What is the role of percutaneous nephrostolithotomy in the treatment of nephrolithiasis?

Updated: Jun 21, 2018
  • Author: Chirag N Dave, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Answer

Percutaneous nephrostolithotomy allows fragmentation and removal of large calculi from the kidney and ureter. Percutaneous procedures have higher morbidity than ESWL and ureteroscopy and so are generally reserved for large and/or complex renal stones and cases in which the other two modalities have failed. Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter.

A needle and then a wire, over which is passed a hollow sheath, are inserted directly into the kidney through the skin of the flank. Percutaneous access to the kidney typically involves a sheath with a 1-cm lumen, which will admit relatively large endoscopes with powerful and effective lithotrites that can rapidly fragment and remove large stone volumes. Renal calyces, pelvis, and proximal ureter can be examined and stones extracted with or without prior fragmentation. Normal saline should be used for irrigation, as opposed to sterile water, to prevent electrolyte disturbances and hemolysis. [41]

Stone-free rates for PCNL monotherapy have been shown to be about 56%. As a consequence, multiple sessions of PCNL may be necessary to achieve high stone-free rates. This can result in increased tract-related complications. {ref73) In some cases, a combination of ESWL and a percutaneous technique is necessary to completely remove all stone material from a kidney. This technique, called sandwich therapy, is reserved for staghorn or other complicated stone cases. In such cases, experience has shown that the final procedure should be percutaneous nephrostolithotomy.

Minimally invasive PCNL has been described known as mini-PCNLs, micro-PCNLs or ultra-mini PCNLs. This technique initially was developed in the pediatric population but has become increasingly common in the adult population as well. It  involves a 20Fr (0.67 cm) or smaller working sheath for stone manipulation. Stones can then be fragmented with a holmium laser fiber, or pneumatic lithotripter, and removed through the sheath. This method is associated with fewer complications compared with standard PCNL but its efficacy may be limited to stones less than 2 cm; management of larger stones is especially difficult. [80, 81]

Ultra-mini percutaneous nephrolithotomy, which involves use of a small access sheath, has been shown to be safe and effective for the management of renal stones in children. In a study of this technique in 39 pediatric patients (mean age 5.8 ± 4.6 y), complete stone clearance was achieved in 32 patients (82%), increasing to 34 patients (87.1%) 4 weeks post-procedure. No patient required a blood transfusion. Complications occurred in six patients (15.3%). [82]


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