Individualised treatment for Kidney stone

Percutaneous nephrolithotomy (PCNL) is the surgical method of removing kidney stones. Percutaneous means through skin and Nephrolithotomy is kidney stone removal. This is done when there are bigger or larger numbers of stones that cannot go by themselves or by any other treatment methods. It is the standard surgical procedure done to remove large and complex kidney stones. Size, composition, location, and number are some of the factors that are considered before doing this surgery to remove the kidney stones.

Indications:

PCNL is done to remove complex kidney stones. This is indicated when there are:
It is a standard choice for stones larger than 20mm.
This is also indicated in stones that are present in the tubes called ureters that connect kidneys with the bladder.
It can be used as an alternative to retrograde internal surgery (RIRS) procedure for stones between 10 to 20mm.
PCNL along with RIRS can be used for stones that are < 10 mm in size which are present at the lower pole of the kidney.
Kidney stones that are composed of brushite, calcium oxalate monohydrate, and cystine can be treated by PCNL
It is the treatment of choice when other treatment modalities have failed.

Contraindications:

PCNL is not indicated in individuals who are on medications like blood thinners. It is also not for those with urinary tract infections. It can also be not done in individuals with renal cancer. Pregnancy is also a contraindication for this procedure.

Advantages:

PCNL is the treatment of choice for removing large kidney stones. This has many advantages:
It has high success rates with better stone removal
It has the advantage of removing complex stones that are located at relatively inaccessible locations in the kidneys
It has the advantage of removing complex and large stones in a single go
Staghorn stones are large kidney stones that can be successfully removed using the PCNL technique

Before the procedure:

Before undergoing a PCNL procedure, an individual should be informed the importance and necessity of the procedure by discussing it with the HCP. All the medications taken by the individual should be informed to the HCP along with the history of any previous diseases, infections, surgeries, and allergies. Based on the medications taken, sometimes some medicines are advised to stop depending on the health condition and risk vs. benefits. These include over-the-counter medications, blood thinners, and opioid painkillers. Other medicines may be prescribed by the HCP before undergoing a biopsy.

Certain routine blood and urine investigations and imaging studies are carried out to rule out any infections or any other conditions not known to the individual. Imaging studies are done to locate the position, number, and size of the kidney stones. These are also done to understand that other factors are stable in the body. PCNL is done on an empty stomach. Hence it is advisable to stop eating or drinking 8 hours before the procedure.

During the procedure:

PCNL is done under general anesthesia. During the procedure, a small tube called the catheter is inserted in the bladder to drain the urine. Another catheter is placed that passes from the urethra, bladder, and ureters to enter the kidneys. A special tracer is passed through this tube to locate the presence of the stones. This is done using guidance from the CT or MRI scan or an ultrasound.

Once the stone is located, a thin wire called a guidewire is passed through the urethra to reach the location of the stone. A small lens called a nephroscope is used to view the insides of the kidney and locate the stones exactly for viewing. The access area is enlarged to remove the stones. Using a special instrument called the grasper some small stones can be easily removed. While larger stones will be broken down into small sizes using a laser for easy removal.

The complete removal of the stones is confirmed by sending a contrast material that freely flows through the system. A small tube is placed to ensure proper drainage of the urine without any blockage. This is called the Double J Stent. A drainage catheter called a ‘nephrostomy tube’ is placed for proper drainage of the fluid contents and urine. The collected stones are sent to the lab for further investigation and analysis.

After the procedure:

The individual is continuously monitored till the vitals are stabilized. Medications like antibiotics and painkillers are given to ward off the infection and pain. Based on the recovery of the individual they are discharged in 1 or 2 days if they can urinate completely and there are no signs of infection. Instructions are given to avoid strenuous exercises for 2 to 4 weeks after surgery. Dietary instructions include drinking plenty of fluids about 1.5 litres and eating more fruits and vegetables.

A follow-up visit will be scheduled 4 to 6 weeks after the surgery to check the condition and identify any infection. Another imaging study is done to check the condition of the kidneys, the development of any stones, and if all the stones are removed. The nephrostomy tube will also be removed at the same time under local anesthesia.

Risks and complications:

Some risks associated with the procedure include bleeding and pain from the surgical site, the development of infection at the surgical site, burning and discomfort while urinating, the development of temporary clots that can cause pain, and injury to the internal organs or internal parts of the kidney during the procedure. The other complication is the incomplete removal of the stones which may be drained off by other procedures.

Conclusion:

PCNL is a surgical procedure to remove large and complex stones from the kidney. It is a minimally invasive surgery done in individuals when other procedures cannot remove the stones. It is a safe, effective, and successful procedure that improves the quality of life of individuals.

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