Nephrolitholapaxy

Since the 1980s, percutaneous PCNL has largely replaced open stone surgery for large kidney stones (Seitz 2018). In 1985, J R Woodside et al. performed percutaneous PCNL in children for the first time with a special instrument set (Guven 2012).

A PCNL is a sonographically controlled percutaneous endoscopy of the renal pelvis to remove larger stones of ≥ 10 mm (Herold 2020).

Indication: PCNL is preferred for patients with large stones > 2 cm, stones of the lower calyx group already from 1.5 cm (ESWL [extracorporeal shock wave lithotripsy] shows worse results in this area of the kidney) (Seitz 2018)

PCNL is also possible for: stones that cannot be treated satisfactorily by ESWL (Hautmann 2014) children of all ages (Guven 2012) large stones (≥ 1cm) in the renal pelvis, renal calices, renal pelvis effusion stones and stones in the pyeloureteral junction (Kuhlmann 2015).

PCNL can be performed at any age, especially in children (Guven 2012).

Both the complication rate and the mortality rate of PCNL are significantly lower than with open surgery. The complication rate including all degrees is up to 30% according to Clavien- Dindo.

(Seitz 2018)

Among the complications are:

• Bleeding (transfusion is required for about 7%)
• Fever (occurs at 10.8 %)
• Urine leakage (at 0,2 %)
• Obstructions due to residual fragments
• Sepsis (at 0,5 %)
• Organ injury (at 0.4 %)

(Seitz 2018)

• Letality < 1 % (Herold 2020)

The success rate is on average 90% (Herold 2020). The stone clearance rate after one month is 76 % (Kuhlmann 2015).

Contraindications:

• untreated urinary tract infection
• uncontrollable coagulation disorders
• (Kuhlmann 2015)
• ongoing use of anticoagulants or antiplatelet agents (Seitz 2018)
• renal anomalies (Hautmann 2014)
• non-functioning kidney (Häcker 2019)
• Pregnancy
• atypical colonic interposition (Seitz 2018)

Implementation:

• Perioperatively, initiation of antibiotic prophylaxis is required. Some authors consider a 1 - 2 day treatment sufficient, while others recommend a one-week treatment at least for large stones (Seitz 2018).
• Dosage recommendation: e.g. cefuroxime 500 mg / d (Seyrek 2012).
• The procedure can be performed under regional anesthesia or general anesthesia.
• In supine, abdominal or modified lithotomy position, the renal pelvis is first filled retrogradely via a transurethral catheter. Under ultrasound guidance, a lumbar percutaneous catheter is used to puncture the renal calyx, which is the most accessible site for the calculi.
• After bougienage of the puncture channel, the nephroscope is advanced into the renal pelvis. Extraction of the calculi is performed using forceps or percutaneous baskets. Large stones are crushed beforehand using ultrasound or laser technology.
• A postoperative urinary diversion in the form of a percutaneous nephrostomy should be inserted if:
• Presence of residual stones
• infectious stones
• intended 2nd look
• perforation of the renal pelvis
• significant intraoperative bleeding
• Multitract PNL (multiple punctures)
• Urine extravasation
• Single kidney
• known ureteral stricture (Seitz 2018 / Kuhlmann 2015)

1. Guven S et al (2012) Percutaneous nephrolithotomy in children in different age groups: data from the Clinical Research Office of the Endourological Society (CROES) Percutaneous Nephrolithotomy Global Stud. BJU International 148 - 156
2. Hautmann R et al (2014) Urology Springer Verlag: S 275 - 276
3. Häcker A et al (2019) Percutaneous nephrolitholapraxis Current Urol 50: 203 - 212
4. Herold G et al (2020) Internal medicine. Herold Publisher S 659
5. Kuhlmann U et al (2015) Nephrology: Pathophysiology - Clinic - Kidney replacement procedure. Thieme Publishing House S 587
6. Seitz C et al (2018) S2k guideline for the diagnosis, therapy and metaphylaxis of urolithiasis. (AWMF register number 043 - 025) 58 - 66
7. Seyrek M et al (2012) Perioperative Prophylaxis for Percutaneous Nephrolithotomy: Randomized Study Concerning the Drug and Dosage. Journal of Endourology 26: No.11