Per-cutaneous Nephro-Lithotripsy (PCNL)

Percutaneous Nephrolithotomy (PCNL) is a surgical procedure used to remove large or complex kidney stones that are difficult to treat with less invasive methods like shock wave lithotripsy (SWL) or ureteroscopy. PCNL is particularly effective for treating stones larger than 2 cm, staghorn stones (stones that fill the kidney’s collecting system), or stones that are located in difficult-to-reach areas of the kidney.

Procedure Overview:

1. Preparation:

   • The patient is placed under general anesthesia to ensure they are unconscious and pain-free during the procedure.

   • Pre-operative imaging, such as a CT scan or X-ray, is performed to accurately determine the size, location, and number of kidney stones.

2. Creating Access to the Kidney:

   • The surgeon makes a small incision (about 1 cm) in the patient’s back, usually under the ribcage, to access the kidney.

   • Using imaging guidance (usually fluoroscopy or ultrasound), a needle is inserted through the incision and into the kidney's collecting system.

   • A guidewire is passed through the needle, and the tract is gradually dilated to allow the insertion of a nephroscope (a thin, tube-like instrument with a camera and light) into the kidney.

3. Stone Fragmentation and Removal:

   • Once the nephroscope is in place, the surgeon can visualize the stone and break it into smaller pieces using various instruments, such as an ultrasonic or pneumatic lithotripter, or a laser.

   • The stone fragments are then removed using forceps, suction, or a basket device. Larger stones may require multiple fragmentations for complete removal.

4. Post-Procedure Care:

   • After the stones are removed, a nephrostomy tube (a drainage tube) may be temporarily placed in the kidney to help drain urine and any residual stone fragments or blood.

   • A ureteral stent might also be placed to ensure the ureter remains open and urine can drain from the kidney to the bladder during the healing process.

5. Recovery:

   • The nephrostomy tube is usually removed after a few days, depending on the patient’s recovery and the amount of drainage.

   • Most patients stay in the hospital for 1-2 days after the procedure, though this can vary based on the complexity of the surgery and the patient's overall health.

Indications for PCNL:

• Large Kidney Stones: Stones larger than 2 cm or those that are too large to be treated effectively with SWL or ureteroscopy.

• Staghorn Stones: Stones that occupy a large portion of the kidney’s collecting system.

• Multiple Stones: When there are several stones that need to be removed in one session.

• Failed Previous Treatments: Stones that have not been successfully treated with other less invasive methods.

Benefits of PCNL:

• Effective for Large or Complex Stones: PCNL is the most effective method for removing large stones in a single session.

• Minimally Invasive Compared to Open Surgery: While more invasive than ureteroscopy, PCNL is much less invasive than open surgery and involves smaller incisions and quicker recovery times.

• High Success Rate: PCNL has a high success rate for complete stone removal, especially in cases of large or complex stones.

Risks and Complications:

• Bleeding: There is a risk of significant bleeding, as the kidney is a highly vascular organ.

• Infection: Post-operative infections can occur, which may require antibiotic treatment.

• Injury to Surrounding Organs: Rarely, nearby organs such as the bowel, liver, or spleen may be injured during the procedure.

• Residual Stones: Some stone fragments may remain after the procedure, possibly requiring additional treatment.

Dr. Saurabh Mishra's Approach to PCNL:

Dr. Saurabh Mishra, with his extensive experience in urology and complex stone surgeries, would approach PCNL with meticulous planning and precision. His expertise in performing PCNL ensures that patients receive the highest level of care, with careful consideration of the best approach to access and remove the stones effectively.

Dr. Mishra would likely emphasize a personalized treatment plan for each patient, taking into account the specific characteristics of their stones and overall health. His surgical technique would focus on minimizing risks, such as bleeding and infection, while maximizing the chances of complete stone removal.

Post-operatively, Dr. Mishra would provide detailed instructions for recovery, including managing any nephrostomy tubes or stents, and scheduling follow-up appointments to monitor healing and check for any residual stones. His patient-centric approach ensures that each individual receives comprehensive care from pre-operative planning through to post-operative recovery.