For Patients

Percutaneous Nephrolithotomy (PCNL)

Contact: (0191) 213 7001 – Sister or Nurse in Charge, Ward 1, Freeman Hospital

Introduction

Why is Percutaneous Nephrolithotomy (PCNL) necessary?

Whilst the majority of small kidney stones can be treated using the shock wave machine (Lithotriptor), large stones are not suitable for this form of treatment and require removal by means of an operating telescope (PCNL).

There are other situations where relatively small kidney stones may require surgical treatment rather than Lithotripsy, for instance if the stone is difficult to see on x-ray or if it is particularly hard. Even if large kidney stones do not cause symptoms they still require treatment, as we know from experience that left untreated patients eventually run into difficulties.

To help the urologist to decide what is the best treatment for your kidney stones, x-rays will have been taken and these will have been reviewed by a team of urologists and radiologists (x-ray doctors). Your case will have been discussed to ensure there is general agreement that surgery is the correct form of treatment for your stone(s).

Before your procedure

What preparation is necessary?

Routine urine and blood tests will have been taken from the clinic to ensure the kidneys are functioning normally and that there is no infection.

You need to be ready for a 5 day stay in hospital, although you may be able to leave after 2 or 3 days. You should anticipate a two week period of convalescence at home before you are able to get back to a full range of normal activities.

If you are taking blood thinning medication such as warfarin this will need to be discontinued prior to surgery. On the morning of the operation you change into a gown and you will be pushed to the operating room on a trolley. The anaesthetist will then put you to sleep, usually by an injection in the back of your hand.

During your procedure

The first part of the operation is to give you an anaesthetic (put you to sleep) so that you will not be aware of anything whilst the operation is being performed. The first step of the operation is to examine the bladder with a telescope and to pass a fine tube up the pipe with connects the kidney to the bladder (ureter).

A dye called contrast is then passed up the tube so that the kidney can be visualised using x-rays. This part of the procedure is performed whilst you are positioned on your back. You will then be rolled over so that you are lying on your front. One of the doctors will then place a very fine needle through the skin into the kidney and under x-ray guidance a track will then be stretched up around the needle so that an operating telescope can be introduced into the kidney. Once the stone has been identified it will be broken up and removed.

The aim is to remove all stone fragments in one treatment, although sometimes this is not possible. In this situation you may require further key-hole surgery or shock wave treatment (Lithotripsy). At the end of the procedure a small drain or internal stent is left between the kidney and the skin and this is removed after 48 hours. Alternatively a temporary internal stent (hollow tube) is positioned between the kidney and bladder.

A catheter tube is left in the bladder and this is usually removed the morning following surgery. Occasionally if the stone is found to be very infected the kidney is left to drain through for a period of time before proceeding with definitive surgery to remove the stone.

After your procedure

What will happen after the operation ?

You will wake up in the recovery area in your bed and when the nurses there are happy with your condition you will be transferred back to the ward. You will feel “groggy” during the first night after the operation and there may be some pain, which should be relieved by asking the nurse for a painkiller.

The catheter tube in the bladder will be removed on the day following surgery. The kidney drain is usually removed within 48 hours following surgery.

All being well you should be ready for discharge on the 2nd or 3rd day following your surgery. An x-ray will be taken on the morning after surgery to look for any remaining stone fragments. If a stent was inserted you will be readmitted within 4 weeks to have this removed under local anaesthetic (i.e. you will be awake). This takes only a few minutes and involves passing a flexible telescope through the urine pipe into the bladder. The stent is then grasped and removed.

What problems may occur?

PCNL is performed commonly on the urology unit and complications are unusual. The most common problem is one of infection and you will routinely receive antibiotics to try and prevent this happening.

Occasionally the kidney puncture can result in bleeding and approximately 5% of patients will require a blood transfusion. Very occasionally bleeding can be significant and in this situation the bleeding vessel is blocked off by one of our Interventional Radiologists using an x-ray technique called embolisation.

If it is not possible to achieve complete stone clearance with one operation you may require further treatment with either repeated surgery or shock-wave treatment (lithotripsy).

How can I prevent stones reforming ?

The best general advice is to maintain dilute urine and this is easy by drinking lots of water, especially during warm weather. You would aim to produce no less than 2 litres of urine per day. When we know what your stone is made up of we may be able to give you more specific advice regarding medical treatment to prevent stone recurrence. If you have a history of stone formation then you may require more detailed tests such as a 24 hour urine collection. Your doctors will be able to advise you regarding this.

Further information and advice

How can other questions be answered?

If you are concerned about any aspect of your operation you can make an appointment to speak to your consultant in the Out-Patient Clinic by contacting the Secretary on (0191) 233 6161. When you are admitted for surgery you will be seen by your surgeon who will be able to answer any questions you have.

The nurses on the ward have a lot of experience of nursing patients with stone disease and would be happy to answer any specific questions.

A final word

We have a large experience of PCNLs at Newcastle Urology and are proud of our success rates. This type of operation along with shock wave Lithotripsy has revolutionised the treatment of kidney stones.

As with all surgical procedures there is always a small risk of complications but if these do occur the hospital has all the facilities and expertise on site to deal with them. The majority of patients have a trouble free stay and make a quick recovery.

Contact: (0191) 213 7001 – Sister or Nurse in Charge, Ward 1, Freeman Hospital

Introduction

Why is Ureteroscopy necessary?

Whilst most small kidney stones are able to pass down the pipe which connects the kidney to the bladder ( called the ureter), larger stones tend to get stuck. This results in severe pain, which we call ureteric colic. Most small stones will pass and it is just a question of keeping the patient comfortable until nature takes its course. However larger stones may not pass and in this situation additional treatment is required.

This can take the form of either shock wave treatment (Lithotripsy) or telescopic treatment to remove the stones (Ureteroscopy). Both forms of treatment are effective but in certain situations there are advantages to undergoing ureteroscopy. Your urologist has recommended ureteroscopy as the best form of treatment for your stone.

Before your procedure

What preparation is needed?

Ureteroscopy is a relatively minor procedure; however as you will be having a general anaesthetic you will be allowed nothing to eat or drink for 4- 6 hours before the procedure.

You may require an x-ray before surgery to check that the stone has not moved. You may also require a chest x-ray or heart tracing if it is felt that this information would be useful for the anaesthetist.

You will come into hospital usually on the morning of surgery. You will change into a hospital gown and will be taken to the operating department on a trolley. The anaesthetist will give you the anaesthetic, usually by an injection in the back of your hand.

During your procedure

How is the operation done?

The first part of the operation is to give you a general anaesthetic so that you will not be aware of anything whilst the operation is being done. The urologist will pass a very fine telescope into the bladder and up the tube connecting the bladder to the kidney (ureter). Once the stone has been identified it will be broken into small pieces and removed. The ureter tube is very narrow and therefore the operating telescope is very fine. The procedure can be fiddly and sometimes it is not possible to remove all the stone fragments on one occasion. The goal is to remove the stone completely.

After the telescope has been inserted, the ureter becomes a little swollen so an internal stent, which is a fine plastic tube inserted between the kidney and bladder, is placed to help the kidney drain.

After your procedure

What will happen after the operation?

You will wake up in the recovery area in your bed and when the nurses are happy with your condition you will be taken back to the ward. You may have an external stent in place, which may be secured to a catheter tube in the bladder. This is a very fine drain leading from the kidney to the outside.

You will find that on the first few days after surgery there is some discomfort when you pass water. If you have a catheter this will drain into a bag by the side of your bed and will be emptied by the ward staff. The catheter will be removed the day after your operation.

You may also have a drip in a vein in your arm. Depending on your progress and how you are feeling, you may be able to leave hospital on the same day. A minority of patients spend the night in hospital following surgery and leave the following morning. The urologist may request a further x-ray to ensure that there are no remaining stone fragments. You will receive an outpatient review appointment. If you have a stent you will be given a date to be admitted as a day case for this to be removed. This is done using local anaesthetic jelly (you will not need to be asleep).

What problems may occur?

Complications following ureteroscopy are unusual. The most common problem is with urine infection and you will receive antibiotics at the time of the operation in order to prevent this.

In a small percentage of cases it can prove impossible to pass the operating telescope up the ureter, particularly if the ureter is very narrow. In this situation an internal stent may be placed and the procedure repeated after several weeks. There is a small risk of scarring and narrowing of the ureter tube following this procedure.

Is the operation always successful?

The success rate of ureteroscopy depends on the size and location of the stone. Stones at the bottom end of the ureter are easier to treat and those near the kidney are the most difficult to treat. The aim of treatment is to remove all stone fragments and this is possible in over 90% of cases. If we cannot remove all of the stone fragments at one treatment you may be asked to return for either repeat ureteroscopy or shock wave treatment (lithotripsy).

What can I do to prevent further stones?

The best general advice is to drink plenty of fluids. You should aim to produce at least two litres of urine every day. Your stone will be sent for analysis and depending on your stone, other treatment may be appropriate. If you get recurrent stones, further detailed investigation such as a 24-hour urine collection may be appropriate. Your urologist will advise you further.

Further information and advice

How can other questions be answered?

If you are concerned about any aspects of your operation you can make an appointment to see your consultant in the clinic by contacting their secretary (telephone number 0191 233 6161). Alternatively you can speak to staff at the preadmission clinic. Your surgeon will visit you on the ward before surgery to make sure that you understand the treatment. Ask any questions you need to before you sign the consent form.