Kidney Stones

General Kidney Stone Information

  • Urine has many dissolved minerals and salts. Stones may form when urine has high levels of some of these minerals and salts.
  • Kidney stones may start small and not cause any issues at first. However, kidney stones can grow larger in size, even filling the inner hollow structures of the kidney. Some stones stay in the kidney, and will never cause any problems.
  • Kidney stones can travel down the ureter sometimes. (The ureter is the tube between the kidney and the bladder.) If the stone reaches your bladder, it can be passed out of the body through your urine. If the stone becomes lodged in the ureter, it blocks urine flow from that kidney. This may be painful.
  • If a stone is unable to pass (even after adding medication), surgery may be needed. Options include:
    • Shockwave lithotripsy
    • Ureteroscopy
    • Laparoscopic or Robotic Surgery
    • Percutaneous (endoscopic) Surgery (PCNL)
  • Chemical analysis of the stone along with special metabolic testing of the urine and blood can determine the cause of stones in the majority of cases.

Percutaneous Nephrolithotomy (PCNL)

Percutaneous Nephrolithotomy (PCNL) provides patients with a safe and effective way to remove kidney stones using a minimally invasive technique.  Kidney stones are formed in the urinary tract due to crystallization of chemical compounds in the urine.  PCNL is a technique used to remove certain stones in the kidney or upper ureter (the tube that drains urine from the kidney to the bladder).

General Information

This procedure has been used on many patients over the last several years.  It has replaced the open operation in majority of patients with kidney stones.  It has been accepted as a safe and reliable technique. Typically, the length of the surgery is 3-4 hours. The surgery is preformed by making a small 1-1.5 cm (1/2 inch) incision in the back (flank) area. A tube is placed through the incision into the kidney under x-ray guidance.  A small telescope is passed through the tube to see the stone and remove it (Fig. 1 & 2).  If necessary a laser or other device called a lithotriptor may be used to break the stone into smaller pieces.  This procedure has resulted in significantly less post-operative pain, a shorter hospital stay, and earlier return to work and daily activities when compared to the open operation.

Potential Risks and Complications

Although this procedure has been proven to be safe, as in any surgical procedure there are risks and potential complications

  • Bleeding: Blood loss during this procedure is possible and a transfusion is necessary in approximately 2-3% of patients. We will only transfuse in the event of life threatening blood loss.
  • Infection: All patients are treated with broad-spectrum antibiotics to decrease the chance of infection from occurring.
  • Tissue/Organ Injury: Although uncommon, possible injury to surrounding tissue / organs including bowel, vascular structures, spleen, liver, lung, pancreas and gallbladder could require further surgery.  Loss of kidney function is rare but is a potential risk. Scar tissue may also form in the kidney or ureter requiring further surgery.
  • Conversion to open surgery: This surgical procedure may require conversion to the standard open operation if difficulty is encountered during this procedure. This could result in a larger standard open incision and possible a longer recuperation period.
  • Failure to Remove the Stone: There is a possibility that the stone may not be able to be removed in one session, usually due to the size of the stone.  For larger stones, several PCNL sessions may be required.  Additional surgical options may be utilized to completely remove your stone.

What to Expect Before Surgery

Pre-Operative Visit

  • You will also be scheduled for a visit in the Pre-Operative Clinic. You will also be given written instructions regarding arrival time the day of your surgery and when to stop eating and drinking, etc. This visit can take one to three hours depending on the various tests that are ordered for you.

Diagnostic Tests

  • You will have some pre-op tests before your surgery. These may include blood work, EKG, cardiac work up, x-rays, urinalysis, or others.
  • Generally most of the tests can be completed the day of your pre-op visits, however, some of them may need to be scheduled on a different day. Also, some insurance plans have contracts with outside lab and x-ray facilities. In that case, you will be given the appropriate paperwork and maps for those facilities.
  • It will be important to complete your pre operative testing 2 weeks before surgery so that corrective action can take place in time to avoid surgery rescheduling.

Preparing for Surgery

  • Practice deep breaths and coughing before your surgery.
  • Walk a mile each day.
  • No Advil/Ibuprofen 48 hours before.
  • No Aspirin 7 days before. You will be given a list of blood thinners to avoid as well.
  • Avoid garlic and other herbal remedies a week before.

Day before Surgery:

  • Eat light diet, small sandwich, eggs, toast, soup. Limit dairy. Avoid fried foods and lot of seasoning
  • Shower with Hibiclens – use ½ bottle. Rub it on mid-section area.  Then rinse off. Use a clean towel.
  • No eating after midnight. Can drink up to 12 ounces of water up to 2 hours before.

Day of Surgery:

  • Shower with ½ bottle of Hibiclens. Take your medications.
  • Bring lace-up sneakers.
  • Bring Health Care Proxy Form.
  • Bring cell phone and charger.
  • Bring a case for personal items – eyeglasses, hearing aids,
  • You will get an IV. Then meet with Anesthesiologist. Compression boots will be placed. You will get a breathing tube inserted, and a urinary catheter.

What to Expect After the Surgery

Immediately after the surgery, you will be taken to the recovery room and transferred to your hospital room once you are fully awake and your vital signs are stable.

  • Post-operative pain: Pain medication can be controlled and delivered by the patient via an intravenous catheter or by injection (pain shot) administered by the nursing staff.
  • Nephrostomy Tube: You can expect to have a small tube coming out of your back to allow urine to drain from the kidney to a drainage bag. This drain usually remain in for one week. You will be discharged from the hospital with a nephrostomy tube.
  • Stent: You may have an internal ureteral stent in place coming from the kidney to the bladder to promote drainage from the kidney.
  • Nausea: You may experience some nausea related to the anesthesia. Medication is available to treat persistent nausea.
  • Urinary Catheter: You can expect to have a urinary catheter draining your bladder (which is placed in the operating room while you are asleep) for approximately 1 day after the surgery. It is not uncommon to have blood-tinged urine for a several days after surgery.
  • Diet: You can expect to have an intravenous catheter (IV) in for 1 day. (An IV is a small tube placed into your vein so that you can receive necessary fluids and stay well hydrated until you are able to tolerate a diet; in addition, it provides a way to receive medication).  Most patients are able to tolerate ice chips and small sips of liquids the day of the surgery and regular food the next day. Once on a regular diet, pain medication can be given by mouth instead of by IV or shot.
  • Fatigue is common and should subside in a few weeks.
  • Incentive Spirometry: You will be expected to do some very simple breathing exercises to help prevent respiratory infections through using an incentive spirometry device (these exercises will be explained to you during your hospital stay). Coughing and deep breathing is an important part of your recuperation and helps prevent pneumonia and other pulmonary complications.
  • Ambulation: On the day after your surgery it is very important to get out of bed and begin walking with the supervision of your nurse or family member to help prevent blood clots from forming in your legs. You can expect to have SCD’s (sequential compression devices) on your legs to aid in the prevention of blood clots.
  • Hospital Stay: The length of hospital stay for most patients is approximately 1 day.
  • Constipation: you may experience sluggish bowels for several days or several weeks. Suppositories and stool softeners are usually given to help with this problem.  Taking mineral oil at home will also help to prevent constipation.
  • Secondary Procedures: Some patients have stones that are very large or that cannot be safely removed at one setting. You may need a “second look” to remove any remaining stone, either during the hospitalization or at another time. Additional surgery may need to be scheduled for you.

What to Expect After Discharge from the Hospital

  • Pain Control: you can expect to have some pain that may require pain medication for a few days after discharge, and then Tylenol should be sufficient to control your pain.
  • Showering: you may shower at home. Your wound site can get wet, but must be padded dry.
  • Activity: Taking walks is advised.  Prolonged sitting or lying in bed should be avoided. Climbing stairs is possible. Driving should be avoided for at least 1-2 weeks after surgery. Activity can begin as tolerated. You can expect to return to work as instructed by your physician.
  • Follow-up Appointment: You should have a follow-up appointment arranged for you prior to your discharge to remove the tubes or schedule additional surgery if needed.
  • Stent Follow-up: The length of time the stent remains in place is variable. Your doctor will probably request it to be removed within a 2-6 week period.  This can be removed in the doctor’s office. It is common to feel a slight amount of flank fullness and urgency to void, which is caused by the stent.  These symptoms often improve over time if the stent is left in.
  • Nephrostomy Site Care: It is important that urine flow freely through the tube.  Check daily to make sure the tube is not kinked.  Make sure the stopcock, if present, remains in the open position to allow urine to drain.  Keep the tube securely anchored to the skin with tape to prevent pulling and to keep the tube in place.  Monitor the amount of drainage, color and odor.  Blood tinged urine is not uncommon.  Keep the drainage bag below the level of the kidney.  It is important to clean the area around the insertion site with mild soap and water each day when you shower.  Pat the area dry after showering and clean directly around the insertion site with hydrogen peroxide using a cotton tip applicator.  Apply a clean sterile dressing after cleaning the area. If you experience any change in pain, fever, chills, pus forming around the insertion site, the catheter not draining or leaking around the tube you must contact the doctor immediately.

Links for More Information

For more information on kidney stones:
https://urologyhealth.org/urologic-conditions/kidney-stones

For more information on Dr. Sanjay Ramakumar and the Abrazo Urologic Institute:
Abrazomedicalgroup.com

Figure 1. External view

Figure 1. External view

Figure 2. Internal view

Figure 2. Internal view