Introduction
Kidney stones affect about 1 in 11 Americans. These stones can cause awful pain. If not treated, they can lead to serious health problems.
Sometimes, kidney stones are large or have tricky shapes. Regular treatments like pills or shock waves might not work for these. This is where a special surgery called Percutaneous Nephrolithotomy (PCNL) can help. PCNL has changed how doctors treat kidney stones since the 1970s.
This article explains PCNL. You’ll learn what it is, how it works, its good points, and its risks. We’ll also look at what’s new and coming in the future for PCNL.
What is Percutaneous Nephrolithotomy (PCNL)?
PCNL is a surgery that uses small cuts to remove large kidney stones. These stones are usually bigger than 2 centimeters (about the size of a nickel). PCNL also works well for stones with odd shapes or stones in hard-to-reach spots in the kidney.
The name sounds complex, but it’s simple to break down. “Percutaneous” means “through the skin.” “Nephrolithotomy” means “removing stones from the kidney.”
Dr. Sarah Henderson, a kidney stone expert at Northeast Medical Center, explains it well. She says, “PCNL is different from older open surgery. It uses just a small cut in your back.” Doctors then put special tools through this small cut. “They use these tools to find, break up, and take out the kidney stones.” Dr. Henderson adds, “This way, you heal faster. You also have fewer problems than with open surgery.”
Urologists are doctors who specialize in kidney and urinary problems. They perform PCNL. The American Urological Association calls PCNL the best treatment for large kidney stones.
How PCNL Developed
The type of PCNL used today began in the 1970s. Two doctors, Dr. Fernström and Dr. Johansson, did the first recorded PCNL in 1976.
During the 1980s and 1990s, new technology made PCNL even better. Better ways to take pictures inside the body helped surgeons see stones more clearly. New tools also made a big difference. These included special scopes, devices to break stones, and better ways to wash out the kidney. These all led to better results for patients.
Dr. Michael Chen, from Western University Medical School, notes, “PCNL is one of the biggest steps forward in kidney surgery in the last 50 years.” He says, “It started as a new idea. Now, it’s a common surgery that gives good results when skilled doctors do it.”
More recently, new types of PCNL use even smaller cuts. These are called mini-PCNL and ultra-mini PCNL. These newer methods can mean fewer problems and quicker healing, while still working very well.
The PCNL Procedure: Step by Step
Before Surgery
Before you have PCNL, you will need a few things:
- Blood tests. These check how well your kidneys are working and how your blood clots.
- Urine tests. These look for any infections.
- Pictures of your kidneys (like CT scans, ultrasound, or X-rays). These help doctors find the exact spot of the stones.
- A medical check-up. This makes sure you are healthy enough for anesthesia (sleep medicine).
- You may need to stop taking certain pills, like blood thinners, that can make you bleed more.
You will also need to stop eating or drinking for 8-12 hours before your surgery.
During Surgery
Here’s what happens during the PCNL surgery:
- Anesthesia: You will get medicine to make you sleep deeply. You will not feel any pain during the surgery.
- Positioning: You will lie face down or in a special side position. This helps the surgeon reach your kidney.
- Making an Access Point: The surgeon makes a very small cut (about 1 cm, or less than half an inch) in your back.
Dr. Patricia Morales, Chief of Urology at South City Hospital, says, “Getting into the kidney just right is a key part of PCNL. It can be the hardest part.” She explains, “We carefully make a path through skin, muscle, and fat. We go until we reach the part of the kidney where the stones are.” - Widening the Path: The surgeon then gently makes this small path a bit wider. This creates a working channel about 8-10 mm wide (about a third of an inch).
- Inserting the Scope: A special thin tube with a camera, called a nephroscope, goes through this channel. This tool lets the surgeon see inside your kidney. It also has small channels for other tools and for fluid to wash the area.
- Breaking and Removing Stones: The surgeon uses tools like lasers or sound waves to break the stone into smaller pieces. Then, these pieces are taken out with tiny grabbers or by gentle suction.
- Final Check: The surgeon carefully looks inside the kidney to make sure all the stone pieces are gone.
- Tube Placement: In most cases, a soft, flexible tube (called a nephrostomy tube) is left in the kidney for a short time. This tube helps drain urine and any remaining blood. Some patients may also get a tiny internal tube called a stent. It helps urine flow from the kidney to the bladder.
The whole surgery usually takes 1 to 3 hours. The time depends on how many stones you have and how complex they are.
After Surgery
After PCNL, nurses will watch you closely in a recovery room. Once you are stable, you will move to a regular hospital room. Your care after surgery will include:
- Pain medicine. You can get this by mouth or through an IV.
- Checks for any signs of infection or bleeding.
- Making sure you drink enough fluids and pass urine normally.
- Care for your nephrostomy tube, if you have one.
- Walking soon after surgery. This helps prevent problems like blood clots.
- Antibiotics to help prevent infection.
Most people stay in the hospital for 1 to 3 days. The nephrostomy tube is often taken out before you go home. Sometimes, it’s removed at a follow-up visit with your doctor.
Benefits of PCNL
PCNL has several major good points for treating large kidney stones:
High Success Rates
PCNL works very well. It has a 90-95% success rate for completely removing stones, especially those larger than 2 cm. A 2023 study in a top urology journal found PCNL worked better than other methods with small cuts for large stones.
Small Cuts, Big Benefits
Compared to older open surgery, PCNL uses only a small cut. This means:
- Less pain after surgery
- Less blood loss
- A lower risk of infection
- Faster recovery time
- Shorter hospital stays
- Smaller scars that are harder to see
Good for Tricky Stones
PCNL is especially useful for:
- Staghorn stones. These are large, branched stones that can fill up much of the kidney.
- Many stones in different parts of the kidney.
- Stones that did not break up with shock wave treatment.
- Stones in people who have kidneys with an unusual shape.
Dr. Robert Jackson, who leads a Stone Disease Center, says, “PCNL’s flexibility lets us treat complex stone cases. Other methods might not work for these.” He adds, “For patients with large staghorn stones, PCNL offers the best chance of becoming stone-free with just one surgery.”
Saves Money Over Time
While PCNL might cost more at first than some other options, it can save money in the long run for large stones. This is because it works so well. Often, you need fewer extra treatments later on.
A 2022 study looked at costs for stones larger than 2 cm. It found PCNL was cheaper overall than having shock wave treatment many times. This included total treatment costs, time off work, and impact on quality of life.
Risks and Limitations
Even though PCNL has many good points, it does have some risks:
What Are the Risks?
Major problems are not common. They happen in about 1% to 7% of cases, says the American Urological Association. These may include:
- Bleeding: The kidney has many blood vessels. Bleeding can happen during or after the surgery. About 1-3% of patients may need a blood transfusion.
- Infection: Even with antibiotics before surgery, infections can occur in about 5-8% of patients. These can range from mild urine infections to more serious infections in the bloodstream.
- Injury to Nearby Organs: Rarely, other body parts near the kidney (like the colon, lung lining, or spleen) might be accidentally hurt. This happens in less than 1% of cases.
- Urinary Leak: Urine might leak for a short time around the site where the nephrostomy tube was.
- Remaining Stone Fragments: Sometimes, small stone pieces may be left behind. These could potentially lead to new stones forming later.
Dr. Emily Williams, a urologist, cautions, “While PCNL is generally safe, it’s still surgery. All surgery has some risks.” She says, “We carefully choose patients who will benefit most. We weigh the good points against the risks for each person.”
When PCNL Might Not Be a Good Fit
PCNL may not be the right choice for everyone. Some reasons why PCNL might not be best include:
- Having a urine infection that hasn’t been treated.
- Having bleeding problems, or taking blood thinners that you cannot safely stop.
- Being pregnant.
- Certain body shapes or conditions that make it hard for the surgeon to reach the kidney safely through the skin.
- Having severe medical conditions that make anesthesia (sleep medicine) too risky.
For some patients, other treatments might be better. These could include ureteroscopy (a scope through the natural urine passages), shock wave lithotripsy, or, rarely, open surgery.
PCNL vs. Other Treatments
Doctors have several ways to treat kidney stones. Here’s how PCNL compares to two other common methods:
Extracorporeal Shock Wave Lithotripsy (ESWL)
ESWL uses sound waves from outside the body to break stones into small pieces. It needs no cuts.
- Good things about ESWL (compared to PCNL): It’s completely non-invasive (no cuts). You usually go home the same day. It generally has fewer problems and a shorter recovery time.
- Downsides of ESWL (compared to PCNL): It works less well for stones bigger than 2 cm. It doesn’t work well for certain types of hard stones (e.g., cystine stones). One session might not be enough, and you might need more treatments. It may not work as well for stones in the lower part of the kidney.
Flexible Ureteroscopy
This surgery uses a very thin, flexible scope with a camera. The doctor passes it through your body’s natural urine passages (urethra and bladder) up to the kidney.
- Good things about Ureteroscopy (compared to PCNL): No cuts are needed. It can reach most areas of the kidney. There’s often less risk of bleeding and you might stay in the hospital for a shorter time.
- Downsides of Ureteroscopy (compared to PCNL): It’s not as good for removing a large amount of stone. It often needs more than one surgery for stones bigger than 2 cm. The surgery can sometimes take longer. There’s a slightly higher risk of hurting the ureter (the tube from the kidney to the bladder).
Dr. James Thompson, a professor of urology, explains, “The choice of treatment should be made for each patient. We look at the stone’s features, the patient’s health, and the doctor’s skills.” He adds, “For stones larger than 2 cm, especially in the lower part of the kidney, PCNL typically offers the best chance of complete stone removal in a single surgery. But we consider each case by itself.”
What’s New and Next for PCNL?
PCNL keeps getting better. Here are some new changes and future ideas:
Smaller PCNL Tools
Standard PCNL uses an access path into the kidney that is about 8-10 mm wide. Newer methods use even smaller paths:
- Mini-PCNL: Uses a 4.7-6.7 mm path.
- Ultra-mini PCNL: Uses a 3.7-4.3 mm path.
- Micro-PCNL: Uses a path less than 3.3 mm.
These smaller paths may lead to less bleeding, less pain, and shorter hospital stays. They still work very well for the right patients and stone sizes.
Better Pictures and Guides
Dr. Katherine Lee, who researches new kidney surgery tools, says, “Advanced ways of seeing inside the body, like special ultrasound used during surgery and computer-guided systems, help surgeons move tools in the kidney very precisely. This can improve results and lower risks.”
Other new picture tools include:
- Mixing CT scan pictures taken before surgery with live X-rays during surgery.
- Tracking systems that use magnets to guide tools.
- Robots that help doctors make the access path and remove stones.
New Ways to Break Stones
Scientists are always looking for better ways to break stones. New ideas include:
- Thulium fiber lasers. These lasers offer finer control and break stones very well.
- Better ultrasound systems that can clear out stone dust and pieces more quickly.
- Tools that combine different types of energy to break stones.
PCNL Without Tubes
After PCNL, doctors often put in a nephrostomy tube that drains urine outside the body. Newer ways include:
- Tubeless PCNL: The doctor places only a small internal tube (a stent) between the kidney and bladder. There’s no outside kidney tube.
- Totally tubeless PCNL: The doctor does not use an outside kidney tube or an internal stent.
A 2022 review of studies found good news. For some carefully chosen patients, these tubeless ways led to shorter hospital stays and less pain after surgery. They were found to be just as safe as standard PCNL.
Stopping Stones from Coming Back
Kidney stones often come back. If you don’t take steps to prevent them, about half of people will get another stone within 5 to 10 years. After PCNL successfully removes your stones, it’s very important to try to stop new ones from forming.
Medical Check-up
After PCNL, your doctor will likely want you to have:
- A 24-hour urine collection. You collect all your urine for a full day. This test looks for problems in your body chemistry that might cause stones.
- Blood tests to check for any hidden medical conditions.
- A test on your stone (if pieces were saved). Knowing what your stone is made of helps your doctor plan how to stop more stones.
Dr. Jennifer Martinez, a kidney specialist (nephrologist), explains, “Knowing what your stone is made of is very important after PCNL. Different types of stones – like calcium oxalate, uric acid, or infection stones – need different ways to prevent them. If we don’t know the stone type, we are working in the dark.”
Diet Changes
Based on your stone type and test results, your doctor may suggest changes to what you eat and drink:
- Drink more fluids. Aim for about 2.5 to 3 liters (about 10-12 glasses) a day. This helps keep your urine diluted.
- Eat less salt (sodium).
- Get the right amount of calcium. Usually, you don’t need to cut back on calcium. In fact, too little can sometimes be a problem.
- Eat less animal protein (like meat, chicken, and fish) if you have certain types of stones.
- Eat fewer foods high in oxalate (like spinach, rhubarb, nuts) if you have calcium oxalate stones.
- Change your diet in other ways to make your urine less likely to form stones.
Medications
Some people may need to take pills to help stop stones from coming back:
- Water pills (thiazide diuretics) can help lower the amount of calcium in your urine.
- Potassium citrate can make your urine less acidic and stop crystals from forming.
- Allopurinol is a pill that helps people who form uric acid stones.
- There are also special pills for rare types of stones.
Follow-up Care
Regular check-ups with your doctor are very important for long-term success:
- You may need scans from time to time (like an X-ray or ultrasound) to check if any new stones are forming.
- You might need to repeat the 24-hour urine tests to see if your prevention plan is working.
- Your doctor may need to adjust your prevention plan based on these results.
Living with Kidney Stones: Patient Stories
Michael Johnson is 45 years old. He had PCNL for a kidney stone that was 2.5 cm wide. He shares his story: “The pain before surgery was awful. It was worse than when I broke my leg.”
“Healing from PCNL had some pain,” Michael says, “but the pain pills helped a lot. Three days after surgery, I was back home. In about two weeks, I was mostly back to my normal activities. Knowing that huge stone was finally gone made it all worth it.”
Support groups and online communities can offer emotional support. They also provide practical advice for people living with kidney stones. Groups like the American Kidney Fund offer helpful information for patients. They cover stone disease and its treatments.
When to Get Medical Help
If you have had PCNL, or if you think you might have kidney stones, there are certain symptoms you should watch for. Get medical help right away if you have:
- Very bad pain that your prescribed pain pills don’t control.
- A high fever (over 101.5°F or 38.6°C).
- Chills or shaking.
- You cannot pass urine at all.
- Bright red blood in your urine that doesn’t go away quickly.
- Feeling sick to your stomach or throwing up, so you can’t keep fluids or pills down.
- Signs that your wound (the small cut from surgery) is infected. This includes more redness, swelling, warmth, or fluid leaking from it.
Dr. Thomas Wilson, an Emergency Medicine Physician, advises, “Problems after PCNL are not common. But if they do happen, they can be serious if not treated fast.” He warns, “An infection spreading to your bloodstream is very serious. It needs medical care right away. Never wait to get help if you have symptoms that worry you.”
Frequently Asked Questions (FAQs)
How painful is recovery from PCNL?
Most people have some pain for the first few days after PCNL. Pain medicine usually controls this well. The pain slowly gets better over 1 to 2 weeks. The spot where the kidney tube (nephrostomy tube) was might be sore until the tube is out. This tube is usually removed within a few days of surgery.
What is the success rate of PCNL?
PCNL successfully removes all stones 90-95% of the time. This is especially true for stones that are larger than 2 cm. How well it works can depend on the stone’s size, where it is, and what it’s made of. Patient factors also matter.
How long will I be in the hospital after PCNL?
Most people stay in the hospital for 1 to 3 days after PCNL. How long you stay can depend on things like any problems that come up, whether any stones are left, and how quickly your kidney function returns to normal.
When can I return to work after PCNL?
Most people can go back to desk jobs within 1 to 2 weeks after PCNL. If your job is very physical, you might need 3 to 4 weeks to heal fully. Your urologist will give you specific advice for your own situation.
Will I need a second procedure after PCNL?
About 10-15% of people (1 or 2 out of 10) might need a second surgery or procedure. This is usually to remove any small stone pieces that were left behind. You will have a follow-up visit with your doctor, often 2 to 4 weeks after your surgery. Scans at that time will show if you need any more treatment.
Can PCNL be performed on both kidneys at once?
Doing PCNL on both kidneys during the same surgery is possible, but it is not common. Most surgeons prefer to do one kidney at a time. This helps lower the risk of problems. The second kidney is usually treated after you have fully healed from the first surgery.
How can I prevent kidney stones from returning after PCNL?
To help stop stones from coming back, you should: Drink plenty of fluids (about 2.5 to 3 liters, or 10-12 glasses, a day). Follow any diet advice your doctor gives you based on your stone type. Take any pills your doctor prescribes to prevent stones. Be sure to go to your regular follow-up appointments. A 24-hour urine test can help your doctor find out why you form stones and how to best prevent them.
Is PCNL covered by insurance?
Most health insurance plans cover PCNL when it is medically necessary. However, the details of coverage can vary a lot between plans. You might need to get approval from your insurance company before the surgery (this is called prior authorization). You should check with your insurance provider about your specific coverage, how much you will need to pay (your deductible), and any co-payments.
Conclusion
Percutaneous Nephrolithotomy (PCNL) is a big step forward in treating large and tricky kidney stones. It works very well and usually has low risks. PCNL has truly changed how doctors manage a painful problem that once needed major open surgery.
PCNL will likely get even safer and better as tools get smaller and technology improves. However, deciding to have PCNL is a personal choice. You and your doctor should carefully think about your specific stone, your body, and what you prefer. A team approach, where urologists, kidney specialists, and patients work together, often leads to the best results.
For people suffering from large or complex kidney stones, PCNL offers more than just treatment. It offers a chance to get back to a life without stone disease. As research continues and methods get better, the future for PCNL and kidney stone care looks very bright.