PCNL – Percutaneous Nephrolithotomy
PCNL is a keyhole operation used for selected larger, staghorn and complex kidney stones, providing direct access into the kidney through a small tract created through the back or side.
An infected and obstructed urinary system can require emergency drainage. Do not wait for a routine appointment if you are acutely unwell, have fever or chills with suspected urinary obstruction, or are otherwise deteriorating.
What is percutaneous nephrolithotomy?
Percutaneous nephrolithotomy — usually shortened to PCNL — creates a direct working route into the kidney so a substantial renal stone burden can be visualised, fragmented and removed.
During PCNL, a small tract is created through the skin and kidney into the collecting system. A telescope called a nephroscope can then be passed into the kidney.
Stones can be removed directly where possible or fragmented with endoscopic stone-treatment equipment before the pieces are extracted through the access tract.
This direct route can be particularly useful when the amount, distribution or complexity of stone makes another treatment approach less suitable.
Larger renal stones often shift treatment toward PCNL
When active treatment is required for a renal stone burden above approximately 20 mm, PCNL is commonly an important first-line treatment pathway. Size is important, but stone distribution, kidney anatomy, infection, medications and individual circumstances also influence treatment.
Which kidney stones may be suitable for PCNL?
The decision is based on total stone burden, distribution and anatomy rather than using stone diameter alone.
Larger Kidney Stones
Increasing renal stone burden can make direct percutaneous access more efficient than attempting to treat a substantial amount of stone solely through the ureter.
Large & complex stonesStaghorn Stones
Branching stones can extend through several parts of the collecting system and often require treatment designed for a substantial and complex renal stone burden.
Explore staghorn stonesMultiple Kidney Stones
Several stones within different parts of the kidney can collectively represent a large stone burden even when no individual stone appears exceptionally large.
Complex Stone Distribution
Stone position within different renal calyces can influence whether direct access to the kidney provides the most appropriate route for treatment.
Residual Stone
Significant stone remaining after previous ureteroscopy, lithotripsy or stone surgery may justify reconsidering the overall treatment strategy.
Residual kidney stonesIndividual Clinical Factors
Infection, kidney function, medications, bleeding risk, previous procedures, anatomy and general health all form part of PCNL treatment planning.
How is PCNL performed?
The exact operation is adapted to the individual kidney and stone burden. Broadly, PCNL involves establishing access, treating the stone and ensuring appropriate urinary drainage afterwards.
Review the access route
Imaging is reviewed to understand the stone burden, collecting-system anatomy and structures surrounding the kidney.
Access the kidney
A carefully selected tract is created through the skin into the renal collecting system.
Establish the working tract
The access tract is prepared so a nephroscope and appropriate stone-removal instruments can enter the kidney.
Treat the stone
Stone can be removed directly or fragmented using appropriate endoscopic equipment before fragments are extracted through the tract.
Reassess the collecting system
Accessible areas of the kidney can be reassessed and residual stone treated where appropriate.
Ensure drainage
A ureteric stent, nephrostomy tube or other temporary drainage may be used according to the operative findings.
PCNL, ureteroscopy or shock-wave treatment?
The best procedure depends on the stone rather than using the same treatment for every patient. Stone size, location, density, total burden, kidney anatomy and patient factors all matter.
Ureteroscopy & Laser
Fine instruments are passed through the urethra, bladder and ureter to reach the stone.
- No tract through the back
- Useful for many kidney stones
- Common treatment for ureteric stones
- Larger burdens may require staged treatment
PCNL
A working tract is created through the back or side directly into the kidney.
- Designed for substantial renal stone burden
- Important for many stones above 20 mm
- Main pathway for many staghorn stones
- Allows stone material to be extracted
Shock-Wave Lithotripsy
Externally generated shock waves can fragment appropriately selected kidney stones.
- No endoscopic tract into the kidney
- Stone location influences suitability
- Stone density can influence outcomes
- Less suited to many large complex burdens
The CT scan matters before PCNL
Planning a complex kidney stone operation is three-dimensional. The largest diameter alone does not fully describe the stone.
CT imaging can demonstrate how stone is distributed through the kidney, whether there is obstruction, relevant kidney anatomy and structures surrounding a proposed access route.
Stone density can also provide useful information when comparing different kidney stone treatment options.
- Total stone burden
- Stone distribution
- Stone density
- Kidney anatomy
- Urinary obstruction
- Surrounding structures
- Previous procedures
- Access planning
Mini-PCNL broadly describes percutaneous kidney stone surgery using smaller-diameter access tracts and instruments than conventional PCNL.
Smaller access does not automatically mean better treatment
PCNL can be performed using different tract sizes, instruments, patient positions and fragmentation techniques.
Smaller-access techniques can be useful in appropriately selected situations, but the efficiency with which a substantial amount of stone can be removed also matters.
The relevant question is therefore not simply whether conventional or mini-PCNL sounds less invasive. The technique should provide an appropriate balance between access, stone clearance, procedural efficiency and risk for the particular kidney being treated.
Will I have a nephrostomy tube or ureteric stent?
Drainage after PCNL is individualised. The procedure performed, bleeding, urinary drainage, residual stone and operative findings can influence what is required.
Nephrostomy Tube
A temporary tube can be left through the PCNL tract to drain urine externally from the kidney in selected circumstances.
Ureteric Stent
A temporary internal stent may be placed between the kidney and bladder when internal drainage is considered helpful.
No External Tube
In selected uncomplicated procedures an external nephrostomy tube may not be required. Suitability depends on the operative findings.
What is recovery like after PCNL?
PCNL generally involves hospital observation after surgery. Recovery varies according to stone burden, procedure complexity, drainage, bleeding, infection risk and individual health.
A urinary catheter, ureteric stent or nephrostomy tube may be present depending on what was required during surgery.
Some blood in the urine and discomfort around the access site can occur. Your treating team monitors clinical recovery.
Timing varies. More extensive surgery or ongoing drainage can require longer observation.
Follow-up may include imaging, stone analysis and consideration of future stone prevention.
What are the risks of PCNL?
PCNL is an established minimally invasive kidney stone operation, but it is generally more invasive than flexible ureteroscopy. The relevance of individual risks varies according to stone burden, anatomy, infection and patient factors.
The access tract passes through kidney tissue, making bleeding a recognised procedural risk.
Significant bleeding can occasionally require transfusion or another intervention.
Infection is an important consideration, particularly with infected or colonised stone.
Complete clearance cannot be guaranteed, especially with extensive or branching stone.
Additional PCNL, ureteroscopy or another stone procedure can occasionally be required.
Temporary leakage can occur from the access tract or urinary collecting system.
Surrounding organs and structures are considered when planning percutaneous access.
General health and anaesthetic factors form part of individual surgical assessment.
What if the entire stone cannot be cleared in one operation?
Very large or branching stone burdens can occupy several parts of the renal collecting system. Treating every fragment during one operation is not always appropriate.
A treatment strategy can therefore involve staged PCNL, flexible ureteroscopy, combined endoscopic techniques or treatment targeted at clinically important residual stone.
The goal is not simply to perform the largest possible operation in one sitting, but to develop a treatment plan appropriate for the overall stone burden and individual clinical circumstances.
What is reviewed before surgery?
The objective is to understand both the stone and the patient before deciding how PCNL should be performed.
Imaging
CT and other available imaging can be reviewed for stone burden, distribution, kidney anatomy and access planning.
Urine Testing
Urine testing and, when appropriate, urine culture are important because infection can alter the timing and approach to stone surgery.
Kidney Function
Kidney function and the effect of any urinary obstruction form part of the overall clinical assessment.
Blood Tests
Appropriate blood testing can assess factors relevant to surgery, bleeding, infection and anaesthesia.
Medications
Current medications — particularly anticoagulant and antiplatelet medication — require individual peri-operative assessment.
Previous Stone Treatment
Previous ureteroscopy, PCNL, lithotripsy, ureteric stents or nephrostomy procedures can influence future treatment planning.
Removing the stone is only part of stone care
PCNL treats the stone burden that is present now. It does not necessarily remove the underlying tendency to form another kidney stone.
Patients with recurrent, multiple or higher-risk stones may benefit from stone analysis, blood testing and specialised urine assessment such as a 24-hour urine collection.
Related kidney stone information
Explore the pathway that best matches whether you are trying to understand your diagnosis, compare treatment options or plan management for a more complex stone.
Kidney Stones
Symptoms, investigation, imaging, observation and the major kidney stone treatment pathways.
Explore →Kidney Stone Treatment Options
Compare observation, shock-wave treatment, ureteroscopy and PCNL.
Compare →When Does a Stone Need Surgery?
Understand which features make active kidney stone treatment more likely to be considered.
Explore →Large & Complex Kidney Stones
Treatment planning for large, multiple, branching or anatomically complex renal stone burdens.
Explore →Staghorn Kidney Stones
Understand partial and complete staghorn stones and why PCNL is often central to their treatment.
Explore →Ureteroscopy & Laser
Endoscopic treatment through the natural urinary tract for selected kidney and ureteric stones.
Explore →Shock-Wave Lithotripsy
Understand how stone size, location and density influence suitability for shock-wave treatment.
Explore →Stone Density & HU
Understand what Hounsfield units can add to kidney stone treatment planning.
Explore →Residual Kidney Stones
Understand when remaining fragments can be monitored and when further treatment may be considered.
Explore →PCNL FAQs
What does PCNL stand for?
How large does a kidney stone need to be for PCNL?
Is PCNL open surgery?
Is PCNL better than ureteroscopy?
Is PCNL the same as a nephrostomy?
What is mini-PCNL?
Will I have a nephrostomy tube after PCNL?
Will I need a ureteric stent?
Can every stone be removed in one PCNL?
Can significant bleeding occur after PCNL?
Can kidney stones return after PCNL?
What should I bring to a PCNL consultation?
Have you been diagnosed with a large, staghorn or complex kidney stone?
Existing CT imaging can be reviewed to assess the total stone burden, kidney anatomy and available treatment pathways — including whether PCNL, flexible ureteroscopy, a combined approach or staged treatment may be appropriate.
Medical information disclaimer: This page provides general educational information and does not replace individual medical advice, diagnosis, informed consent or emergency assessment. The appropriate treatment for kidney stones depends on factors including stone size, total stone burden, stone location and distribution, kidney anatomy, urinary obstruction, infection, kidney function, previous treatment, medications, bleeding risk, general health and individual clinical circumstances. PCNL has potential risks including bleeding, infection, residual stone, need for further procedures, urine leakage and injury to surrounding structures. Individual outcomes cannot be guaranteed.