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Percutaneous Nephrolithotomy (PCNL)

Dr. Stephen Lukasewycz

What is this procedure?Tap to read

PCNL: a technique to remove large kidney stones through a small incision in the back. The surgeon makes a path straight into the kidney, widens it, and passes a scope through it. The stone is broken up and the pieces are pulled out.

Why the C-arm: live X-ray guides the needle, wire and dilator into the kidney.

Afterward: a drainage tube is often left in the back to drain the kidney while it heals.

Key points

Most patients arrive with a nephrostomy tube (access).
Place the Foley on the transfer cart, before turning the patient prone. It will stay in.
C-arm in the room with foot pedal and ready when the patient enters. Call the tech before the patient is in the room. Scrub drapes the C-arm right away.
ShockPulse and thulium laser in the room. Don't open the probe or fiber until asked.
Send stones fresh and dry for analysis (no liquid).

Supplies

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Perc nephroscopy instruments
Flexible cystoscope
Storz camera, GloShield
Minor pack, C-arm drape, C-section drape with Ioban, blue towels, 3/4 sheet
NephroMax balloon dilator, 30 Fr × 12 cm, with sheath
Sensor wire
Amplatz Super Stiff wire
Dual-lumen ureteral access catheter
Biopsy port seal, clear (BPS-A)
#11 blade
Syringes: 35 mL ×2 (contrast), 60 mL catheter-tip, 12 mL (irrigating), 50 mL
Contrast: Omnipaque 300 mgI/mL, 30 mL ×2, diluted 50/50
Y-type irrigation set, suction tubing, Poole tip
2-0 silk FS on a cutter
Standard Foley 16 Fr
Lubricating jelly on a towel
ChloraPrep ×2
ABD pads ×2, Medipore tape
Surgical jumpsuit (plastic overalls)

Available in room, open only if asked

18 G trocar needle, 15 and 20 cm
Council-tip catheters: 22 Fr (most common), 18 and 20 Fr
Catheter plug
Amplatz renal dilator set
Perc nephroscope set, long
Stone basket: zero-tip nitinol, 1.9 Fr
Stylet dial 8 Fr with 10 Fr introducer
Zip wire, stiff Glidewire
Open-ended catheter, 6 Fr
ShockPulse probe, 3.76 mm
Thulium laser fiber, 200 µm
Pressure bag for irrigation
Cautery

Gloves

Single glove: 7.5.
Surgical jumpsuit (plastic overalls).

Room setup and positioning

Non-surgical side: Neptune at the patient's shoulder, with the saline bags hung from it. C-arm in the center; C-arm monitor beside it toward the feet.
Video (scope) monitor: on the side opposite the surgeon, toward the head from the C-arm monitor.
Surgical side: equipment boom at the patient's shoulder; ShockPulse at the feet.
Foley placed on the transfer cart first.
Prone on the OSI flat top, ProneView insert for the face.
Arms cephalad on padded armboards, toward anesthesia.
Three pillows for the chest, with the pink foam roll; foam under the knees.
SCDs on.

Anesthesia

General anesthesia.
Perioperative antibiotics: generally cefazolin (Ancef) 2 g IV, but this varies; check the order. Contact the surgeon if none is ordered.
Bupivacaine 0.5% with epinephrine, 30 mL: ask before opening.

Prep and drape

ChloraPrep: flank. Include the nephrostomy tube if present.
Rolled towel, then the C-section drape with Ioban pouch.

Irrigation

Saline, 3000 mL bags, warmed.
Hang two at a time, at different heights, from the Neptune.
Pressure bag available; use only if asked.

Lithotripsy

ShockPulse and thulium laser both in the room.
Don't open the disposables (ShockPulse probe, laser fiber) until asked.

End of case

Nephrostomy tube: Council-tip catheter, 22 Fr most common, secured with 2-0 silk on a cutter.
Connect it to a Foley drainage bag at the end of the case.
Dressing: ABD pads ×2 and Medipore tape.
Stones fresh and dry to pathology, "for analysis only."

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