Operative note 19 Advanced
PCNL
What it does: stone out through a back track, 1 cm.
- Culture urine. Treat infection 24-48 h before.
- Lithotomy. Cystoscope (17-22 Fr or flexible). 0.035 wire up. Ureteric catheter over it: 5-6 Fr open-ended, or 7 Fr occlusion balloon inflated at the PUJ. Tape it to a 14-16 Fr Foley.
- Contrast 30-50% (stone stays visible) +/- air +/- methylene blue. Air floats to the POSTERIOR calyces when prone.
- Prone. Pad all points. Drape with a pouch.
- Plan the track: straight line into the stone calyx. Below the 12th rib if you can. Pleura sits above. Do not hug under the rib. Colon lateral.
- Vessels: go posterolateral, end-on to a posterior calyx, through the papilla. Never medial. Never into the pelvis direct.
- 18G needle, 15-20 cm (or 21/22G Chiba first). Bull's-eye: hub and tip one dot. Triangulate: 0 then 20-30 degrees for depth. US option: 3.5-5 MHz, Doppler. Feel 2 gives: fascia, capsule.
- Stylet out. Urine / contrast / blue at the hub = in. Nothing dilated before this.
- Hydrophilic angled wire in. Kumpe or Cobra steers it to the pelvis and down the ureter. Occlusion balloon up at the PUJ: past the stone into a distant calyx instead. Exchange: super-stiff WORKING wire.
- 8/10 coaxial: SAFETY wire in alongside. 10 outer off. Clip the safety wire to the drape. Both wires down the ureter. Occlusion balloon up: both coiled in the kidney (pelvis or a distant calyx), never down the ureter.
- 1-1.5 cm cut (No. 11) along the wire. Open the fascia.
- 8 Fr guide. Amplatz 10 -> 30 Fr in 2s, twist-push along the wire, each to the calyx on screening, same depth mark. Alternatives: Alken metal (scarred), balloon 30 Fr (watch the waist go), one-shot 24-30 Fr, mini 16.5-22 Fr.
- Sheath (30 Fr) over the last dilator into the calyx. Dilator and guide out. Sheath + 2 wires.
- Rigid nephroscope 24-26 Fr, saline, low pressure: outflow round the scope. In line with the tract. Never lever.
- Litho: ultrasonic (soft, sucks), ballistic (hard, pushes), laser 365-550 micron. Out of line with the tract: flexible nephroscope 15-16 Fr, never lever the rigid one. Scope out: small fragments wash out. Tri-radiate grasper or basket, one piece at a time. Too big for the sheath? It jams at the mouth: release, break it again.
- Clear? Rigid then flexible, every calyx. Screen in 2 planes. One fragment out is not stone-free.
- Drain (main path): Malecot 16-22 Fr over the safety wire, flared in the pelvis. Sheath out over the tube; the tract closes round it. Occlusion balloon down, wires out. Nephrostogram through the tube: down the ureter, no leak. Stitch. Bag. Other exits: pigtail 8-10, Council-tip, re-entry Malecot, or tubeless (antegrade JJ 6-7 Fr / ureteric catheter overnight).
- Bleeding: venous = sheath back in, pause, clamp tube or Kaye balloon. Arterial (pulsatile) = stop, big tube, angioembolisation.
- 2026 update: Mini tracts (mini, ultra-mini, micro) bleed less. Same stone-free rate. Now mainstream.
- 2026 update: Supine PCNL and ECIRS (supine + scope from below at the same time) match prone results. Better ergonomics.
- Watch: Sizes and settings in this note are the owner's typical values.
From the UroRef Operative Quick Guide.