Surgical Treatment of Kidney and Ureteric Stones
Surgery may be needed to remove a kidney stone if it
- does not pass after a reasonable period of time and causes constant pain
- is too large to pass on its own or is caught in a difficult place
- blocks the flow of urine
- causes an ongoing urinary tract infection
- damages kidney tissue or causes constant bleeding
- has grown larger, as seen on follow-up imaging
Until 20 years ago, open surgery was necessary to remove a stone. The surgery required a recovery time of 4 to 6 weeks. Today, treatment for these stones is greatly improved, and many options do not require major open surgery and can be performed using minimally invasive techniques requiring only a few hours hospital stay.
Percutaneous nephrolithotomy (PCNL) is a surgical procedure in which kidney stones are removed using a scope passed through a small skin incision made in the flank or the back into the kidney containing the stone(s).
Before the procedure
The risk of bleeding is increased in patients taking blood thinners, Aspirin, Clopidogrel or Warfarin. These drugs will need to be stopped prior to surgery. Please discuss this with your Urologist. Pre-operative antibiotics may be recommended. Your urologist may require special X-rays such as a contrast enhanced CT scan prior to the procedure to help with planning how to reach and remove all of your stones.
Establishing the tract (access)
PCNL first requires developing an access or channel through the skin to the kidney allowing the introduction of surgical instruments. There are different methods of establishing this access into the kidney. It is performed at the same time as the stone removal procedure, usually under general anaesthesia or high-spinal and local. This access is often obtained by first passing a thin needle into the kidney. Once this access is performed a guidewire is left until the second part of the surgery takes place. In some cases, more than one access tract is required to reach all of the stones.
In the operating room, the access tract is stretched to allow the introduction of surgical instruments. Once the tract is dilated up to about one centimetre (less than half an inch) a plastic tube is then placed into the kidney. An operating scope (nephroscope) is then passed through the tube into the kidney on to the stone(s). Small stones can be removed with a grasper. Larger stones need to be broken up before they can be removed. An attempt is made to remove all of the stones through a single tract. In some patients this may not be possible and may require simultaneous flexible ureterorenoscopy, a second tract to access the stone or additional treat such as ESWL.
Once stone removal is complete, a small tube may be left in the kidney, through the access tract to allow urine to drain. This tube usually can be removed after 48hours. In some, temporary kidney drainage is obtained with an internal drainage tube. A ureteric stent is an internal drain running from the kidney to the bladder. A bladder drainage catheter may be left for 24 hours.
The procedure is usually recommended for patients with kidney stones which are too large or numerous for shock wave lithotripsy. The procedure involves two major steps. The first is establishing a tract or access path into the kidney containing the stones, and the second is stone removal using special operating instruments.
A major advantage of percutaneous nephrolithotomy is that the Urologist can remove all of the stone fragments directly instead of relying solely on their natural passage from the kidney.
After Your Surgery
A hospital stay of two nights is usually all that is required. In some patients a longer hospital stay is necessary.
Recovery from percutaneous stone removal is usually rapid. Patients may return to normal but not excessively strenuous activity as soon as they leave hospital. Return to work is usually possible within a week after discharge from hospital.
Major complications from PCNL are uncommon, but, potentially, these can be serious. Possible complications are:
- Injury to other organs, particularly the bowel
- Major bleeding requiring blood transfusion or additional procedures for control
- Collection of fluid in the chest requiring drainage
You may be asked to take antibiotics after percutaneous stone removal. Usually antibiotics are only taken for a week or less, but in some patients a prolonged course of antibiotics may be recommended. A follow up visit with your urologist will be recommended. At that time you will have x-rays to determine if there are any residual stones.