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Percutaneous Nephrolithotomy (PCNL): This is a procedure where renal calculi (kidney stones) that are too large
to pass independently are removed. This is done percutaneously (through the skin).
Indications: It is indicated when the stone is too large or less invasive means aren’t feasible. Recommended when
– Large kidney stones block more than one branch of the collecting system of the kidney- these are known as
Staghorn kidney stones (gold standard for removal of Staghorn kidney stones).
– Kidney stones that are larger than 2 centimeters (0.8 inches) in diameter.
– Large stones that are in the tube connecting the kidney to the bladder (ureter)
– When other therapies have failed.
Description: Prior to the procedure, an interventional radiologist will first insert a nephrostomy tube into the renal pelvis. The tube (sometimes a wire) guides the urologist to access the renal pelvis. The patient is then moved to the main OR, already intubated. After the patient is placed in a prone or lateral position, the urologist advances a nephroscope into the renal pelvis to visualize and remove stones. Occasionally the interventional radiologist will insert wires into the nephrostomy tube and remove the tube, leaving the wires in the renal pelvis. These wires will be used as a guide to enter the kidney with the scope. Fragmentation of the stones can be done with an ultrasonic probe or laser though the scope.
– The pathway tract is dilated, this allows the passage of larger instruments, and the urologist can suction out fragments or grab the stone/ particles as they are produced.
– Once complete, the nephrostomy tube is usually left in the flank to drain the kidney overnight or for several days.
– If the patient arrives from radiology with only wires, the urologist will insert a council tip foley catheter over the wire into the renal pelvis to act as a nephrostomy tube for drainage.
– This is often left in for 2 to 3 days.
– A ureteral stent is also placed in the ureter to drain urine from the kidney while its healing.
Surgical time: 1-4 hours, depending on the size of the stone and the familiarity of the urologist. Position: Usually prone, but sometimes lateral
EBL: 500mL
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Patient History and Anesthetic Management
Case Concerns and Anesthetic Management
1 Prone Position
● Nerve Injury Considerations- Brachial plexus injury, radial nerve injury, ulnar nerve injury, neck injury.
● Upper: Do not abduct arms more than 90 degrees, secure arms from falling off the table, support the head and
maintain neutral alignment. Place sufficient padding around the elbow, ensure adequate padding between arm
or ensure its not pressing against a pole. Forearm supports/pads should be used to prevent compression of the
ulnar nerve in the cubital tunnel. Pre-op evaluation to check patients’ cervical ROM.
● Lower: Utilize supportive pads and frames to reduce tension in the axilla and the abdomen (prone).
● Physiological changes
– Prone: Careful positioning to avoid pressure on abdomen, high intra-abdominal pressure can cause IVC
compression, reduced venous return, and reduced CO. Increase in transdiaphragmatic pressure leads to a reduction in thoracic compliance. FRC increases, changes in diaphragmatic excursion and improved V/Q matching significantly improve oxygenation in prone. This position may result in facial and airway edema, particularly in prolonged cases. Head below the level of the heart may lead to venous congestion and subsequent optic neuropathy. It is important that a foam or padded headrest be used in procedures done in prone position. The patients’ eyes must be in the opening of the headrest and checked periodically throughout the case.
– Prone position checklist: Eyes/ears, taped closed/padded eyes, all extremities, penis/breast in the clear- move breasts inward medially, clear catheter tubing, Chest rolls in good position, below the clavicle and below the inguinal space, clavicle/mandible checks, check eyes and nose for no pressure every 15 minutes- document.
2 Hypothermia
● Patient may need forced-air warming (Bair hugger), blankets, fluid warming, temperature probe.
● Goal is to keep the patient above 36 Celsius
● Consequences of hypothermia include increased intraoperative blood loss, increased chance of surgical
wound infection, increased length of hospital stay, decreased patient comfort and increased rate of cardiac complications.
3 Hypotension
– Maintain the patients MAP within 20% of the baseline MAP in pre-op.
– Potential need for arterial line placement if pre-existing cardiopulmonary disease is present, otherwise
noninvasive blood pressure will suffice.
– Replace blood loss with crystalloids (3:1) ratio
– Utilize Phenylephrine 20-100mcg IV Push, or 40-60mcg/min infusion then 100-180 mcg/min
4 Intraoperative Injuries/Hemorrhage
– Surgeon may inject epinephrine or vasopressin to decrease bleeding- hypertension and brady or
tachydysrhythmias may occur
– Consider having PRBC on hold, particularly in patients with anticipated blood loss or comorbidities.
– Replace blood loss with 1:1 ratio, albumin 1:1 ratio, crystalloids 3:1
– Activate massive transfusion protocol if needed for severe hemorrhage.
– There is a possibility of large blood loss for this case, it may be a good idea to get CBC before the
case and type and cross.
5 Wound Infection
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6 TUR ●
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A potential complication following this procedure, the incidence is low (5%).
Gentamycin 80 mg IV given preoperatively.
Ensure preoperative skin prep is completed with chlorhexidine or an iodine solution to minimize the bacterial loads on the skin.
Syndrome
Intravascular volume overload that can result in hyponatremia and hypotonicity
Large volumes of irrigation are used to cool ultrasound probe and wash away debris, potentially leading to this complication.
Signs and symptoms include circulation abnormalities such as hypertension (or hypotension), bradycardia, arrhythmia, apnea, seizure, and heart failure.
Treatment includes of general life support and in specific, treatment directed towards hypotension, hyponatremia, and anuria. Loop diuretics can be used to eliminate fluid excess, hypertonic solution can be used to treat severe hyponatremia if the diuretics don’t work.
