PCNL ( percutaneous nephrolithotomy )

What is percutaneous nephrolithotomy? 

(PCNL)

Percutaneous (through skin) nephrolithotomy (PCNL) is a removal of kidneys stones for large multiple or complex kidney stone by incision on back made by urosurgeon where kidney is located and nephroscope used to remove kidney with Laser or Lithoclast.

Nephro=kidney 

Litho =stone

Tomy=remove

Causes of kidney stone:

-Hypercalcemia (High intake of calcium).

-Hyperthyroidism (enlarged throid gland).

-High intake of sodium in food.

-Gastrointestinal disorders normally -calcium and oxalates bind together in the cyst.

-Gastrointestinal issues ulcerative colitis and digest fats.

-When forms too much urine acid in urine. 

-Low intake of water (dehydrated), gout, metabolic issue. 

-Diabetes.

-High intake of purine foods and animal proteins.

-Cystine stone when forms too much amine acids.(rare/genetics).

-Struvite stone forms when chronic   urinary track infection (UTI).

-Bacterial causes urine to be too alkaline....magnesium ammonium sulphate. 

-Calcium phosphate stones forms in alkaline urine due to renal tubule issue.

-Structural blockage of stasis of urine (prostate problem, strictures & deformity )

Symptoms & sign of enlarged prostate:

-Back pain

-Pelvic pain

-Dull, deep aching in flank/costavertebral area

-Burning during urination 

-fever 

-severe pain 

-Urinary track infection. 

What happens if kidney stones untreated :

1.Prostatitis (infection in prostate )

2.Loss function of kidney. 

3.Block urinary track if stone moves kidney to ureter. 

4.Increase hydrostatic pressure and decrease kidney ability to filters.

5.infection 

6. Hydronephrosis.

7.Thick walled  & inflammed bladder.

8. urinary track infection. 

9.kidney damage

10.Urinary retention requiring catheterization. 

11.Nephron damage.

General clinical evolution and diagnosed by:

1.Medical history. 

2.Physical exam 

3. Urinary flow diagnose by uroflowmetry procedure. 

4.Bladder ultrasonography 

5. CT scan

6.KUB (X-ray of kidneys &ureters, bladder)

7.Urine test

8.IVP (intravenous pyelogram) IV dye (iodine based) given x-ray taken urinary system. 

Duration of surgery : 2 to 3 hours

Stay of the hospital : 2 to 3 days (depends on patient condition and doctor advice).

What  should before the surgery? 

Blood test

HIV and HBSag test

Chest x-ray for cardiac assessment  physical fitness bcoz patient will goes under the anesthesia before the surgery.

Stop eating and drinking at the time your doctor tells you before surgery.(approximately 6 hrs before the surgery )

Procedure of PCNL in the operation theatre:

Start intravenously fluid or antibiotic for prevent infection and  fluids allowed to run until administration of the prescribed dose is completed.(as per doctors advised )

PCNL (PERCUTANEOUS NEPHROLITHOTOMY )  procedure done under the general anesthesia  for pain relief during surgery and comfort to patient.

 If general anesthesia give than endotracheal intubation will given and hypnotic agent like propofol given. 

Than anesthesist continue watching monitor and watch vital signs including pulse, spo2(saturation ), E.C.G,  body temperature and blood until the  patient  will not shifted from operation theatre to recovery  

Procedure of the PCNL:

Paint and cleanse the Surgical site and space of urethra with betadiene antibacterial solution it contains  Povidone-iodine, then patient draped by sterile drap.

A topical anesthetic, 2% xylocaine jelly this  viscous lidocaine like jelly  is introduced  into the urethra, and  hold the tip of the penile atleast for  five minutes, then removed and introduce the  cystoscope. 

First position is lithotomy position:

An instrument called a cystoscopy which connect with camera and light source is inserted through the tip of patient penile and into the tube that carries urine from your bladder (urethra) with the help of cystoscopy (4mm telescope ) and uretric catheter 5fr or 6fr keep inside for dye insertion after the changing position (prone position ) and catheterization done for urine output. Than change the position. 

Second position is prone position :

After the changing the position again back side of the patient painted by povidine iodine antiseptic solution where kidney is located and draped by sterile drap than kidney puncture with sheeba needle this needle is pink in colour than guide wire introduce and dilation done by pistal dilators and alkane dilators than nephroscope introduce and assess the stone with the help of urograffin dye and fluoroscope  than laser introduced through the channel of nephroscope and break the stone this broken stone remove out side through stone forcep and other fragment automatic move out and remaining crushed fragments move through the urine. Than stent keep inside for 7 to 15 days and last end time nephrostomy tube keep inside the kidney  with drainage bag for drainage of fluid and fragments of stones for 1-2 days than incision sutured and apply small dressing.

After the removal of kidney stone sent to be laboratory for examination.

Reason of foley's  cathetherizatoon

1.It provides drainage of the urine and fragments of stones.

2.catheterization takes for 24 to 48 hours.

Post operations management :

-Post shifted in recovery room for observation for 2 to 3 hours.

-Continued intravenous fluid as per doctor order.( 3 to 4 litre fuids per day)

For dilute urine helps to pass stone and decrease risk of infection.

-Give antibiotics for prevents infection. 

-Continue watch monitoring the nephrostomy tube.

-Monitor and record urine output.

Complications after the surgery :

-Risk of general anesthesia. 

-Possible heart & lung complications. 

-Infection 

-Catheter blockage and dislodgement. 

-Inability to urinate when the catheter comes out.

After the hospital discharge :

-Drinks lots of water 

-Take medicines right time.

-Don't take heavy materials for 4 to 6 weeks

-Keep stool loose to avoid straining for bowel.

-Limited calcium diet, limit proteins diet and limits sodium foods.

PATIENT EDUCATION :

#Stone can reoccur

#Stay hyadrated atleast 2litre water per day

#Light diet

For know more details & appointment contact us : 

+91 7692976910

DR. VIMAL KESWANI

MBBS, MS, DNB Urologist & andrologist, Mumbai

Consultant urosurgeon

Former consultant at R.G. stone hospital, mumbai