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Kidney stone removal through a small percutaneous incision (PCNL)

The video included in the following demonstrates a kidney stone surgery through a small skin incision, a procedure referred to as Percutaneous Nephrolithotomy (PCNL). The surgery recorded in the video is being operated by Dr. Samad NikNahad at Mortaz Hospital, Yazd.

Kidney stones are among the most prevalent urinary system diseases. All large kidney stones used to be removed through open surgeries (kidney stone operation) making large incisions on the patient's abdomen or side, causing patients to complain of pain at the incision area for months alongside its side effects such as hernia at the surgical site. The fortunate news is that methods such as lithotripsy through focused ultrasonic energy for stones smaller than 2cm and PCNL for stones larger than 2cm have been introduced over the past decades, through which most kidney stones can be removed without any complications or wide-side incisions. 

PCNL is currently the standard treatment for large kidney stones and stones that remain irresponsive to lithotripsy. Here, you will get a step-by-step description of what goes into this procedure as demonstrated in the image and video. 

In which cases is PCNL to be used to remove kidney stones?

• Large and staghorn kidney stones

• Stones larger than 2cm found in the renal pelvis

• Stones irresponsive to lithotripsy

• Stones blocking the connection between the renal pelvis and the ureter tube

What has to be done before a PCNL surgery?

The patient receives consultation from an anesthesiologist before the surgery. Anti-inflammatory drug administration is ceased ten days before the surgery to minimize the risk of bleeding during the PCNL surgery and afterward. 

You will have to cease taking aspirin, Plavix, and other blood thinners seven to ten days before the PCNL surgery.

Make sure to undergo an Intravenous pyelogram (IVP) or a CT scan before the surgery to help remove the stone more efficiently. 
You will undergo all necessary blood tests before the operation.

You will be admitted to the hospital on the morning of the surgery, which will be later operated on you at noon. You could expect to be discharged from the hospital within two to three days post-surgery with the catheters removed.

How PCNL is operated?

The patient is generally admitted to the hospital one day before the operation as injectable serums and antibiotics are administrated. Three units of blood are reserved for the patient. 

A narrow ureteral catheter is the first place in the stone site following general or lumbar anesthesia. The patient is then placed on the bed on their side. 

A thin needle pierces through the skin and is guided to the kidney through ultrasound, the accuracy of which is confirmed as urine is discharged from it. 
The skin incision made by the needle to the kidney is widened using metal and plastic expanders. 
An Amplatz tube sheath is used to create a tunnel into the kidney, through which a special camera is guided toward the kidney for stone visualization and endoscopy. 
After the stone is identified, it is completely shattered and crushed using a lithotripter and removed using tweezers. 

• Ultimately, another imaging is performed to confirm the kidney removal, the sheath is removed, and the incision is closed with one stitch. The operation takes one to two hours depending on the stone size. 

The patient can start drinking fluids three hours after the surgery. 
The patient will experience mild pain, which is natural and can be controlled with painkillers. 
The ureteral catheter is generally removed the morning following the operation, while the lateral catheter is removed the following day and the patient is discharged. 
In the case that a Double J stent is implanted, the patient would have to be referred three to four weeks post-operation to remove the stent through the bladder with an endoscope. 
PCNL may cause complications as with any other procedure. 

Possible PCNL surgery complications 

There is a low risk of bleeding during and within a few days of the operation, which is minimized through the surgeon’s skills. 
Probable damage to the adjacent organs such as damage to the intestine at risk of less than 2% and is treatable if diagnosed timely. 

Fever following the operation in some cases, which is controllable using drugs. 

Some important post-operation notes

1. Avoid heavy physical work for two weeks.
2. Drink plenty of fluids and use the prescribed drugs and recommendations to prevent stone recurrence.
3. There are no bathing prohibitions.
4. Refer to your doctor in case of discharge from the surgical site or fever. 
5. Consume fresh vegetables and fruits. 
6. Carry on with the prescribed drugs for as long as the appointed time (there is usually no need for re-prescription).
7. You may find blood in your urine for a couple of days after the surgery, in which case you will have to increase your fluid intake. 
8. Do not place a cold or hot compress on the surgical site
9. You will have to have a nephrostomy tube after a month if one is implanted for you. 
10. See the doctor at the appointed time for monitoring measures. 
11. Refer to the emergency room immediately if the blood in your urine persists or thickens.