Percutaneous nephrolithotomy (PCNL) is a minimally-invasive procedure to remove stones from the

kidney The kidneys are two reddish-brown bean-shaped organs found in vertebrates. They are located on the left and right in the retroperitoneal space, and in adult humans are about in length. They receive blood from the paired renal arteries; blo ...

by a small puncture wound (up to about 1 cm) through the skin. It is most suitable to remove stones of more than 2 cm in size and which are present near the

pelvic The pelvis (plural pelves or pelvises) is the lower part of the trunk, between the abdomen and the thighs (sometimes also called pelvic region), together with its embedded skeleton (sometimes also called bony pelvis, or pelvic skeleton). The p ...

region. It is usually done under

general anesthesia General anaesthesia (UK) or general anesthesia (US) is a medically induced loss of consciousness that renders the patient unarousable even with painful stimuli. This effect is achieved by administering either intravenous or inhalational general ...

spinal anesthesia Spinal anaesthesia (or spinal anesthesia), also called spinal block, subarachnoid block, intradural block and intrathecal block, is a form of neuraxial regional anaesthesia involving the injection of a local anaesthetic or opioid into the subara ...

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Procedure

retrograde pyelogram Pyelogram (or pyelography or urography) is a form of imaging of the renal pelvis and ureter. Types include: * Intravenous pyelogram – In which a contrast solution is introduced through a vein into the circulatory system. * Retrograde pyelogram ...

is done to locate the stone in the kidney. Contrast is diluted to the ratio of 1:3. If the ureteric catheter is placed in the upper pole of the kidney, it should be pulled down so that the tip is inside the renal pelvis. This helps for proper filling of the

renal calyces The renal calyces are chambers of the kidney through which urine passes. The minor calyces surround the apex of the renal pyramids. Urine formed in the kidney passes through a renal papilla at the apex into the minor calyx; two or three minor c ...

. The contrast is injected slowly to prevent extravasation. Fluoroscopy monitoring should be continuous so that the sequence of calyces be filled can help to identify the position of posterior calyx. With a small 1 centimeter incision in the

loin The loins, or lumbus, are the sides between the lower ribs and pelvis, and the lower part of the back. The term is used to describe the anatomy of humans and quadrupeds, such as horses, pigs, or cattle. The anatomical reference also applies to pa ...

, the percutaneous nephrolithotomy (PCN) needle is passed into the pelvis of the kidney. The position of the needle is confirmed by

fluoroscopy Fluoroscopy () is an imaging technique that uses X-rays to obtain real-time moving images of the interior of an object. In its primary application of medical imaging, a fluoroscope () allows a physician to see the internal structure and function ...

. A guide wire is passed through the needle into the pelvis. The needle is then withdrawn with the guide wire still inside the pelvis. Over the guide wire the dilators are passed and a working sheath is introduced. A nephroscope is then passed inside and small stones taken out. In case the stone is big it may first have to be crushed using ultrasound probes and then the stone fragments removed. The most difficult portion of the procedure is creating the tract between the kidney and the flank skin. Most of the time this is achieved by advancing a needle from the flank skin into the kidney, known as the 'antegrade' technique. A 'retrograde' technique has recently been updated wherein a thin wire is passed from inside the kidney to outside the flank with the aid of a flexible ureteroscope. This technique may reduce radiation exposure for patient and surgeon.

Complications

The following complications may take place: * Injury to the colon * Injury to the lungs * Injury to the renal blood vessels * Urinary leak may persist for a few days * Infection and

sepsis Sepsis, formerly known as septicemia (septicaemia in British English) or blood poisoning, is a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage is follo ...

Hydrothorax Hydrothorax is a type of pleural effusion in which transudate accumulates in the pleural cavity. This condition is most likely to develop secondary to congestive heart failure, following an increase in hydrostatic pressure within the lungs. More ...

if PCNL is done through 11th intercostal space * Bleeding * Death

Notes and references

* {{cite journal , title=A Novel 5-Part Percutaneous Access Needle With Glidewire Technique (5-PANG) for Percutaneous Nephrolithotomy: Our Initial Experience , journal=Urology , volume=75 , issue=5 , pages=1206–1208 , doi=10.1016/j.urology.2009.11.027 , pmid=20138340 , date=May 2010, last1=Patil , first1=Ashish V. Urologic surgery