Percutaneous nephrolithotomy

Percutaneous nephrolithotomy (per-kyoo-TAYN-ee-uhs NEF-roe-lih-THOT-uh-me) is a procedure used to remove kidney stones from the body when they can't pass on their own.

"Percutaneous" means through the skin. The procedure creates a passageway from the skin on the back to the kidney. A surgeon uses special instruments passed through a tiny tube in your back to locate and remove stones from the kidney.

Percutaneous nephrolithotomy is used most often for larger stones or when less-invasive procedures don't work or aren't possible.

Percutaneous nephrolithotomy is typically recommended when:

• Large kidney stones block more than one branch of the collecting system of the kidney. These are known as staghorn kidney stones.
• Kidney stones are larger than 0.8 inch (2 centimeters) in diameter.
• Large stones are in the tube connecting a kidney and the bladder (ureter).
• Other therapies have failed.

The most common risks from percutaneous nephrolithotomy include:

• Bleeding
• Infection
• Injury to the kidney or other organs
• Incomplete stone removal

Before percutaneous nephrolithotomy, you will have several tests. Urine and blood tests check for signs of infection or other problems, and a computerized tomography (CT) scan shows where the stones are in your kidney.

You may be instructed to stop eating and drinking after midnight on the night before your procedure. Let your care team know about all of the medications, vitamins and dietary supplements you're taking. In some cases, you may need to stop these medications before your surgery.

Your surgeon may prescribe antibiotics to reduce your chance of developing an infection after the procedure.

Before the procedure

Percutaneous nephrolithotomy is usually performed in the hospital under general anesthesia. With general anesthesia, you won't be awake for the procedure and you won't feel any pain.

Sometimes, the first step of the procedure is performed in the radiology department. In this case, you may be given a medication that numbs only a small area of your body (local anesthesia) in the radiology department. Then you would receive general anesthesia after you're moved to surgery.

During the procedure

To start the procedure, a specialized needle is inserted into a urine-collecting chamber of the kidney (calyx). The path of this needle becomes the passage for performing the rest of the procedure.

A surgeon or a radiologist with specialized training in this procedure uses X-ray, CT or ultrasound images to guide the placement of the needle. The needle placement may occur in the operating room or in the radiology department.

You may have a flexible tube (catheter) passed through the urethra, bladder and ureter into the kidneys. The urethra is the tube where urine exits the body. The ureter is the tube connecting a kidney to the bladder. Through this catheter, your doctor can put a specialized tracer substance into the kidney that outlines structures inside the kidney so that they're more visible during imaging. Or, a tiny camera may be threaded through the catheter, which allows your doctor to see the needle as it's placed in the kidney and other work during surgery.

Next, the surgeon place a tube (sheath) along the path of the needle. Using specialized instruments that pass through the sheath, the surgeon breaks up the stones and removes them.

The surgeon may then place a different tube, called a nephrostomy tube, in this same passageway. The nephrostomy tube allows urine to drain directly from the kidney into a bag worn outside the body during recovery. For complicated cases, this tube also leaves access to the kidney if more kidney stones or fragments of kidney stones need to be removed during the recovery time.

The kidney stones are sent to a lab to check what types of stones they are. Knowing what type of kidney stones you have may help your care provider suggest ways to prevent future stones.

After the procedure

You may stay in the hospital for 1 to 2 days after the procedure. You may need to avoid heavy lifting and pushing or pulling for 2 to 4 weeks after surgery. You may be able to return to work after about a week.

If you have drainage tubes in the kidney left after surgery, you'll need to watch for any bleeding. If you notice blood or thick clumps of ketchup-like blood in your urine or drainage tube, go to the emergency department.

If you develop a fever or chills, contact your primary care provider or surgical care team. These could be signs and symptoms of infection, and you may need emergency care. If you have significant pain that's not relieved by pain medication, contact your care provider.

You'll likely see your surgeon 4 to 6 weeks after surgery for a follow-up visit. If you have a nephrostomy tube for draining the kidney, you may return sooner.

You may have ultrasound, X-ray or a CT scan to check for any stones that may be left and to make sure that urine is draining as usual from the kidney. If you have a nephrostomy tube, your surgeon will remove it after giving you a local anesthetic.

Your surgeon or primary care provider may recommend blood tests to learn what caused the kidney stones. You may also talk about ways to prevent getting more kidney stones in the future.