Kidney Stone Treatment
Kidney stones are a very painful fact of life for many people. It is estimated one in every 10 people will have a kidney stone at one point in their lives. And to the dismay of many, once you have had one kidney stone your chance of having another increases over time.
University of Maryland Baltimore Washington Medical Center (UM BWMC) offers a wide variety of Percutaneous Nephrolithotomy (PCNL) surgeries, an innovative, minimally invasive surgical treatment for large, complex kidney stones (usually stones greater than 2 cm in diameter) that cannot be passed through the urinary tract or that may be difficult to treat with other common kidney stone therapies such as shock wave lithotripsy (SWL) or ureteroscopy (URS). Percutaneous refers to a surgical technique performed via a very small incision through the skin, rather than an open, more invasive procedure.
UM BWMC specializes in Tubeless PCNL – a groundbreaking surgical technique that provides additional benefits to PCNL patients including no pre or post-surgical external drainage tube, a quicker recovery and less discomfort. Selected patients may also be candidates for Totally Tubeless PCNL. This refers to no post-surgical drainage tubes what so ever (either external or internal).
Outpatient PCNL surgery is also routinely performed at UM BWMC—one of only a few hospitals in the United States offering this procedure with same day discharge.
One of our newest advances is Mini-PCNL surgery where an even smaller incision and tract are used to enter the kidney. Again offering appropriate patients speedier recovery and decreasing the need for post-surgical drainage. Nearly all patients undergoing Mini-PCNL surgery go home the same day with no external drainage tubes.
How PCNL surgery is usually performed elsewhere
Most urologist require the assistance of an interventional radiologist prior to your surgery. The interventional radiologist uses X-ray imaging called fluoroscopy to help guide the precise placement of the renal access tube (nephrostomy tube) into the kidney. This tube is placed through your back and into your kidney near the stone. This procedure is usually done one to two days before the PCNL surgery. The tube is utilized by your surgeon to gain access into the kidney to remove the stone. However, at UM BWMC our urologists are specially trained to perform this step on the same day as your surgery. Thus eliminating the need for an external drainage tube and streamlining your procedure into a one-step surgery.
A review of the steps involved in PCNL Surgery
• On the day of your PCNL procedure, your surgeon utilizes special imaging to map out the internal drainage system of the kidney. A needle is then placed precisely into the kidney where the stones are located. This is called gaining renal access.
• Through the renal access, a thin wire is passed into the kidney and a balloon is used to dilate a tract.
• A tube is placed over the balloon and a scope is inserted into the tract to look into the kidney.
• Special instrumentation is placed through the tube to break up the stone(s) into tiny pieces that can be removed or passed through the urinary system. The goal is to clear all stones and fragments from the kidney.
• Once the stones are removed, it is not uncommon to have a ureteral stent placed to allow the kidney to internally drain better while it heals from the procedure.
• In rare cases, an external drainage tube called a nephrostomy tube will remain in the kidney following surgery for drainage of infected urine or to allow the kidney more time to heal. Timing of the tube removal is at your surgeon’s discretion. Typically the tube is removed within about three days following surgery.
• Stones will be sent for analysis to aid in developing a program to prevent further stone formation.
What is a nephrostomy tube?
A nephrostomy tube is a catheter that is placed in your kidney and attaches to a drainage bag that collects urine outside of your body. The tube is sometimes removed before discharge from the hospital. However, some PCNL patients may go home with the external drainage tube still in place to give the kidney more time to heal. If this is the case, the nephrostomy tube is removed in your surgeon’s office at a later time.
Advantages of PCNL
• High post-procedure success rates with most patients achieving 100% stone free status
• The most accurate localization of the kidney stone(s) and the best potential for complete removal of the stone(s).
• Less post-operative pain as compared to open surgery.
• Fewer complications as compared to open surgery due to the small incision and minimally invasive access to the kidney.
• Quicker return to activities of daily living and work compared to open surgery.
• In some cases, a quicker return to daily activities as compared to less invasive kidney stone treatments such as SWL or ureteroscopy (due to the fact that in most scenarios the stones can be completely cleared in one procedure).
• Better stone-free rates post-procedure for larger and more complex stones as compared to less invasive options (SWL and ureteroscopy).
Tubeless PCNL – A new standard of care for treating large kidney stones
The tubeless PCNL procedure is performed as a standard PCNL surgery; however, patients do not have a nephrostomy tube placed by an interventional radiologist prior to surgery as they do with standard PCNL. Your surgeon will create his own renal access tract during the surgery, eliminating the need for an interventional radiologist and two separate procedures. No drainage tube is the unique advantage in the tubeless PCNL procedure and our surgeons are among the most experienced in the nation in performing this advanced, minimally invasive technique.
How tubeless PCNL is performed
• PCNL is performed to remove the stone(s) from the kidney.
• In place of a nephrostomy (drainage) tube following extraction of the stone, the renal access tract leading from the outside of the body (the skin, or percutaneous) to the kidney is sealed using a specially designed plug. This plug is made from a gelatin sealant that then seals the access tract internally from your skin into the kidney.
• Most patients receive a urinary stent that dilates the urinary tract and maximizes the drainage of the kidney. This gives the kidney time to heal from the procedure and also allows small stone fragments to easily pass through the urinary system without causing a blockage. The stent is usually removed in your surgeon’s office in three to five days following your surgery.
What is a ureteral stent?
In place of an external drainage tube, most tubeless PCNL patients receive a ureteral stent, a small plastic tube placed in the urinary tract internally, which dilates the urinary tract and maximizes the drainage of the kidney. This gives the kidney time to heal from the procedure and also allows small stone fragments to easily pass through the urinary system without causing a blockage. The stent is usually removed in your surgeon’s office in three to five days following your tubeless PCNL surgery.
Advantages of tubeless PCNL
Tubeless PCNL offers patients a number of significant advantages including:
• Less post-operative pain than PCNL and open surgery to remove kidney stones.
• Minimal trauma to the kidney and surrounding tissue.
• No leakage of fluids from a nephrostomy tube thanks to the placement of the special plug, or seal, in the renal access tract in place of the tube.
• A quicker recovery and quicker return to daily activities compared to open surgery and even to traditional PCNL surgery.
• Shorter hospital length of stay and the potential for same day discharge outpatient surgery.
Mini-PCNL surgery is performed via an even smaller incision in the skin. A “standard” PCNL has about a one inch skin incision and tract (opening into the kidney); however, in a Mini-PCNL the incision and tract size are cut in half (1/4 inch). This allows for even less trauma to the kidney while still allowing for efficient and effective clearance of stones. Mini-PCNL is typically performed for complex stones ranging in size from 8 – 20 mm. Mini-PCNL surgery is designed to be performed tubeless (no nephrostomy tube) and may also be performed totally tubeless (no nephrostomy tube and no ureteral stent) in selected patients. All Mini-PCNL surgeries are planned as outpatient procedures.
Outpatient PCNL surgery
With the many advances in PCNL surgery (Tubeless, Mini-PCNL and Totally Tubeless) about half of the patients undergoing PCNL surgery at UM BWMC are discharged home on the same day as their procedure. UM BWMC is one of only a few hospitals in the United States and the world where outpatient same day discharge PCNL surgery is performed.
Preparing for your PCNL surgery
Your urologist will provide you with pre-surgical instructions to ensure you are ready for your surgery. Prior to your PCNL procedure, your urologist will have you to do the following:
• Schedule a visit with your primary care physician for a physical examination, blood work and possibly an EKG. Your surgeon’s office will provide a list of tests needed for surgical clearance.
• Do not eat or drink after midnight the night prior to your procedure unless otherwise instructed.
• You may need to stop aspirin or blood thinners depending on your physician’s instructions (never stop aspirin and blood thinners without discussing with your primary care physician).
• Please bring a list of your current medications to your surgery and arrive 120 minutes prior to your scheduled procedure.
• Arrange for a ride home. After surgery, you will need a family member or trusted friend to drive you home.
What to expect after PCNL surgery
Your surgeon may perform a CT scan to ensure that all fragments of the kidney stone have been removed. You may have a chest x-ray and laboratory blood tests performed at this time as well. Your doctor will review the results of your surgery with you prior to discharge.
• If your procedure is planned with an overnight stay, you will usually have a catheter in the bladder until the following day.
• You may see blood in the urine, which may last several days to weeks. This is common.
• You may have a ureteral stent placed during your procedure. The stent will stay in for several days to one week depending on your situation and your surgeon will remove it in the office.
• You will be given prescriptions that may include antibiotics (typically 24 hours), pain medications and stool softeners.
• Your surgeon will give you instructions for follow up.
• Most patients return to work and full activity within one to two weeks..
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