Endourology is the branch of urology that deals with the closed manipulation of the urinary tract. It has lately grown to include all urologic minimally invasive surgical procedures. As opposed to open surgery, endourology is performed using small cameras and instruments inserted into the urinary tract. Transurethral surgery has been the cornerstone of endourology. Most of the urinary tract can be reached via the urethra, enabling prostate surgery, surgery of tumors of the urothelium, stone surgery, and simple urethral and ureteral procedures. Recently, the addition of laparoscopy and robotics has further subdivided this branch of urology.

PCNL is a well-established procedure by which stones in the kidney or the upper ureter are removed by making a small incision in the flank. Generally, an incision, that is 1 cm or less than 1 cm, is made in the flank. A guide wire is passed through this incision into the kidney. This is performed under fluoroscopy or x-ray control.

A passage is then created around this guide wire by dilatation. Through this passage, a nephroscope is passed into the kidney to visualise the stone and remove it. Larger stones can be fragmented by different methods and removed. Stones are therefore cleared easily. Once the procedure is complete, a tube is left through this tract as drainage for one or two days.

The main advantage of this approach is that, unlike traditional open surgery, only a 1 cm incision is made in the flank. The stones can be visualised directly and removed. Unlike ESWL or ureteroscopy, the stones are removed in the same sitting and the kidney is cleared of calculi. The stay in the hospital is only for 3-4 days.

This surgery would be recommended as a treatment of choice, if the patient has kidney stones larger than 2 cm, upper ureteric stones bigger than 1 cm, or at times for stones found in the lower pole of the kidney that cannot be effectively treated with either ureteroscopy or ESWL. This procedure is also performed following failure of other modalities of treatment such as medical therapy, ESWL, etc., for renal and upper ureteric stones.

This procedure is commonly performed under general anaesthesia, and therefore you also need to be admitted to the hospital for this procedure. In special circumstances, it can be performed under intravenous sedation, regional anaesthesia or local anaesthesia.

The success rate of clearance of stones with this procedure ranges between 90 to 95%. This actually depends upon the size, number and location of these stones. Sometimes, complete clearance may require a second procedure after a few days.

For the post-operative course, the patient will generally need to stay in the hospital for 2 to 3 days after the procedure. He or she will also undergo additional x-rays or ultrasound studies, to determine if there are any residual stone fragments present. A large amount of residue will require the urologist to look again with a nephroscope to remove it. The other alternative is to treat the remaining fragments with ESWL. From the site of the puncture, the patient will have a drainage tube and a urethral catheter, for a day or two. Following the removal of the flank drainage tube, urine may leak for a day. Post-operatively, the urologist will also encourage a high fluid intake to keep the daily volume of urine produced to more than 2 litres a day.

By and large, this procedure is safe. Some risks that can be associated with all surgical procedures are the possibilities of bleeding (1%) and infection, sometimes requiring blood transfusion.

Some patients have prolonged leakage of urine from the flank site, requiring ureteric stenting. Fever, if present, will require a change in antibiotic.

Rare complications include persistent uncontrolled bleeding due to arteriovenous malformations or pseudo-aneurysms (0.4%), which would need secondary procedures or even a nephrectomy to control the same. When a supracostal puncture (above the 12th rib) is made, complications would then include pneumothorax (commonly called collapsed lung caused due to the accumulation of air or gas in the space surrounding the lungs) or fluid accumulation in the thorax. Again, the incidence of these is only 0-4%.
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