PCNL Surgery - Procedure, Steps, Benefits and Recovery

PCNL is an innovative procedure for kidney stones. But what are the side effects after PCNL surgery, and are they preventable? Our comprehensive guide covers these risks, benefits, procedures, and all the necessary information about the technique that every patient should know.

According to Singh et al., (2023), kidney stones significantly burden Indian healthcare. With a prevalence rate of 12%, innovative treatment modalities like PCNL procedures are needed. Read on to learn more about the stone surgery and make informed decisions for adequate recovery.

PCNL, full form in medical terminology, is Percutaneous Nephrolithotomy. It is a minimally invasive surgical procedure used to remove kidney stones. The technique is an effective treatment option for larger and more complex stones that cannot be effectively treated with conventional methods. The usual length of the surgery is approximately three to four hours, which can vary based on the patient's condition.

Renal stones develop in the kidneys when individuals have less fluid in urine than the minerals. The urologist recommends treatments based on the stone size and type, including surgery. PCNL is used when the kidney stone blocks the urinary tract or is bigger. 

Anatomy of the Urinary System

Understanding kidney stones requires exploring their anatomy and physiology. This section examines the cause of stone formation, symptoms, and complications.

1. Kidneys: These are a pair of bean-shaped organs. They maintain bodily homeostasis by filtering blood to remove waste products and excess substances. This process occurs within nephrons, complex designs.
2. Nephrons: They consist of a renal corpuscle (glomerulus) and renal tubules. It filtrates waste products, excess minerals (like oxalic and uric acid, calcium, cystine, phosphate, and xanthine), and fluids from the bloodstream. Higher mineral concentrations can cause crystallisation and stone formation. The new stones can combine and create blockages in the kidneys.
3. Ureters: Muscular tubes connect and transport urine from the kidneys to the bladder. However, kidney stones may obstruct these. It causes urine to back up, leading to intense pain and potential infection.
4. Bladder: It is part of the collecting system for urine until it is expelled from the body. Kidney stones causing blockage can impact this storage function, contributing to the urgency and frequency of urination.
5. Urethra: The final pathway for urine to exit the body is affected when kidney stones cause discomfort. The obstruction can also lead to complications like hydronephrosis (swelling of the kidney due to trapped urine).

Generally, kidney stones are smaller and do not require any treatment. However, larger stones may take a longer time to pass through your ureter, causing severe pain and other symptoms. The higher success rate for complicated conditions suggests the need for this treatment modality.

It is performed when kidney and ureteral stones are more in number, dense, and large (usually larger than two centimetres). The procedure also helps treat or access complicated stone locations efficiently. Your urologist may suggest PCNL when:

1. Extensive pain and stones do not pass on their own.
2. Cystine kidney stones (formed due to cystine accumulation in the urine). These are resistant to treatments like extracorporeal shock wave lithotripsy.
3. No improvement in kidney stone removal from conventional techniques and remedies.
4. Staghorn kidney stones (crystals with extensive branching) can lead to the blockage of multiple renal branches.

There are several benefits to undergoing the procedure for kidney stone removal. It provides appropriate relief to patients with extensive pain and stones. It is also an ideal choice for removing renal stones, which cannot be removed from conventional or open surgery.

PCNL offers numerous advantages for patients, including:

1. Small incisions prevent the need for long stitches and reduce symptoms of infection.
2. Less postoperative pain due to the laparoscopic approach.
3. Quicker procedure time and recovery from PCNL surgery.
4. Fewer potential complications imply that often, patients do not require significant additional postoperative care.
5. Promotes expulsion of larger and complex stones after the procedure.
6. No urine leakage and minimal discomfort due to the urinary catheter and external drainage bag.

Before undergoing PCNL, you will have a pre-surgical check-up with your operating surgeon and anesthesiologist. The standard procedure followed before the surgery includes:

Before the Surgery

Before undergoing PCNL, you will have a pre-surgical check-up with your operating surgeon and anesthesiologist. The standard procedure followed before the surgery includes:

On the Day of the Surgery

Patients and their families often get curious about what happens on the day of the surgery. It helps them understand the procedure better and prepare psychologically. The table below provides a run-down of the same:

During PCNL, your endourologist will:

1. Make a cut of one cm in your flank (the area between the upper abdomen and the lower back).
2. Insert a tube with a small diameter into a part of the kidney using X-ray guidance.
3. Insert a small telescope (nephroscope) inside the kidney to visualise the stone.
4. A lithotripter device is integrated into the tube to break the stone into smaller pieces.
   
   
   
   
5. Extract the stone fragments through the internal tube.
6. Place a bladder catheter inside your kidney to restore the urine flow, which is blocked due to stones. The urine is collected into a small bag through a drainage tube.
7. A ureteral stent is placed inside the kidney to promote the appropriate urinary frequency and prevent further obstruction.
8. Close the incision site with non-absorbable sutures (stitches) and an adhesive strapping.
   
   

Immediately after a surgical procedure, the patient enters a recovery period which lasts for about 3-4 weeks. Prior to the discharge, a patient is required to stay at the hospital for 2-3 days. What can a patient and the family expect during the recovery? Well, let’s find out in detail.

In Hospital

A patient must be ready for the in-hospital care regime followed after the surgery. Generally, in-hospital postoperative care includes:

1. After the surgery, patient is transferred to a recovery room.
2. The diet is gradually shifted from clear liquids to solid foods as tolerated.
3. An endourologist/urologist regularly monitors the vital signs, pain levels and surgery site.
4. It is recommended to stand and walk under the supervision of a caregiver to prevent blood clotting in the legs.
5. After two to three days of observation, the patient is discharged from the hospital.

At Home

After discharge, individuals always wonder about what changes they must implement and what precautions are necessary. The following are the primary aspects to be considered:

Diet

Appropriate dietary changes are essential in preventing any future recurrence of kidney stones after the procedure. One must remember the points mentioned below to achieve effective and long-lasting outcomes:

1. Ensure that you drink at least 6-8 glasses of water/hydrating fluids (coffee, lemonade, etc.). It helps in avoiding mineral and fluid imbalance in the body.
2. Avoid consumption of food items like spinach, berries, chocolate, nuts, and tea. These have higher concentrations of oxalate (responsible for oxalate stones). Minimise consumption of excess vitamin C supplements (which promote oxalate production) is also recommended.
3. Regulate the amount of sodium intake to prevent enhanced calcium production in urine and stone development.
4. Physicians recommend an appropriate amount of calcium in the diet. Usually, three servings of dairy products are encouraged with the meals.

Bathing

Patients are released from the hospital with a nephrostomy tube intact until the doctor gives further advice. It is important to maintain significant precautions while indulging in everyday activities like bathing. Some preventive measures to consider are:

1. Patients can shower with soap and water while the nephrostomy tube is in place. 
2. A clean gauze should be applied over the area after pat drying.
3. Avoid bathtubs or hot tubs until the nephrostomy tube is removed.

Activity

After any surgical procedure, it is important to understand the limitations of physical activities and appropriate exercises to enhance the postoperative recovery. To name a few such recommendations, the patient must do the following:

1. Increase the duration of walking (4-6 times daily as per doctor’s prescription) after getting discharged from the hospital.
2. Avoid heavy lifting and intense exercise for two to four weeks after the surgery. 
3. Experts suggest deep breathing exercises. It is beneficial in preventing respiratory diseases such as pneumonia.
4. Avoid driving for seven days.
5. You can return to work after seven to 14 days post-surgery.

The First Follow-up Appointment

The surgeon will schedule a follow-up two to six weeks after surgery. During the follow-up, a patient can expect the following:

Check the laboratory results along with blood and urine reports to:

1. Determine if a patient is at high risk for recurrence of symptoms. 
2. Identify and mitigate potential causes of kidney stones.

Perform an ultrasound or X-ray to check:

1. If there are pieces of stone left in the kidney after surgery.
2. The passage of urine from the kidneys to the bladder.

After two to three weeks of the procedure, the nephrostomy tube is removed.

Compared to other minimally invasive lithotripsy techniques, PCNL is usually considered safer and offers the highest stone-free rates.

Side-Effects of PCNL Surgery

Procedural risks are common and expected after any surgical technique. These can be easily managed and include:

1. Postoperative pain in the flank area (side of the abdomen between lower ribs and hips)
2. Nausea for one or two days after surgery 
3. Fatigue (can last for two to three weeks to a month)
4. Systemic inflammatory response syndrome and postoperative fever. The risk for a postoperative fever depends on the following:

1. Your gender (more common in females).
2. Size of the stone.
3. A positive preoperative urine culture.
4. Time required for the surgery.

Complications of PCNL Surgery 

Apart from the common risks associated with the procedure, certain complications can lead to complex health situations. Some of these include:

1. Renal haemorrhage (loss of blood).
2. Injuries to the colon, lung, liver, pleura, duodenum, and spleen. Damage to the pelvicalyceal system (renal pelvis and major and minor calyces) during tract dilatation or manipulation with the rigid nephroscope.
3. Various bacterial toxins and cultures are exposed during kidney stone fragmentation. Thus increasing the chances of infection, which is readily controlled through antibiotics. Although highly unlikely, the infection can progress into a septic reaction.
4. Collection of urine outside the urinary system (urinoma) and into the retroperitoneum area (abdominal space). This is a rare complication and develops due to trauma and obstruction caused by the surgery.

Visit a Doctor If You Experience the Following After Surgery

1. Pain is not relieved by the pain medications.
2. You experience fever and chills. Higher than 104 degrees F for a prolonged period and frequently.
3. You notice significant bleeding (particularly blood clots) in your urine.

The need for PCNL surgery indicates a medically complex condition with potential healthcare complications. Thus, seeking appropriate medical advice and treatment at the right time is essential. Some of the potential risks associated with delaying kidney stone treatment include:

1. Excruciating pain
2. Severe renal and urinary obstruction
3. Enhanced risk of infection and sepsis
4. Increased chances of suffering significant kidney failure

Success and Survival Rate of PCNL

The success rate of PCNL surgery in completely removing kidney stones is around 80-90%. This means that most patients experience complete stone clearance after the procedure. The survival rate, concerning long-term outcomes and preventing stone recurrence, is also favourable.

Percutaneous nephrolithotomy is a successful technique in India. Most patients have a good outcome. Around 75% to 98% have positive results. However, only 80% to 90% of patients become stone-free after the first procedure. After the second procedure, the success rate increases to 100%.

Patients worry about the cost of the surgery. The expense depends on several factors, including size and number of stones, hospital, doctor, and patient's condition. These factors affect the overall cost of the procedure. The estimated expenditure associated with the procedure is:

Please remember that these are approximate values for the PCNL cost in India. Please visit your preferred healthcare provider to acquire more accurate and recent information.

Percutaneous Nephrolithotomy (PCNL) is a cutting-edge medical procedure designed to remove kidney stones efficiently. This minimally invasive technique provides patients with decreased pain, faster healing, and a high success rate, particularly for larger stones.

If you are looking for treatment for kidney stones, HexaHealth can help. We have experienced urologists who can guide you through the procedure. Our platform provides detailed information, enabling you to make informed decisions about your treatment. Get in touch with HexaHealth now to learn more.

Suggested Reads