(I) Concept
Percutaneous nephrolithotomy is to create a channel from the skin to the kidney at the waist, through which the nephrolithoscope is inserted into the kidney and the kidney stones are broken and removed using laser, ultrasound and other lithotripsy tools. This is called “perforation and extraction”. Percutaneous nephrolithotomy is a modern, minimally invasive technique for kidney stone treatment, and has basically eliminated open surgery for stone extraction.
(B) Indications for percutaneous nephrolithotomy
1.Kidney stone is suitable for diameter larger than 2cm;
2.Complex kidney stones: including cast stones, antler-shaped stones, multiple stones, residual stones, cystine and uric acid stones with poor results of extracorporeal shock wave lithotripsy, renal calyx diverticulum, combined stenosis of the junction, horseshoe kidney, transplanted kidney stones;
3.Ureteral stones: stones larger than 1.5 cm in the upper segment and located above the fourth lumbar vertebra;
4.Extracorporeal shock wave lithotripsy (ESWL) is ineffective, encapsulated stones;
5. Non-stone field: stricture and tumor of upper urinary tract.
(C) Contraindications to percutaneous nephrolithotomy
1. Absolute contraindications.
(1) Those with uncorrected bleeding disorders;
(2) Those who cannot tolerate the procedure;
③Stone combined with ipsilateral renal tumor, non-functioning kidney, pregnancy.
2. Relative contraindications.
① extreme obesity, resulting in difficulties in establishing the skin-kidney channel;
②Patients with severe kyphosis who cannot lie prone;
③ Malformation of liver, spleen and colon;
(iv) Uncontrolled urinary tract infection.
(D) Prevention and management of complications of percutaneous nephrolithoscopy
1.The main complications include.
①Intraoperative and postoperative bleeding, which can lead to kidney loss in the most severe cases.
②Infection, which can lead to life-threatening if infectious shock occurs.
③Injury to adjacent organs including pleura, lung, colon, liver, spleen, etc. For injuries to the pleura and lung, if the injury is mild, you can wait for the blood circulatory system to absorb itself or leave closed drainage in place. Injuries to the colon, liver, and spleen are less common, and when they do occur, they are treated differently depending on the actual situation, or even open surgery is performed to repair and stop the bleeding. It is important to note that if bilateral percutaneous nephrolithotomy is performed, postoperative dyspnea may not necessarily be caused by pleural or pulmonary injury, but may be due to perirenal exudate that irritates the diaphragm bilaterally, causing a symptom. A chest radiograph can be a good differentiator.
Perforation and injury of the renal collecting system is also a common complication that occurs during percutaneous renal dilatation and lithotripsy. If the perforation and injury are not serious, percutaneous nephrolithotomy can be continued. When the perforation is large and the exudate is large, the procedure must be terminated, a nephrostomy tube and D-J tube must be placed, and the procedure and treatment of the lesion must be performed again in phase II.
⑤ For residual stones, secondary primary access lithotripsy, soft ureter for lithotripsy and stone extraction, or extracorporeal shock wave lithotripsy with some appropriate adjuvant therapy can be performed.