Percutaneous Nephrolithotomy (PCNL) Procedure, Essays (university) of Medicine

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PERCUTANEOUS NEPHROLITHOTOMY (PCNL)

2.2.1 Definition Percutaneous Nephrolithotomy (PCNL) Percutaneous Nephrolithotomy (PCNL) is a minimally invasive procedure in the field of urology which aims to remove kidney stones using percutaneous access to reach the pelviokaliceal system. Since the invention of the percutaneous procedure using a needle to decompress hydronephrosis in 1955 by Willard Goodwin, endourology has developed very rapidly, especially to treat disorders of the kidneys and upper urinary tract. In the early 1980s the PCNL procedure was very popular as a therapy for kidney stones, but since the discovery of Extracorporeal Shock Wave Lithotripsy (ESWL) in the mid 1980s its use has declined. In subsequent developments, several weaknesses were found in the ESWL procedure, so that PCNL was once again popular as a treatment for kidney stones with the rapid advancement of its techniques and equipment. 2.2.2 PCNL indication Although kidney stones may be asymptomatic, ureteral stones generally cause colicky pain in most cases. Treatment decisions for upper urinary tract stones are based on several aspects such as stone composition, stone size, and symptoms. Treatment can be in the form of conservative therapy or active removal of stones through ESWL, PCNL, and others. Indications for active removal of kidney stones are as follows:  Stone growing in size (Stone growth)  Patients at high risk of stone formation  Urinary tract obstruction caused by stones  Infection  Symptomatic kidney stones (eg, pain, haematuria)  Stone size > 15 mm  Stone size < 15 mm but conservative therapy is not possible  Patient preference  Comorbidity  Patient's social situation (profession, traveling, etc.)

several operating sessions, and the possibility of residual stones must be anticipated. Success has a lot to do with operator experience. (6) Stones in a solitary kidney. Stones in the solitary kidney are safer to treat with PCNL compared to open surgery. so this technique is recommended only for the experienced. (5) Large kidney stones. PCNL on large stones, especially staghorn, requires a longer operating time, may also require several operating sessions, and the possibility of residual stones must be anticipated. Success has a lot to do with operator experience. (6) Stones in a solitary kidney. Stones in the solitary kidney are safer to treat with PCNL compared to open surgery. It can be concluded that the recommended indications for using PCNL are as follows:  Stone size > 2 cm or 1.5 cm in inferior calyx stones  Kidney stone  Stones with compositions that are difficult to integrate using ESWL (calcium- oxalate monohydrate, brushite, cystine)  Stones that are refractory after ESWL or URS  Urinary tract obstruction requiring simultaneous correction (eg PUJO)  Malformations associated with decreased probability of passage of stone fragments in WSWL (eg horseshoe kidney, dystrophic kidney, calix diverticula)  Obesity The development of advanced urological procedures such as PCNL, Ureterocystoscopy (URS), and Electrical Shochwave Lithotripsy (ESWL) has significantly reduced the indication for open stone surgery, where open surgery is now a second or third line therapy option and is only needed in 1.0-5.4% case. The incidence of open surgery alone ranges from 1.5% of all stone removal interventions, having decreased from 26% to 3.5% in previous years. 2.2.3 PCNL procedure A. Percutaneous Nephrolithotomy (PCNL) Preparation and Technique In general, the PCNL technique includes four stages of the procedure, namely: percutaneous renal access, dilatation, fragmentation and stone extraction, and drainage. B. Percutaneous Nephrolithotomy (PCNL) Patient Preparation

Preparation includes a complete history of the disease, physical examination, and supporting examinations. Absolute contraindications for PCNL treatment need to be identified before the procedure, namely: coagulopathy and urinary tract infection that is active and has not been treated. The use of anticoagulant drugs must be stopped at least 7 days before the procedure. Recommended investigations are peripheral blood, kidney function, electrolytes, and urine culture C. Patient Position in PCNL Procedure Before starting the PCNL procedure, a ureteral catheter was placed in the lithotomy position. PCNL is performed in the lithotomy position with the side of the kidney to be treated 30 degrees higher. D. Renal puncture site Optimal and non-traumatic access is a crucial step of PCNL. In the majority of cases, this access can be obtained from a subcostal puncture. However, the supracostal approach is preferred in cases of cast stones, complex kidney stones, and proximal ureteral stones. There are no large-scale randomized prospective studies that have compared the success and complication rates of these two approaches. An SFR of up to 87% was reported in one supracostal PCNL session. Disadvantages of this approach are the high incidence of intrathoracic complications, as well as the higher risk of liver and spleen damage. The overall pleural complication rate ranges from 0% to 37%. E. Urinary tract dilation Nephrostomy tract dilations are commonly performed with Alken telescopic dilators, Amplantz progressive facial dilators, or balloon dilators. Research has shown that balloon dilation is a faster and safer technique, as well as reducing patient and operator exposure to X-rays, so balloon dilators are considered the gold standard technique. Frattini et al conducted a randomized study using various dilation techniques, including the “one-shot” technique. This technique uses one 25 F or 30 F dilator. This technique requires shorter fluoroscopy time, but the difference is not statistically significant. None of the patients required blood transfusions. Although superior, this technique requires further research to obtain consistent results.

conditions above can cause intravascular absorption of irrigation fluid. FluidIrrigation should always use normal saline to reduce the risk of developing delusional hyponatremia

4. Pleural Cavity Trauma The risk of trauma to the lung or pleural cavity is increased by performing a superior puncture. Puncture performed at the end of inspiration increases the risk of intrathoracic complications. Complications that can occur include: pneumothorax (0-4%) and pleural effusion (0-8%). Postoperatively it is advisable to have a chest X-ray in the recovery room to exclude hydrothorax or pneumothorax in patients undergoing intercostal puncture. If pleural complications occur, they can be treated by placing a chest tube.
5. Bowel perforation Colonic perforation is a rare complication of PCNL, less than 1%. Hadar and Gadoth in 1984 reported colonic retrorenal findings in 0.6% of cases. Colonic retrorenals are common in thin female patients. Patients with anatomical abnormalities of the kidney and patients who have had bowel surgery are at increased risk for colonic perforation if PCNL is performed. The use of CT guided nephrostomy or preoperative CT examination can be used as a guide in the above cases. The diagnosis of colonic perforation is considered if there is intraoperative hematoschezia, peritonitis, sepsis, or drainage of gas or faeces from the nephrostomy tube. Colonic perforations are often asymptomatic and only postoperative symptoms can be confirmed by postoperative nephrosography. Extraperitoneal perforations can be managed conservatively by inserting a DJ stent and removing the nephrostomy, administering broad-spectrum antibiotics, and colonography 7-10 days later. Surgical exploration is performed in cases of intraperitoneal perforation or if there are signs of peritonitis and sepsis. Duodenal perforation can also occur in right PCNL and is usually treated conservatively by inserting a nephrostomy and NG tube..
6. Liver and Spleen Trauma Trauma to the liver and spleen usually occurs in cases of splenomegaly or hepatomegaly. The use of CT-guided can reduce the risk of trauma in the above cases. In cases of spleen trauma often require exploratory management, whereas inIn cases of hepatic injury, management is conservative and rarely requires surgical exploration
7. Sepsis

It is recommended that all patients before undergoing the PCNL procedure have urine culture results and be given antibiotics according to the culture so that the urine is sterile. Post-PCNL sepsis has been reported in 0.25-1.5%