PCNL – Percutaneous Nephrolithotomy
PCNL is a keyhole procedure used to treat selected larger or more complex kidney stones by accessing the kidney directly through a small tract created through the back or side.
What is percutaneous nephrolithotomy?
Percutaneous nephrolithotomy, usually shortened to PCNL, is a procedure that creates a small access tract directly into the kidney through the skin.
A telescope called a nephroscope can then be passed into the kidney. Stones can be visualised, fragmented where necessary and removed through this tract.
Because PCNL provides direct access to the kidney, it is particularly useful when the amount, size or complexity of stone makes another treatment approach less suitable.
Which kidney stones may be suitable for PCNL?
The decision is based on the overall stone burden, location and anatomy rather than stone size alone.
Larger Kidney Stones
PCNL is an established treatment pathway for selected larger renal stones where direct access to the kidney provides an appropriate treatment approach.
Staghorn Stones
Stones that occupy a substantial part of the kidney collecting system often require a treatment strategy designed for a larger and more complex stone burden.
Multiple Kidney Stones
Several stones within different parts of the kidney can sometimes make direct percutaneous treatment appropriate.
Complex Kidney Anatomy
The position of the stones and anatomy of the kidney collecting system can influence which surgical approach is most appropriate.
Previous Stone Treatment
PCNL may sometimes be considered when significant stone remains after previous treatment or when another approach is unlikely to adequately address the stone burden.
Individual Treatment Planning
Stone density, infection, kidney function, medications, previous surgery and other medical factors are considered when planning PCNL.
How is PCNL performed?
The exact technique varies according to the kidney, stone burden and surgical plan, but the procedure generally involves four stages.
Access the Kidney
A carefully planned tract is created through the skin into the kidney collecting system.
Create the Working Tract
The access tract is prepared to allow a nephroscope and stone-removal instruments to pass safely into the kidney.
Treat the Stone
Stones can be removed directly or fragmented using appropriate endoscopic stone-treatment equipment before the fragments are extracted.
Ensure Drainage
A ureteric stent, nephrostomy tube or other temporary drainage may be used when appropriate following the procedure.
How are the stones removed?
Once the nephroscope is inside the kidney, the stone can be seen directly through the telescope.
Depending on its size and composition, a stone may be removed in pieces or fragmented first using endoscopic stone-treatment equipment. Fragments can then be removed through the percutaneous tract.
The aim of the procedure and whether a staged approach may be needed depend on the individual stone burden and surgical findings.
- Direct endoscopic access to the kidney
- Fragmentation of larger stones when required
- Removal of stone fragments through the access tract
- Assessment of the kidney collecting system
PCNL or ureteroscopy?
Both are endourological procedures, but they reach the kidney in different ways and are suited to different clinical situations.
Through the urinary tract
Ureteroscopy passes fine instruments through the urethra, bladder and ureter. Flexible instruments can then enter the kidney to treat selected renal stones.
It avoids creating a tract through the skin but may be less suitable for some larger or more complex stone burdens.
Learn About UreteroscopyDirectly through the back
PCNL creates a small tract through the skin directly into the kidney, allowing larger instruments to reach and remove renal stone material.
This approach is particularly relevant when treating selected larger or more complex renal stone burdens.
What is mini-PCNL?
PCNL can be performed using access tracts and instruments of different sizes. The term mini-PCNL is generally used for techniques that use smaller-diameter percutaneous instruments than conventional PCNL.
A smaller tract is not automatically the best choice for every stone. The appropriate technique depends on factors including stone burden, kidney anatomy, the planned method of stone removal and the individual clinical situation.
Will I have a nephrostomy tube or ureteric stent?
Temporary drainage after PCNL is individualised according to what was found and performed during surgery.
Nephrostomy Tube
A temporary tube may be left through the PCNL tract to drain the kidney externally after surgery in selected circumstances.
Ureteric Stent
A temporary internal stent may be placed between the kidney and bladder to maintain drainage where appropriate.
No External Tube
In selected uncomplicated cases, an external nephrostomy tube may not be required. The decision is made according to the operative findings and individual circumstances.
What is recovery like after PCNL?
PCNL generally requires a hospital admission. The length of stay and speed of recovery vary according to the complexity of the procedure, drainage required, stone burden and individual health factors.
Blood and urine tests, clinical observation and sometimes follow-up imaging may be used after surgery depending on the circumstances.
Blood in the Urine
Some blood in the urine can occur following surgery. Your treating team will monitor recovery and provide individual discharge advice.
Tubes & Drains
A urinary catheter, ureteric stent or nephrostomy tube may be present temporarily depending on the procedure.
Stone Assessment
Follow-up may include imaging, stone analysis and discussion of strategies aimed at reducing future stone recurrence.
What are the risks of PCNL?
PCNL is an established kidney stone procedure, but it is more invasive than ureteroscopy and carries potential surgical risks. The relevance of each risk depends on the stone, kidney anatomy and individual patient factors.
Can significant bleeding occur?
PCNL creates a tract through kidney tissue, so bleeding is an recognised risk. Most postoperative bleeding can be managed with observation and supportive treatment, but some patients may require transfusion or further intervention.
Rarely, ongoing bleeding may require a radiological procedure to identify and treat the responsible blood vessel.
Can more than one procedure be needed?
Yes. With a very large or complex stone burden, complete treatment in one operation may not always be appropriate or achievable. Further PCNL, ureteroscopy or another stone procedure may occasionally be required.
When should I seek urgent medical attention after PCNL?
Seek urgent medical assessment if you become significantly unwell after surgery, particularly with fever or chills, worsening severe pain, persistent vomiting, difficulty passing urine, significant ongoing bleeding or other concerning symptoms. Follow the specific discharge instructions provided by your treating team.
How is PCNL planned?
Planning usually includes review of imaging to understand the size, location and distribution of the stones as well as the surrounding anatomy.
Urine testing is important before stone surgery because urinary infection can affect the timing and approach to treatment.
- CT imaging and stone burden
- Kidney anatomy and access planning
- Urine testing or urine culture
- Kidney function
- Blood tests where appropriate
- Current medications
- Blood-thinning medications
- Previous stone procedures
Removing the stone is only part of stone care
Patients with recurrent, multiple or higher-risk kidney stones may benefit from investigation into why stones are forming. Assessment can include stone analysis, blood tests and specialised urine testing such as a 24-hour urine collection.
Prevention strategies should be individualised according to stone type, urine chemistry, medical history and other relevant risk factors.
Explore Stone PreventionExplore other kidney stone pathways
Kidney Stones
Understand kidney stone symptoms, diagnosis, observation and the main treatment options.
Ureteroscopy & Laser Surgery
Learn about endoscopic treatment of selected ureteric and kidney stones through the natural urinary tract.
Large & Complex Kidney Stones
Learn about assessment and treatment planning for larger, multiple or more complex renal stone burdens.
PCNL FAQs
What does PCNL stand for?
PCNL stands for percutaneous nephrolithotomy. “Percutaneous” means accessing the kidney through the skin, while “nephrolithotomy” refers to removing stones from the kidney.
How big does a kidney stone need to be for PCNL?
Stone size is important but is not the only consideration. PCNL is particularly relevant for larger renal stones, while stone location, total stone burden, kidney anatomy, infection, previous treatment and individual circumstances are also considered when choosing a procedure.
Is PCNL open surgery?
No. PCNL is a keyhole or percutaneous procedure. A small tract is created through the skin directly into the kidney rather than using a conventional open surgical incision.
Is PCNL the same as a nephrostomy?
No. PCNL is a procedure performed to treat kidney stones. A nephrostomy is a drainage tube placed directly into the kidney. A nephrostomy tube may sometimes be left temporarily following PCNL, but the two terms do not mean the same thing.
Is PCNL better than ureteroscopy?
Neither procedure is universally better. They use different routes to reach the kidney and are suited to different stones and clinical situations. Larger or more complex renal stone burdens may favour PCNL, while ureteroscopy can be appropriate for many other kidney and ureteric stones.
What is mini-PCNL?
Mini-PCNL refers to percutaneous stone surgery using smaller access tracts and instruments than conventional PCNL. Whether a smaller tract is appropriate depends on the stone burden, anatomy and planned procedure.
Will I have a nephrostomy tube after PCNL?
Not necessarily. A nephrostomy tube may be used after PCNL when temporary external drainage or access is considered helpful. In selected cases it may not be required.
Will I need a ureteric stent?
A ureteric stent may be used after PCNL to provide temporary internal drainage between the kidney and bladder. Whether one is required depends on the individual operation.
Can all of my kidney stones be removed in one PCNL?
Not always. The ability to treat the entire stone burden in one procedure depends on stone size and distribution, anatomy, access, bleeding, visibility and other operative factors. Some complex stone burdens require staged treatment.
Is bleeding normal after PCNL?
Some blood in the urine can occur following PCNL. Significant or persistent bleeding is less common but can require further assessment or treatment. Follow the discharge instructions from your treating team and seek urgent review for concerning bleeding or deterioration.
Can kidney stones return after PCNL?
Yes. PCNL treats the existing stone burden but does not necessarily remove the underlying tendency to form stones. Further investigation and prevention strategies may therefore be appropriate for selected patients.
What should I bring to a PCNL consultation?
If available, bring your CT images and reports, previous stone imaging, urine and blood test results, information about previous stone procedures, your medication list and previous stone-analysis or 24-hour urine results.
Have you been diagnosed with a large or complex kidney stone?
Existing CT imaging can be reviewed to assess the stone burden, kidney anatomy and available treatment pathways, including whether PCNL, ureteroscopy or another approach may be appropriate.
This information is general educational information and does not replace individual medical advice. The appropriate investigation and treatment of kidney stones depends on factors including stone size and location, total stone burden, symptoms, obstruction, infection, kidney function, urinary anatomy, previous treatment, medications and individual clinical circumstances.