Percutaneous Nephrolithonomy (PCNL) Print This Page
Kidney stones are formed in the urinary
tract due to crystallization of chemical compounds in the urine.
PCNL is a technique used to remove certain stones in the kidney
or upper ureter (the tube that drains urine from the kidney to the
bladder) that are too large for other forms of stone treatment (e.g.
shock wave lithotripsy, ureteroscopy).
To make an appointment for consultation please call 410-955-6100 .
For directions to Johns Hopkins Hospital please click here
Prior To The Surgery
What to expect during you preoperative
During your initial consultation with your
surgeon, he will review your medical history as well as any
outside reports, records, and outside Xray films (e.g. KUB,
CT scan, MRI, sonogram). A brief physical examination will
also be performed at the time of your visit. If your surgeon
determines that you are a candidate for surgery, you will
then meet with a Patient Service Surgery Coordinator to arrange
for the date of your operation.
NOTE: It is very important
that you gather and bring ALL of your Xray films and
REPORTS to your initial consultation with your surgeon.
What to expect prior to the surgery
Since insurance companies will not permit patients to be admitted
to the hospital the day before surgery to have tests completed,
you must make an appointment to have pre-operative testing
done at your family doctor or primary care physician's office
within 1 month prior to the date of surgery.
For Johns Hopkins Hospital Patients: These
results need to be faxed by your doctor's office to the Pre-operative
Evaluation Center at 443-287-9358 two weeks prior to your surgery. Please call The Documentation
Center at 410-955-9453 two weeks before your surgery date to confirm that this information
Once your surgical date is secured, you will receive a form
along with a letter of explanation to take to your primary
care physician or family doctor in order to have the following
pre-operative testing done prior to your surgery.
- Physical exam
- EKG (electrocardiogram)
- CBC (complete blood count)
- PT / PTT (blood coagulation profile)
- Comprehensive Metabolic Panel (blood
Medications to Avoid Prior to Surgery
• Aspirin, Motrin, Ibuprofen, Advil,
Alka Seltzer, Vitamin E, Ticlid, Coumadin, Lovenox, Celebrex,
Voltaren, Vioxx, Plavix and some other arthritis medications
can cause bleeding and should be avoided 1 week
prior to the date of surgery (Please contact your
surgeon’s office if you are unsure about which medications
to stop prior to surgery. Do not stop any medication without
contacting the prescribing doctor to get their approval).
It is very important that your last urine
culture was negative prior to having this procedure. Please
call the physician’s office at least one week before
this procedure to confirm your urine culture results. If you
suspect that you may have a urinary tract infection, please
call the physician office immediately so that proper antibiotics
can be prescribed before your surgery.
This procedure has been performed on many
patients over the last several years and is accepted standard
of care for patients with kidney stones that are large, very
firm, or resistant to other forms of stone treatment. As such
it has replaced open operations for kidney stones in the vast
majority of patients.
Typically, the length of the surgery is
3-4 hours. The surgery is performed by making a small 1 cm
incision in the patient’s flank area (Figure 1). A tube
is placed through the incision into the kidney under x-ray
guidance. A small telescope is then passed through the tube
in order to visualize the stone, break it up and remove it
from the body. If necessary a laser or other device called
a lithotripter may be used to break up the stone before it
can be removed. This procedure has resulted in significantly
less post-operative pain, a shorter hospital stay, and earlier
return to work and daily activities when compared to open
This technique also has a higher success
rate for clearing all stones in one setting than other techniques
such as extracorporeal shock wave lithotripsy (ESWL), which
often require several attempts.
these video clips include footage from an actual surgery which
some viewers may find difficult to watch.
Potential Risks and Complications
Although this procedure has proven to be
very safe, as in any surgical procedure there are risks and
potential complications. The safety and complication rates
are similar when compared to the open surgery. Potential risks
- Bleeding: Some blood loss will occur with this procedure but rarely
do patients require a blood transfusion. If you are interested
in autologous blood transfusion (donating your own blood)
you must make your surgeon aware. When the packet of information
is mailed to you regarding your surgery, you will also receive
an authorization form for you to take to the Red Cross.
You must coordinate this with the Red Cross in your area.
- Infection: All patients
are treated with broad-spectrum antibiotics to decrease
the chance of infection from occurring after surgery. If
you develop any signs or symptoms of infection after the
surgery (fever, drainage from incision, urinary frequency/discomfort,
pain or anything that you may be concerned about) please
contact us at once.
- Tissue / Organ Injury: Although uncommon, possible injury to surrounding tissue/organs
including bowel, vascular structures, spleen, liver, lung,
pancreas and gallbladder could require further surgery.
Loss of kidney function is rare but is a potential risk.
Scar tissue may also form in the kidney or ureter requiring
- Conversion to open surgery: This surgical procedure may require conversion to the standard
open operation if difficulty is encountered during this
procedure. This could result in a larger standard open incision
and possibly a longer recuperation period.
- Failure to Remove the
Stone: There is a possibility that the stone(s)
may not be able to be removed completely, usually either
due to the size or location of the stone(s). Additional
treatment may be required.
What To Expect After Surgery
During your hospitalization
Immediately after the surgery you will be
taken to the recovery room, then transferred to your hospital
room once you are fully awake and your vital signs are stable.
pain: Pain medication
can be controlled and delivered by the patient via an intravenous
catheter or by injection (pain shot) administered by the
- Nephrostomy Tube: You
can expect to have a small tube called a nephrostomy tube
coming out of your back to allow urine to drain from the
kidney into a drainage bag. The nephrostomy tube typically
remains in place for 1-2 days. There is a possibility that
you will be discharged from the hospital with the nephrostomy
tube as deemed necessary by your surgeon.
- Stent: You may have
an internal ureteral stent in place within the ureter between
the kidney to the bladder to promote drainage from the kidney.
This will be removed in your surgeon’s office in typically
1-2 weeks following surgery.
- Nausea: You may experience
some nausea related to the anesthesia. Medication is available
to treat persistent nausea.
- Urinary Catheter: You
can expect to have a urinary catheter draining your bladder
(which is placed in the operating room while the patient
is asleep) for approximately one day after the surgery.
It is not uncommon to have blood-tinged urine for a several
days after surgery.
- Diet: You can expect
to have an intravenous catheter (IV) in for 1-2 days. (An
IV is a small tube placed into your vein so that you can
receive necessary fluids and stay well hydrated until you
are able to tolerate a diet; in addition it provides a way
to receive medication). Most patients are able to tolerate
ice chips and small sips of liquids the day of the surgery
and regular food the next day. Once on a regular diet, pain
medication can be given by mouth instead of by IV or shot.
- Fatigue is common and
should subside in a few weeks following surgery.
- Incentive Spirometry: You will be expected to do some very simple breathing exercises
to help prevent respiratory infections through use of an
incentive spirometry device (these exercises will be explained
to you during your hospital stay). Coughing and deep breathing
is an important part of your recuperation and helps prevent
pneumonia and other pulmonary complications.
- Ambulation: On the
day after your surgery it is very important to get out of
bed and begin walking with the supervision of your nurse
or family member to help prevent blood clots from forming
in your legs. You can expect to have SCDs (sequential compression
devices) along with tight white stockings on your legs to
also aid in the prevention of blood clots.
- Hospital Stay: The
length of hospital stay for most patients is approximately
- Constipation: You may
experience sluggish bowels for several days or several weeks
following surgery. Suppositories and stool softeners can
be taken to help with this problem. Taking mineral oil at
home will also help to prevent constipation.
- Secondary Procedures: Some patients have stones that are very large or that cannot
be safely removed at one setting. You may need a "second
look" operation to remove any remaining stones, either
during the hospitalization or at another visit.
What to expect after discharge
from the hospital
- Pain Control: you can
expect to have some pain that may require pain medication
for a few days after discharge. Most patients, however,
find that Tylenol is sufficient to control the incisional
- Showering: You may
shower at home. Your wound site can get wet, but must be
padded dry afterwards. Tub baths can soak your incision
and therefore are not recommended in the first 2 weeks after
- Activity: Taking daily
walks is advised. Prolonged sitting or lying in bed should
be avoided. Climbing stairs is possible, however, should
be taken slowly. Driving should be avoided for at least
1-2 weeks after surgery. After this time, activity can begin
as tolerated. You can expect to return to work as soon as
1-2 weeks following surgery or as instructed by your physician.
- Follow-up Appointment: You
will need to call The Johns Hopkins Out Patient Center
( 410-955-6707) or Johns Hopkins Bayview (410-550-7008) soon after your discharge to
schedule a follow up visit. .
- Stent Follow-up: The
length of time the stent remains in place is variable. Your
doctor will probably request it to be removed within a 1-4
week period. This can be removed in the doctor's office.
It is common to feel a slight amount of flank fullness and
urgency to void as a result of the stent. These symptoms
often improve over time as the body adjusts to the indwelling
stent. It is critical that patients return to have
their stent removed as instructed by their physician as
a prolonged indwelling ureteral stent can result in encrustation
by stone debris, infection, and obstruction of the kidney.
- Nephrostomy Site Care: If you are discharge home with a nephrostomy in place, it
is important that urine flow freely through the tube. Check
daily to make sure the tube is not kinked. Make sure the
stopcock, if present, remains in the open position to allow
urine to drain from the kidney. Keep the tube securely anchored
o the skin with tape to prevent pulling and to keep the
tube in place. Monitor the amount of drainage and color.
Blood tinged urine is not uncommon. Keep the drainage bag
below the level of the kidney at all times. It is important
to clean the area around the insertion site with mild soap
and water each day when you shower. Pat the area dry after
showering and clean directly around the insertion site with
hydrogen peroxide using a cotton tip applicator. Apply a
clean sterile dressing after cleaning the area. If you experience
any change in pain, fever, chills, pus forming around the
insertion site, the catheter not draining or leaking around
the tube you must contact your doctor immediately.