthesia is required to perform a PNL. The main advantage of this approach compared to traditional open surgery is that only a small incision (about one centimeter) is required in the flank.
A kidney or a ureter (tube leading from the kidney to the bladder) can become blocked. This may be due to kidney stones, tumors, or other causes. The blockage can cause a backup of urine in the kidney. Percutaneous nephrostomy is a procedure that drains the urine from the kidney to prevent pain, infection, kidney damage and allow access for stone removal procedures.
This part of the procedure is performed by a Radiologist in the Interventional Radiology department and then you are transferred to the surgical suite then the urologist places a guide wire through the incision. The wire is inserted into the kidney under fluoroscopic guidance and directed down the ureter. A passage is then created around the wire using dilators to provide access into the kidney.
|Pieces of stone are plucked or sucked out through the incision.
The Urologist uses an instrument called a nephroscope that is then passed into the kidney to visualize the stone. Fragmentation can then be done using an ultrasonic probe or a laser. Because the tract allows passage of larger instruments, your urologist can suction out or grasp the stone fragments as they are produced. This results in a higher clearance of stone fragments than with ESWL (lithotripsy) or URS (ureteroscopy) for larger stones.
|An instrument inserted through a viewing tube cracks the stone.
Percutaneous lithotripsy - removal of larger stones through a small incision in your side. Your doctor places a viewing tube through your incision. The stone is sighted, shattered with a special device if needed, and removed. Afterward, you’ll briefly have a small soft tube in your incision. This tube carries urine away from your kidney and out of your body.
Our surgery scheduler will make these arrangements for you:
Pre-operative lab work, EKG and chest x-ray as needed
Order blood bank donations – you will need to schedule the appointment(s) at phone number provided if needed.
Schedule the surgery at the hospital
Secure insurance preauthorizations as required by your insurance
Schedule pre-op appointments with our nurses and physicians
You are responsible for inquiring with your insurance company if you have additional expenses.
NURSE VISIT PRIOR TO SURGERY
This visit will allow you to go over surgery preparations, post op concerns and recovery issues. Please allow about 30-60 minutes for this appointment and we encourage family members, caregivers or friends to attend.
SURGEON VISIT PRIOR TO SURGERY
This visit is usually within the two weeks prior to surgery. Your doctor will review the surgery and obtain your surgical consent. This visit usually does not involve any physical exam.
LAB WORK/EKG PRIOR TO SURGERY
This is generally done 1-2 weeks prior to surgery and can often be done in the same visit as your pre-op surgeon’s visit. You do not need to fast for this lab work. If you have any other medical problems (heart, lung, blood disorders) you may need to evaluated further for surgical clearance – we will notify you if this is needed.
PRIOR TO SURGERY
Your activity level, social calendar and/or work schedule need not to be interrupted in the weeks prior to surgery. You want to be well rested and eat a nutritious diet prior to surgery.
TWO WEEKS PRIOR, PLEASE HOLD ALL HERBALS AND SUPPLEMENTS. TYLENOL IS OKAY TO USE. HOLD ALL ASPIRIN, OR ASPIRIN – LIKE, PRODUCTS FOR AT LEAST ONE WEEK PRIOR TO SURGERY.
Potential Risks and Complications
Bleeding of the kidney
Skin infection around the catheter site
Blockage of the catheter
Problems due to contrast medium, including allergic reaction or kidney damage
Once the procedure is complete, a tube is left in the flank to drain the kidney. This tube is attached to a drainage bag. If you go home with the catheter in place, please see catheter care instructions.
After the tube is removed from your kidney you will experience some leakage of urine from the small incision site. Keep this clean and covered with a 4x4 dressing for dryness and comfort until the drainage stops in several days. The urine drainage varies from damp dressings to need for frequent changes for a few days. You will be instructed in site care prior to discharge
You may spend 1–3 days in the hospital. Your urologist may choose to have additional X-rays done while you are still in the hospital to determine if any stone fragments are still present. If some remain, your urologist may want to look back into the kidney with a nephroscope to remove them. This secondary procedure usually can be done with sedation and through the existing tract into the kidney. Once the stones have been removed, the stent coming out of the flank is removed. Normal activity can be resumed after approximately one to two weeks.
AT HOME CARE
After surgery, it is a good idea to have someone staying with you at home. When you are discharged, someone will need to drive you home. Arrange to get your prescriptions filled before you go home so that you have the necessary medications at home when you need them.
You may eat or drink anything you can tolerate. Some people notice a change in their appetite and also their sense of taste after surgery. This is temporary. Eat nutritious, small and frequent meals. Adding a nutritional supplement such as Instant Breakfast between meals can boost your increased nutritional needs for healing. Add fiber to your diet to reduce constipation. Drink 6-8 glasses of water a day to keep the catheter clear.
You may notice a change in stamina and a need to sleep more. This is OK – it is part of the healing process. The primary restriction is not to lift more than 10-15 pounds during the first several weeks. Minimize stairs when possible. It is important that you sit, stand and roll out of bed correctly so that you do not put excessive strain on your site and catheter. You should not drive while the catheter is in or while taking narcotic pain medication. Use of exercise equipment is generally restricted in the first 6 weeks. Otherwise, you may walk – we recommend it. Social activities are restricted only by your stamina. Returning to work is generally not recommended until 4-6 weeks after surgery. Finding a comfortable position while the drainage tube is still in place is sometimes a challenge.
Continue the use of the incentive spirometer several times a day as you used it in the hospital. Continue to use the spirometer for a week after discharge. This will help prevent respiratory complications.
You may shower within 24 hours after surgery. You must cover up the dressing with plastic wrap and seal the edges with tape if you tube is still in place. This will prevent and water from tracking along the tube into the kidney. If you are unsteady, sit on a shower stool and use a hand held shower.
This is very common after surgery due to your bowels being “asleep” in surgery and/or due to the use of narcotic pain medications. You may use Milk of Magnesia, stool softeners (Ducolax or Colace) or mineral oil. High fluids, fruits and vegetables, and physical activity may help.
Take good care of your tube site by keeping it clean, dry, and free of infection.
Keep the dressing clean and dry and watch for signs of infection.
keep the skin around the catheter clean and dry.
Be careful not to dislodge or move the catheter.
Keep the drainage bag secured to back, waist or leg to prevent catching or tugging.
Empty the drainage bag often to keep the weight of a full bag of urine from pulling on the catheter.
Call your doctor if the urine becomes cloudy or smells.
A follow-up visits will include imaging studies (x-rays and/or CT-scans) to verify there are no stones. Later visits will help your doctor spot new stones if any form. Additional follow-up care may involve a metabolic workup(lab and urine tests) to determine why you produced kidney stone(s) so he can assist you in preventing recurrences. Your Urologist will advise you of your specific follow-up care.
Call Your Doctor If You Have:
Sudden pain or flank pain.
A fever over 100.1°F.
Nausea that lasts for days.
Heavy bleeding when you urinate or through your drainage tube.
Swelling or redness around your incision.