Nephrolithotomy, percutaneous


Percutaneous nephrolithotomy, or PCNL, is a procedure for removing medium-sized or larger renal calculi (kidney stones) from the patient's urinary tract by means of an nephroscope passed into the kidney through a track created in the patient's back. PCNL was first performed in Sweden in 1973 as a less invasive alternative to open surgery on the kidneys. The term "percutaneous" means that the procedure is done through the skin. Nephrolithotomy is a term formed from two Greek words that mean "kidney" and "removing stones by cutting."


The purpose of PCNL is the removal of renal calculi in order to relieve pain, bleeding into or obstruction of the urinary tract, and/or urinary tract infections resulting from blockages. Kidney stones range in size from microscopic groups of crystals to objects as large as golf balls. Most calculi, however, pass through the urinary tract without causing problems.

Renal calculi are formed when the urine becomes supersaturated (overloaded) with mineral compounds that can form stones. This supersaturation may occur because the patient has low urinary output, is excreting too much salt, or has very acid urine. Urolithiasis is the medical term for the formation of kidney stones; the word is also sometimes used to refer to disease conditions associated with kidney stones.

There are several different types of kidney stones, in terms of chemical composition:

Some people are more likely than others to develop renal calculi. Risk factors for kidney stones include:

During a percutaneous nephrolithotomy, the surgeon inserts a needle through the patient's back directly into the kidney (B). A nephroscope uses an ultrasonic or laser probe to break up large kidney stones (C). Pieces of the stones are suctioned out with the scope, and a nephrostomy tube drains the kidney of urine (D). (Illustration by GGS Inc.)
During a percutaneous nephrolithotomy, the surgeon inserts a needle through the patient's back directly into the kidney (B). A nephroscope uses an ultrasonic or laser probe to break up large kidney stones (C). Pieces of the stones are suctioned out with the scope, and a nephrostomy tube drains the kidney of urine (D). (
Illustration by GGS Inc.


Calculi in the urinary tract are common in the general United States population. Between seven and 10 in every 1,000 adults are hospitalized each year for treatment of urolithiasis; in addition, kidney stones are found in about 1% of bodies at autopsy. An estimated 10% of the population will suffer from kidney stones at some point in life. For reasons that are not yet known, the percentage of people with kidney stones has been rising in North America since 1980. In addition, the gender ratio is changing as more women are developing kidney stones. In 1980, the male:female ratio was 4:1; as of 2002, it was 3:1. Although more men develop renal calculi in general than women, more women develop infection calculi than men.

In terms of age groups, most people with urolithiasis are between the ages of 20 and 40; kidney stones are rare in children. A person who develops one kidney stone has a 50% chance of developing another.

With regard to race, Caucasians are more likely to develop kidney stones than African Americans.


Standard PCNL

A standard percutaneous nephrolithotomy is performed under general anesthesia and usually takes about three to four hours to complete. After the patient has been anesthetized, the surgeon makes a small incision, about 0.5 in (1.3 cm) in length in the patient's back on the side overlying the affected kidney. The surgeon then creates a track from the skin surface into the kidney and enlarges the track using a series of Teflon dilators or bougies. A sheath is passed over the last dilator to hold the track open.

After the track has been enlarged, the surgeon inserts a nephroscope, which is an instrument with a fiberoptic light source and two additional channels for viewing the inside of the kidney and irrigating (washing out) the area. The surgeon may use a device with a basket on the end to grasp and remove smaller kidney stones directly. Larger stones are broken up with an ultrasonic or electrohydraulic probe, or a holmium laser lithotriptor. The holmium laser has the advantage of being usable on all types of calculi.

A catheter is placed to drain the urinary system through the bladder and a nephrostomy tube is placed in the incision in the back to carry fluid from the kidney into a drainage bag. The catheter is removed after 24 hours. The nephrostomy tube is usually removed while the patient is still in the hospital but may be left in after the patient is discharged.

Mini-percutaneous nephrolithotomy

A newer form of PCNL is called mini-percutaneous nephrolithotomy (MPCNL) because it is performed with a miniaturized nephroscope. MPCNL has been found to be 99% effective in removing calculi between 0.4 and 1 in (1 and 2.5 cm) in size. Although it cannot be used for larger kidney stones, MPCNL has the advantage of fewer complications, a shorter operating time (about one and a half hours), and a shorter recovery time for the patient.



Kidney stones may be discovered during a routine x ray study of the patient's abdomen. These stones, which would ordinarily pass through the urinary tract unnoticed, are sometimes referred to as silent stones. In most cases, however, the patient seeks medical help for sudden intense pain in the lower back, usually on the side of the affected kidney. The pain is caused by the movement of the stone in the urinary tract as it irritates the tissues or blocks the passage of urine. If the stone moves further downward into the ureter (the tube that carries urine from the kidney to the bladder), pain may spread to the abdomen and groin area. The patient may also have nausea and vomiting, blood in the urine, pain on urination, or a need to urinate frequently. If the stone is associated with a UTI, the patient may also have chills and fever. The doctor will order both laboratory studies and imaging tests in order to rule out such other possible causes of the patient's symptoms as appendicitis, pancreatitis, peptic ulcer, and dissecting aneurysm.

The imaging studies most commonly performed are x ray and ultrasound. Pure uric acid and cystine calculi, however, do not show up well on a standard x ray, so the doctor may also order an intravenous pyelogram, or IVP. In an IVP, the radiologist injects a radioactive contrast material into a vein in the patient's arm, and records its passage through the urinary system in a series of x ray images. Blood and urine samples will be taken to test for indications of a urinary tract infection. If the patient passes the kidney stone, it is saved and sent to a laboratory for analysis.


Most hospitals require patients to have the following tests before a PCNL: a complete physical examination ; complete blood count ; an electrocardiogram (EKG); a comprehensive set of metabolic tests; a urine test; and tests that measure the speed of blood clotting.

Aspirin and arthritis medications should be discontinued seven to 10 days before a PCNL because they thin the blood and affect clotting time. Some surgeons ask patients to take a laxative the day before surgery to minimize the risk of constipation during the first few days of recovery.

The patient is asked to drink only clear fluids (chicken or beef broth, clear fruit juices, or water) for 24 hours prior to surgery, with nothing by mouth after midnight before the procedure.


A standard PCNL usually requires hospitalization for five to six days after the procedure. The urologist may order additional imaging studies to determine whether any fragments of stones are still present. These can be removed with a nephroscope if necessary. The nephrostomy tube is then removed and the incision covered with a bandage. The patient will be given instructions for changing the bandage at home.

The patient is given fluids intravenously for one to two days after surgery. Later, he or she is encouraged to drink large quantities of fluid in order to produce about 2 qt (1.2 l) of urine per day. Some blood in the urine is normal for several days after PCNL. Blood and urine samples may be taken for laboratory analysis of specific risk factors for calculus formation.


There are a number of risks associated with PCNL:

Normal results

PCNL has a high rate of success for stone removal, over 98% for stones that remain in the kidney and 88% for stones that pass into the ureter.

Morbidity and mortality rates

Standard PCNL has a higher rate of complications than extracorporeal shock wave lithotripsy; however, it is more successful in removing calculi. The overall rate of complications following PCNL is reported as 5.6% in one recent study and 6.5% in a second article. About 20% of patients scheduled for PCNL require a blood transfusion during the procedure, with 2.8% needing treatment for bleeding after the procedure. The rate of fistula formation is about 2.5%.


Patients with kidney stones may be treated with one or more of the following procedures in addition to PCNL, depending on the size of their renal calculi and possible complications. One frequently used combination, known as sandwich therapy, is extracorporeal shock wave lithotripsy for smaller stones followed by PCNL to remove larger calculi.

Conservative approaches

Conservative forms of treatment include the following:

Open surgery

Open surgery is the most invasive form of treatment for urolithiasis. As of 2003, it is performed primarily to remove very large and complex staghorn calculi or extremely hard stones that cannot be broken down by lithotripsy. Other indications for open surgery are extreme obesity, an anatomically abnormal kidney, or an infected and nonfunctioning kidney requiring complete removal. Patients are usually hospitalized for a week after open kidney surgery and take about six weeks to recover at home.

Extracorporeal shock wave lithotripsy (ESWL)

ESWL is a noninvasive procedure that was developed in the 1980s as a less invasive alternative to PCNL. It is presently used more often than PCNL to treat smaller renal calculi. In ESWL, the patient is given a local anesthetic and placed in a water bath or on a soft cushion while shock waves are transmitted through the tissues of the back to the stones inside the kidney. The shock waves cause the calculi to break up into smaller pieces that can be passed easily in the urine.

Although patients need less time to recuperate from ESWL, it has several disadvantages. It has lower success rates (50–90%) than PCNL. Moreover, it cannot be used to treat cystine calculi or calculi larger than 1.2 in (3 cm). An additional concern with shock wave lithotripsy is its safety in treating small or anatomically abnormal kidneys; it has been reported to cause temporary damage to kidney tubules in smaller-than-average kidneys.


Ureteroscopy refers to removal of calculi that have moved downward into the ureter with the help of a special instrument. A ureteroscope is a small fiberoptic endoscope that can be passed through the patient's urethra and bladder into the ureter. The ureteroscope allows the surgeon to locate and remove stones in the lower urinary tract without the need for an incision.

Complementary and alternative (CAM) approaches

Vegetarian and other low-protein diets have been found helpful in preventing kidney stone formation. In addition, recent ethnobotanical studies of ammi visnaga (toothpick weed), a plant belonging to the parsley family, and Phyllanthus niruri , a traditional Brazilian folk remedy for kidney stones, indicate that extracts from these plants are effective in increasing urinary output and inhibiting the development of calcium oxalate calculi.

See also Urologic surgery .



Pelletier, Kenneth R., MD. "CAM Therapies for Specific Conditions: Kidney Stones." In The Best Alternative Medicine. New York: Simon & Schuster, 2002.

"Urinary Calculi." In The Merck Manual of Diagnosis and Therapy , edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.


Battino, B. S., W. DeFoor, F. Coe, et al. "Metabolic Evaluation of Children with Urolithiasis: Are Adult References for Supersaturation Appropriate?" Journal of Urology 168 (December 2002): 2568–2571.

Chan, D. Y., and T. W. Jarrett. "Mini-Percutaneous Nephrolithotomy." Journal of Endourology 14 (April 2000): 269–272.

Freitas, A. M., N. Schor, and M. A. Boim. "The Effect of Phyllanthus niruri on Urinary Inhibitors of Calcium Oxalate Crystallization and Other Factors Associated with Renal Stone Formation." BJU International 89 (June 2002): 829–834.

Jin, Chua Wei, and Chin Chong Min. "Management of Staghorn Calculus." Medical Progress (February 2003): 1–6.

Khan, Z. A., A. M. Assiri, H. M. Al-Afghani, and T. M. Maghrabi. "Inhibition of Oxalate Nephrolithiasis with Ammi Visnaga (Al-Khillah)." International Urology and Nephrology 33 (2001): 605–608.

Kim, S. C., R. L. Kuo, and J. E. Lingeman. "Percutaneous Nephrolithotomy: An Update." Current Opinion in Urology 13 (May 2003): 235–241.

Kinn, A. C., I. Fernstrom, B. Johansson, and H. Ohlsen. "Percutaneous Nephrolithotomy—The Birth of a New Technique." Scandinavian Journal of Urology and Nephrology Supplement 138 (1991): 11–14.

Lahme, S., K. H. Bichler, W. L. Strohmaier, and T. Gotz. "Minimally Invasive PCNL in Patients with Renal Pelvic and Calyceal Stones." European Urology 40 (December 2001): 619–624.

Parsons, J. K., T. W. Jarrett, V. Lancini, and L. R. Kavoussi. "Infundibular Stenosis After Percutaneous Nephrolithotomy." Journal of Urology 167 (January 2002): 35–38.

Ugras, M., A. Gunes, and C. Baydinc. "Severe Renal Bleeding Caused by a Ruptured Renal Sheath: Case Report of a Rare Complication of Percutaneous Nephrolithotomy." BMC Urology 2 (September 18, 2002): 10.


American Foundation for Urologic Disease (AFUD). 1128 North Charles Street, Baltimore, MD 21201. (800) 242-2383. .

American Urological Association (AUA). 1120 North Charles Street, Baltimore, MD 21201. (410) 727-1100. .

National Kidney Foundation. 30 East 33rd Street, Suite 1100, New York, NY 10016. (800) 622-9010 or (212) 889-2210. .

National Kidney and Urologic Diseases Information Clearing-house (NKUDIC). 3 Information Way, Bethesda, MD 20892-3580.


National Kidney and Urologic Diseases Information Clearing-house (NKUDIC). Kidney Stones in Adults. February 1998 [cited April 30, 2003]. NIH Publication No. 94-2495. .

Rebecca Frey, Ph.D.


A PCNL or mini-PCNL is performed under general anesthesia in a hospital by a urologist, who is a surgeon with specialized training in treating disorders of the urinary tract. ESWL may be done as an outpatient procedure in an ambulatory surgery facility.


User Contributions:

Clarice LeRoy
What is the recovery time for Percutaneous nephrolithotomy (PCNL)?
Thank you.
Ada Co
I need to know how to prevent further deterioration of the kidney. The doctor said that my husband's kidney deteriorates faster than his age. He is now 55 years old but tests showed that his kidney is 57% functional.
Please advise.
Ada Co
This is a procedure I guess I could go through next
nurhazerah binti isa
i wont to about the indication,pre operative and post aperative nursing care for nephrolithotomy
in how many days urine report will be normal after pcnl? .my report shows puss cells but i dont feel fever .
My husband just had this procedure done 3 days ago. He was discharged after two days in hospital and now at home there seems to be urine coming out of the incision where the procedure was done. The liturature we were sent home with said a small amount of discharge is normal for up to one week after the procedure is done. What is a small amount?
my mother who is 58 years old had pcnlfor left kidney stone 1 year back. she still complains of microscopic hematuria and flank heaviness/pain which comes after sitting for 1 hour or doing some exertion. her urine cultures are repeatedly negative and her CT angiography revealed no fistula or stone. what are possibilities and what should we do next.will she need nephrectomy? she has asymptomatic stones in lower pole of right kidney as well.
Carolyn Kosdemba
My 91 year old mother is set up with Delaware Valley Urology for a PCNL with Dr. Burno at Virtual Memorial Mt Holly NJ. Should we be trying to get her into the U of PA or a teaching hospital for the best results?
I'm 52, I've recently had pcnl on both kidneys and I'm recovering quite well. I'd like to know how to prevent further deterioration of my kidneys. Before the surgeries my creatinine was between 117 and 218.
Since we have URS Flex and Holmium Laser no need more for PCNL.
I want to know which procedure is the best one for 75 years old man with stone in Ureter? The size of stone is 2.7mm*6mm and he have heart disease.
Just went through having percutaneous nephrolithotomy procedure to remove kidney stones 5 days ago and came home with the nephrolithotomy tube.I had it removed yesterday. I was told that that there would be some oozing from the incision and could continue to ooze up to 48hours. I never expected what I am going through.I wish I was told about this prior to the surgery. I would have prepared myself for it. I am beside myself changing the dressing every hour and a half and being soak and wet. I don't know where to sleep,do I sleep on my stomach or my back. Sleeping very little. It doesn't seem to make a difference because I am getting everything soak and wet. Any ideas as how to pack the incision other then what I am doing?I have several large pads then covering with a disposable diaper.I would appreciate any input. Thank you
Trina Chandler

This is the procedure I'm going to have on January/27/2012

Barb I have had this very uncomfortable surgery done three times. the second time my nurse finally devised a plan that work. She placed an ostomy bag over the hole in my back and the urine collected in a little sack in the back that we just drained into a container the hospital gave us every so often. it is my my more comfortable. I was a soaking sopping wet mess before they figured this fix out. We tried everything. We went through so many bandages and such, that my skin started to get raw from changing the tape for the bandages so often. Mention this to your nurse - I'm sure they could place one for you. It's simple, doesn't hurt and works wonderfully.

Hope you heal up nicely and quickly. these surgeries have always been miserable for me, but I realize things could be worse than kidney stones. Stay well.
Oh my I am going to do this in less then a week, does not sound fun at all... how long out of work after?
Sardool Singh
I have lost my right kidney to cancer and three surgeries to my left kidney and fourth done recently.My symptoms are swelling on both sides,itching starting from belly button and spreading all over. Despite all the procedures and good care I seems to go down hill very quickly with all body pain,slight rise in body temperature and vomiting once.Any body has similar symptoms or experience, please help me.
My 85 year old grandmother had this surgery on Thursday and one of her stones was 6cm big and ruptured. The doctor basically told us that we'll wait a week but things are not looking well. It's my birthday as of 23 minutes ago and all I want for my birthday is for her to get better. She needs to meet her new great grand daughter.
Pat B.
In the paragraph under "Risks" 1 inch = 2.5 cm, not 0.5 cm.
I was wondering if i should return to the hospital because the amount and frequency of urine coming from the hole left after PCNL surgery? My bandages are compleatly soaked an hour after i change them. Is this normal? Im worried the hole wont close because of the amount of urine coming out so often?
carole beland
im going for nephrolithotomy percutaneous opperation for a large kidneystone i almost didnt make it 5 months ago due to the kidney infection going through my blood and lungs and i was an emergency surgery patient and it now is 5 1/2 months and i still have kidney infection what can happen to me im sooo scared
I had this surgery on Jan 24th 2012. I was in surgery for 5 hours and they were not able to get the stone because i was bleeding to much so I had to go back on the 29th so they could try again. The 2nd time was successful. I was in the hospital for one night. I went home with a tube out my back to drain the urine and blood had that removed 2 days later. It took about a week for it to stop discharging anything and completely scab over. I still have a stint in from the surgery which will be removed on Feb 18th 2012. I still have a little blood in my urine every once in a while. The only thing I'm not sure about is I have had really bad night sweats since my surgery. Has anyone else had night sweats after this surgery?
For anyone who wants to know this surgery is a pain in the butt. For at least 1 1/2 to 2 weeks after the surgery I was not able to be comfortable in any position. The drain out of my back leaked constantly no matter how much we bandaged it up so i ruined a lot of shirts and had to have our couch cleaned from leaking all over it.
I am feeling pretty good now after 3 weeks still get wiped out if i do to much in a day.
At least I have the 1 1/2 inch kidney stone gone.
Hi i have 4 kiddney stones and i have kiddney stant right now i m suffering badly kiddney infaction the dr told me that they remove the kiddney first but my right kiddney was function on 35% and i have stone in my right kiddney too now i have gone on august 22 for pcnl surgery but i m so scare i have one little baby boy just advise me everything is going better after the surgery.thankx
I had this surgery done exactly a week ago on both sides and I'm thrilled to report that I'm doing great now! I had numerous large stones in both kidneys, with stones causing blockages in the ureter on both sides. I guess I got very lucky or my doctor is extremely competent, but I had the surgery on Wednesday, spent 2 nights in the hospital, spent one more uncomfortable night at home, and by the next morning I was feeling pretty good. By Sunday I was out walking around and even went to a movie, and I've been back at work full time beginning on Monday. I still have the tiniest bit of bloody seepage from the insertion sites on either side of my lower back, but I'm just using a large waterseal bandage over both sites, changing them once a day.

I'm a 63-year-old woman in otherwise good health, so I hope that my story is encouraging to anyone reading this thread who may be about to undergo this surgery. I certainly don't mean to sugarcoat this: I was absolutely miserable the first day and I was scared to death they were going to kick me out of the hospital that first day after surgery--after all, I had been told it was a "23-hour observational hospital stay." They pulled the first nephrostomy tube Thursday morning after surgery but were planning to send me home with the other one still attached, with instructions to return TO THE DOCTOR'S OFFICE ON MONDAY! That would have meant walking around with that tube hanging out of my body for an entire weekend. I still think it was insane that this wasn't initially approved as a 2-night stay.
I had this done for a 7 size stone on Jan 28. I had no pain at all until I went back on Jan 30 to have the tube removed from my back. It was excrusiating pain and I all but passed out twice. I hurt so bad that I could hardly walk and had trouble breathing. Got home, still severe pain and trouble breathing and took 2 oxycodone pills. This was the first pain killer that I had needed. I guess I finally just passed out from the meds for a few hours. Upon waking up was still having severe pain and needed help to even get out of bed. Today is Feb 5 and I still have pain but on the opposite side from surgery and all the way accross my middle upper body. I also feel like I am not getting a really good deep breath on that side. I am not urinating a lot either, even though I am taking 20mg lasix. I would never again have someone just yank that tube out of my back with nothing for pain before doing it. I feel worse than I did before the surgery. Done in Greenwood sc at Urology Associates.
I went in January 29th for the neph tube insertion. On the morning of January 30th they went to take me down for the nephrolithotomy & I was septic. 24 hrs of being close to death. 5 days of recovery in ICC, then sent home WITH neph tube & pee bag in place to recover & conquer infection. The horrendous winter has interfered with following up, but I went back for the nephrolithostomy completed last Thursday. The 1.5 he procedure took 2,5 hrs. They couldn't get at my 3cm staghorn, it's blocking my ureter. The next day they removed the tubes & sent me home. The worst pain was from the abdominal gas from inflation. They "superglued" the neph hole &only problem was trying to not scratch it. They must have done some sound bombardment, because some bruising later showed up, Similar to lithotrypsi. I returned to work on Monday, moving very slow. Painkillers to sleep &most of th e DAY. By yesterday, Thursday again, I was ALMOST myself. Sore muscles& easily tired more than anything.
Now I have to heal up & look forward to more lytho or other treatments, to get that staghorn! I am only 45,but had lytho 5your ago. Been having infections since I was 20.
I undergone PCNL before about four months. Although stone was removed successfully, but there is painful swelling (about one inch) around the incision site with some amount of water drainage out of incision site. While discharge after surgery, I am told that cut will heal in two to three days, but it's not healing for such long period... I am afraid that Kidney is leaking due to non healing? Sinus track formed?
What do I do?
mubarak shaikh
Hi sir my Sister,s pcnl operation is happened it was 41 mm but after operation doctor shown us very little stone like 6-7 mm and that also 5-6 no. I am confused all stone has been clear or not.staghorn type stone.
Barbara Carmichael
Mini PCNL on left kidney was done on Wednesday. Thursday, I felt like I was hit by a train in my entire torso and stayed in bed most of 24 hrs. Friday I was able to move around a lot better and do light housework in spite of feeling like I just did 100 or more situps. Saturday I was ok until the evening when I started having sharp pains in my side whenever I coughed, just inhaled more than slightly, or bent forward. Pain meds seem to help, but Sunday was like day before with the sharp left side pains. I don't feel constipated, however I haven't had a bm in 5 days. After surgery, Dr said it was a success. Any ideas on the sharp pain in my side when I breathe?
I had this procedure 4 weeks ago. It was successful. However, puncturing the kidney can cause damage. This was a 2 step process. A radiologist actually did the tube insertion under conscious sedation and then I went to the operating room for the Urologist to blast and remove the stones. I was in the hospital for 1 day and the pain meds were great. However, when I came home the pain was unbearable and oral pain killers made me sick. You need to insist on staying in the hospital for several days. I am still tender internally when breathing deep. I hope and pray I never go through this again.
sir im going to have pcnl after 4 weeks. i am having 2 cm kidny stone (calcium oxalate). i want to know that how much time i will need to recover. and will i be capable of tough physical training? and could i go to gym after my recovery? waitinf for your kind reply
I am going into hospital in 10 days for staghorn removal, I need a 3inch staghorn removed from my left kidney, my surgeon has said he will try to go through the Uretha and if not then will go through my back, How much pain comes with each procedure?
I am terrified of staying in hospital also and have asked for my husband to stay with me for the entirety of my stay, I have been told this might not be possible and i told them if this doesn't happen i will discharge myself, So how much pain am i looking at? Out of 100 being totally unbearable? I have Diabetes too.
PCNL last Thursday. Saturday noticed a "swelling" which begins at incision site and continues around to abdomen getting larger as it approaches abdomen. Dr's checked it while in hospital and said it wasn't any bleeding. What is it? Why would it still be there five days post-op? Should I be concerned??
Six days since surgery, I am having symptoms of incontinence, the feeling that I have to urinate. I'm hoping this is temporary. Anybody else?
Michael Chamis
had pcl surgey 2 weeks ago all tubes removed but urinating blood how long should blood be in urine
Charlie Tuna
I love how you can ask questions for this but no one ever answers.

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