Percutaneous Nephrolithotomy

Percutaneous nephrolithotomy

Preoperative tips


  1. Intubate, flip patient prone
  2. Pad chest/abdomen/hips
  3. Arms towards head but elbows/shoulders flexed
  4. Legs abducted, knees/feet padded
  5. Drape with window all the way to midline for total renal access
  6. Second drape with access to urethra
  7. Give culture-specific antibiotic coverage, otherwise use ampicillin + cefepime

Retrograde access

  1. Pass flexible cystoscope into urethra
  2. Identify ureteral orifice, pass bentson exchange wire up to kidney
  3. Pass occlusion balloon over wire
  4. Inflated balloon with 1mL contrast and position at UPJ, lock balloon
  5. Pass catheter (council) over occlusion balloon into bladder, inflate

Choose a calyx

  1. Using occlusion balloon access, fill collecting system with air then contrast
  2. Identify appropriate calyx and position hemostat on skin in appropriate line
  3. Make small skin incision with scalpel and place hemostat tip below skin

Renal access option #1

  1. Use spinal needle to access calyx via fluoroscopy or ultrasound, check in A/P and oblique
  2. Once needle in calyx, look for urine drip, draw back for air/urine
  3. Pass stiff angle glide through needle, attempt to pass down UPJ or coil in upper pole, use kumpe catheter if needed for better access
  4. Use double access catheter to pass down super stiff wire, can exchange glide for bentson or other stiffer wire

Renal Access option #2

  1. Use 22G Chiba needle to access calyx via fluoroscopy, check in A/P and oblique
  2. Once needle in calyx, look for urine drip, draw back for air/urine
  3. Pass 0.018in platinum-tipped guidewire through needle, attempt to pass down UPJ or coil in upper pole, then exchange Chiba for Jeffrey introducer set
  4. Use 0.035in angled Terumo guidewire and pass 5Fr Kumpe catheter over wire, exchange for super stiff wire, and place J-wire as well (two wire access)

Sheath placement

  1. Incise skin to allow for balloon passage
  2. Pass balloon dilator over wire, position mark just inside calyx and inflate to 20mmHg
  3. Pass sheath over balloon, remove balloon, cut sheath for access, secure wires

Removing Stones

  1. Pass rigid nephroscope into kidney with cyber wand
  2. Fragment stones with cyber wand (right pedal)
  3. Visualize just the tip of cyber wand, do not push into stone (can backwall), break down bits and bits
  4. Replace with flexible nephroscope, basket stones as needed in different calyces
  5. Once all stones removed, enter each calyx and inject contrast, take picture to confirm all calyces clear of stone, assess antegrade drainage at UPJ

Nephrostomy tube

  1. Confirm wire passes all the way to bladder
  2. Place 5Fr angiocath all the way to bladder, confirm with fluoro
  3. Place council over angiocath into renal pelvis, inflate balloon with 3mL, confirm with fluoro at each step
  4. Place sidearm fitting to secure angiocath and allow drainage
  5. Remove sheath, suture catheter to skin with 2-0 silks x2
  6. Once drainage confirmed and drapes removed, place gauze, abd, and tape, with PCN exiting laterally


  1. CT without contrast to assess for residual stone burden
  2. If residual stones, obtain XR antegrade to assess for drainage down ureter and renal anatomy for subsequent surgery
  3. If no residual stones, obtain contrast-enhanced US to assess for antegrade drainage
  4. If stone free and antegrade drainage, can remove tubes and discharge
  5. If residual stones, second look PCNL vs URS in future
  6. If not draining, usually watch and repeat the following day


  1. Once superstiff wire placed, place 12Fr dilator over wire (avoid kinking wire during passage)
  2. Exchange 12Fr for 17Fr dilator, taking care not to kink wire
  3. Place metal sheath over dilator, use fluoroscopy to confirm sheath is level with tapering tip

  1. Use miniPCNL scope to laser stone, removing scope through sheath vacuums stones out
  2. Place stent over wire, confirm location under fluoroscopy
  3. Once done, inject floseal into tract and use pusher to place floseal into tract