Percutaneous Nephrolithotomy (PNL) Surgery

Percutaneous Nephrolithotomy

The procedure is performed under general anesthesia. Under anesthesia, first a thin tube (catheter) is inserted from the urinary tract to the kidney. This catheter is to assist the delivery or flow of fluid into the kidney and is usually removed the day after surgery.

After the catheter is inserted, the patients are turned to the prone position. A path is created that extends into the kidney from an incision of approximately 1 cm on the back of the patients, and the kidney is entered with a camera device (nephroscope) through the tube placed in this path. At this stage, portable x-ray devices (fluoroscopy) used in the operating room are used as a guide to the surgeon. The stones in the kidney are broken down and taken out.

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In large stones that fill different chambers (calyx) of the kidney, sometimes it may not be possible to clean all the stones by entering through a single tube. In this case, it may be necessary to enter the kidney chambers more than once through the skin. Making an additional access route is a decision that the surgeon will make according to his experience during the operation. At the end of the procedure, a tube (nephrostomy) is placed in the patient's kidney to ensure a safe flow of urine.

Are There Types of This Surgery?

Since 1976, when this method was first defined, there have been innovations in the surgical technique with the development of technology. The diameter of the tube inserted into the kidney became smaller with the development of thinner nephroscopes and was named accordingly.

In the standard technique, a tube with a diameter of 30 Fr (1 cm) is inserted into the kidney, while tubes with a diameter of 15-20 Fr are used in mini-percutaneous nephrolithotomy. It has been shown that the tube diameter used affects bleeding during surgery. In addition, a nephrostomy tube may not be inserted in patients after surgery with smaller diameter instruments. Thus, patients experience a less painful period after surgery.

In recent years, less invasive surgical techniques, defined as micro-percutaneous nephrolithotomy and ultra-mini percutaneous nephrolithotomy, have been developed. In these methods, the stones are treated by entering the kidney through tubes with a diameter of 5Fr and 13Fr (2-4mm). Thus, the possible risks of the transaction are minimized.

Can this method be applied to children?

In pediatric patients, especially in preschool patients, it is recommended to apply the less invasive operation technique made from small diameter tubes. The standard method can be applied in school-age or adolescent patients, taking into account the child's physical structure.

Who Cannot Be Applied to Percutaneous Nephrolithotomy?

Since the procedure will be performed under general anesthesia, it cannot be applied to patients who are not suitable for anesthesia. Since the operation is technically performed by placing a tube from the skin to the kidney, it is inconvenient for patients taking blood thinners.

In these patients, drugs can be discontinued under the control of internal medicine-cardiologists. The procedure cannot be performed in patients with urinary tract infections, kidney tumors and pregnant patients.

How to Prepare Before the Procedure?

Before the procedure, the anesthesiologist will definitely want to examine you and see some of your laboratory tests, chest x-ray and heart electron. Before the surgery, your urine should also be checked for infection. If there is an infection, it must be treated beforehand. Again, the blood pressure, sugar or heart medications you use should be used in consultation with your doctor.

Eating and drinking water should be stopped 6-8 hours before the scheduled surgery time the night before the surgery.

How should patients be followed up after surgery?

Postoperative patients are approached in terms of possible complications. Especially vital signs (blood pressure, pulse, fever, respiratory rate), urine amount and color, laboratory tests (blood count, electrolytes and creatinine), respiratory distress are followed closely. Post-operatively, patients feel pain due to the tube placed in the kidney and the catheter inserted, especially in the back. Patients cannot be fed orally until the effect of the anesthesia wears off.

In some patients, a tube is inserted between the ribs to enter the kidney. In this case, patients may have respiratory distress. A temporary tube can be placed in patients who have a significant amount of fluid accumulated between the lung membranes in the chest X-ray to draw this fluid.

How long is the hospital stay after the operation?

The day after the percutaneous nephrolithotomy procedure, the patient's catheter and catheter are removed and they are stood up. Bleeding in the urine coming from the tube (nephrostomy tube) placed in the kidney is followed. In addition, blood is taken from the patients and it is followed whether there is a decrease in their blood after the surgery.

Patients with bleeding may require blood transfusion. Vital signs such as fever, blood pressure and pulse are monitored. Patients who have no problems in their follow-up are usually discharged on the 2nd day by taking nephrostomy tubes.

What are the Risks of Percutaneous Nephrolithotomy Surgery?

Although it is an endoscopic method, the surgery has some complications. It has risks such as high fever, urinary tract infection, bleeding, injury to the neighboring organs of the kidney.

Postoperative blood transfusion may be required in 0-20% of patients. Although it is seen rarely (0.4%), it may be necessary to close the bleeding vessel with angio procedure (angio-embolization) in patients whose bleeding continues despite blood transfusion.

There is a continuous flow of fluid from the endoscopes during surgery. This fluid given into the kidney leaves the body through the tube placed in the kidney from the back. As a result of the absorption of this fluid, postoperative fever may occur. Fever is usually controlled with antibiotics.

Some stone types (especially magnesium-ammonium-phosphate-struvite stone) are associated with infection and may cause serious post-operative infections. Rarely, the infection may enter the blood and cause organ failure (0.5%) and loss of the patient (0.05%).

How Long After To Return To Daily Activities Or Work?

The biggest advantage of endoscopic surgeries compared to open surgeries is the short return time to work and normal daily activities. It is recommended to spend the first week after discharge, especially at rest. Heavy exercise should be avoided for the first 2 weeks. If you experience high fever, bleeding, discharge or swelling from the entrance on the back during this period, you should definitely consult your doctor.

What to do with the removed stones?

The extracted stones are sent to the laboratory for analysis in order to learn the chemical substances they contain. Knowing the chemical content of the stone formed in the patient's kidneys can guide the doctors in preventing the recurrence of these stones.

In some patients, the stones become infected and contain germs (bacteria). During surgery, these bacteria can enter the blood and cause serious infections. For the most accurate and rapid treatment of these infections, the stones are placed in special containers during the surgery and sent to the microbiology laboratory in these patients. According to the results of this test, appropriate antibiotic therapy is given to the patients.

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