Percutaneous Nephrolithotomy PCNL Keyhole Surgery
Keyhole surgery to remove kidney stones
This page tells you about the procedure known as Percutaneous Nephrolithotomy (PCNL) and serves to explain what is involved and the possible outcomes and complications. It is not meant to replace informed discussion between you and your consultant but can act as a starting point for such a discussion.
A Percutaneous Nephrolithotomy is likely to be a pre-planned operation and you should have plenty of time to discuss it with your consultant so you have sufficient explanation before you agree to the operation.
Why do I need this operation? What are the benefits?
You have been diagnosed as having a kidney stone (or stones) causing some, or all, of these symptoms: pain, infections, bleeding or obstruction of your kidney, which if left untreated, may lead to further symptoms or complications, such as severe infection or loss of kidney function.
This operation (PCNL) is performed to remove large kidney stones using a keyhole approach. This is a major operation despite the term ‘keyhole surgery’.
The procedure requires a general anaesthetic and may last 1 to 3 hours with a hospital stay from 4 to 7 days. The success rate of kidney stone clearance ranges from 75% to 100% depending on various factors.
The consultant will usually discuss with you if any alternative procedures are possible or may be required after this.
What to expect before the operation?
- You will be seen in a pre-assessment clinic a few days before the operation and have blood tests, Chest x-ray and ECG (echocardiogram) if needed. You might also have an x-ray to check the size and position of the kidney stone either in the pre-admission clinic or on the day of the operation. You will also be required to produce a fresh mid-stream urine specimen.
- It is important to bring all your medication or a list of mediation, and inform the doctor about all or any new medical problems. It is especially important to let the doctor know if you are on Warfarin / Clopidrogel / Aspirin as this may need to be stopped before the operation. If for some medical reason you are considered unfit, the operation may have to be deferred until you are fit enough and this may require consultation with other medical colleagues.
- Please tell the doctor if you have any allergies to medication or have had any allergy to the dye used to take special x-rays in the past.
- You might have a further x-ray of your abdomen on the day of the operation to check the latest position of the stone. If you are a woman of child bearing age it is important to let the doctor or the nurse know if there is any possibility of your being pregnant. If in doubt we may need to perform a pregnancy test. This is important to avoid any inadvertent radiation exposure to a baby in the womb during the x-ray.
How is the operation performed?
While you are under the general anaesthetic the surgeon will examine your bladder with a long, thin, semi-rigid or flexible telescope and pass a small tube up to your kidney, which has the stone. This is used to pass a mixture of a coloured dye and x-ray dye to the kidney making it easier to see during the operation.
You will then be placed face down on the operating table and the consultant will make one or more small incisions into your back. This is done using special metal or balloon dilators (see diagram). This enables the consultant to pass a telescope into your kidney.
The stone or stones in the kidney are then removed either intact or in pieces after breaking them with special instruments. X-rays will be taken during and at the end of the procedure to ensure that all accessible bits of the stone have been removed from your kidney.
A telescope is passed down into the kidney so that the surgeon can see the stone.
The stone is broken up and then the pieces are removed using a special instrument.
What can I expect after the operation?
- There will be a catheter in your bladder to drain your urine. Your urine may be coloured with blood or bluish-green dye used during the procedure. The catheter will be removed once you are up and about or when the consultants are satisfied with your progress
- There will be a tube in your back connected to a drainage bag to allow the kidney to drain a mixture of blood and urine. The blood in this tube will gradually clear in a day or two. Occasionally further x-rays may be necessary before this tube is removed. Removing the tube does not usually require any painkillers or sedation
- There will be a drip in one or both of your arms to give intravenous fluids until you are able to drink and eat normally. This may sometimes be used to give a blood transfusion if required
- You may be given antibiotics post-operatively either orally or through the drip in your arm
- You will be prescribed and given appropriate painkillers after the procedure
What are the risks?
(Problems and complications specific to this operation only are listed here. This does not cover every possible complication but covers the more common or serious. Complications may result from anaesthesia and should be discussed with your anaesthetist).
- Failure to establish a tract into the kidney or locate the kidney stone may make it impossible to proceed with the operation.
- Bleeding either during the operation or post-operatively via the tube in your kidney and the bladder is common but soon settles. Heavy bleeding is uncommon (less that 1% of patients experience this). Rarely, the consultant may have to abandon attempts to remove the stone and take active steps to control the bleeding.
This might take the form of open surgery or using x=ray techniques to selectively control the bleeding. In very rare circumstances patients have had to have the kidney removed because of uncontrolled bleeding.
- Infection of the bladder is common although all patients are given antibiotics before and after the operation. Some stones have bacteria trapped within them which are released during the operation. Severe infection occurs in less than 1% of patients.
- Injury to the lung or chest cavity may lead to the collection of fluid or blood in the chest or lung which may require a separate tube temporarily to let it settle.
- Chest Infection might arise if you are a smoker or if you have pre-existing breathing or chest problems. It is important you stop smoking before the operation and inform the consultant if you have had a recent chest infection.
- Abdominal distension (bleeding) may occur after the operation because of leakage of fluid used during the surgery or due to bowel distension. This usually settles in a day or two. During this time the amount you drink should be reduced.
- Injuries to other organs such as the bowel, liver or spleen are very rare and usually settle with conservative management of may rarely require other surgical procedures. This may however prolong your stay in the hospital.
What are the alternatives?
The consultant will usually discuss with you before the operation alternative ways of treating the kidney stone. This might require an alternative procedure whilst still under the anaesthetic or a different procedure on another occasion.
Before the operation
- Stop smoking a week or two before the operation: this reduces the risk of chest infection and clots in your legs
- Get some gentle exercises: the fitter you are the easier your postoperative recovery
After the operation
- Maintain a high fluid intake (4 – 6 pints per day) this will help clear the blood in your urine and flush out stone fragments and reduce the risk of constipation
- Eat lots of fruits and vegetables: besides being part of a good diet it also helps to reduce constipation, straining to open your bowel may increase the risk of bleeding
- Try to get active as soon as possible after the operation to reduce the chances of pneumonia and clots in your legs
- Avoid, if possible, heavy lifting or straining for 4 weeks after the operation
- Do not drive until you feel comfortable making an emergency stop
- You may see some blood in your urine for up to 2 weeks after the operation. If this persists or you have a sudden appearance of blood contact your GP or alternatively contact the Urology ward to which you were admitted. You should be directed to come to the A & E department of the hospital to be assessed by an appropriate member of the Urology team
- If you develop high fever or chills, contact your GP or the Urology ward to which you were admitted
What will happen after discharge?
Depending on the outcome of your operation you will either be given an outpatient appointment or if you require further treatment the consultant will discuss this with you and schedule this appointment.
It is important that you make a list of all medicines you are taking and bring it with you to all your follow-up clinic appointments. If you have any questions at all, please ask your surgeon, or nurse.
It may help to write down questions as you think of them so that you have them ready. It may also help to bring someone with you when you attend your appointments.
Authors – Consultant Urologist Panel West Midland Stone Network
Comprehensive diagnostic service for a wide range of urological conditions