What is the recommended procedure for removing large kidney stones using Percutaneous Nephrolithotomy (PCNL)?

From the Guidelines

Percutaneous Nephrolithotomy (PCNL) is the recommended procedure for removing large kidney stones, particularly those larger than 20 mm, due to its higher stone-free rates and less invasive nature compared to open surgery or laparoscopic/robotic assisted procedures. The procedure involves accessing the kidney through the skin under fluoroscopic or ultrasound guidance, followed by tract dilation and insertion of a nephroscope to visualize and fragment the stone using ultrasonic, pneumatic, or laser lithotripters 1.

Key Considerations for PCNL

• The patient is typically positioned prone or in a modified supine position under general anesthesia.
• Access to the kidney is gained by inserting a needle through the skin into the kidney's collecting system, followed by guidewire placement and tract dilation to create a working channel, typically 24-30 French in diameter.
• A nephroscope is inserted through this tract, and the stone is visualized and fragmented, with fragments removed using graspers or suction.
• Complete stone clearance is confirmed with fluoroscopy or flexible nephroscopy.
• A nephrostomy tube may be placed for drainage, although tubeless procedures are increasingly common in uncomplicated cases.

Post-Procedure Care

• Patients typically stay hospitalized for 1-2 days and receive pain management with medications like ketorolac or opioids as needed.
• Antibiotics are administered if infection is present.
• The use of normal saline irrigation during PCNL is recommended to avoid electrolyte abnormalities and other complications 1.
• Flexible nephroscopy should be a routine part of standard PCNL to ensure removal of all stone fragments 1.

Recommendations Based on Stone Size

• For symptomatic patients with a total renal stone burden >20 mm, PCNL is recommended as first-line therapy due to its higher stone-free rates compared to shockwave lithotripsy (SWL) or ureteroscopy (URS) 1.
• For patients with stone burdens ≤20 mm, SWL or URS may be considered, depending on the specific clinical scenario and patient factors 1.

From the Research

PCNL Procedure Overview

• Percutaneous Nephrolithotomy (PCNL) is an effective procedure for removing large kidney stones 2, 3.
• The procedure involves establishing percutaneous renal access, which requires a thorough understanding of renal, retroperitoneal, and thoracic anatomy to minimize the risk of complications 3.

Patient Positioning

• Patient positioning during PCNL is crucial, with the prone position being the most common, but supine position is also being used as an alternative 4, 5.
• The choice of position depends on the patient's condition and the surgeon's preference 4.

Nephrostomy Tube Selection

• The selection of a nephrostomy tube (NT) after PCNL is important, with different types of NTs available, including Cope loops, reentry Malecot catheters, and circle loops 6.
• The choice of NT depends on the patient's condition, stone type, and access site 6.

Operative Characteristics

• The operative characteristics of PCNL include the use of fluoroscopy, proper equipment, and a thorough understanding of renal anatomy 3.
• The procedure can be performed in an ambulatory surgery center (ASC) with a high-volume endourologist 2.
• The mean operative time for PCNL can range from 32-305 minutes, with a mean postanesthesia care unit time of 97 minutes 2.

Postoperative Care

• Postoperative care for PCNL includes monitoring for complications, such as bleeding, infection, and respiratory problems 2, 6.
• The use of ureteral stents and nephrostomy tubes can help minimize complications and promote healing 2, 6.