When kidney stones become too large or complex for less invasive treatment options, doctors may recommend percutaneous nephrolithotomy (PCNL). It is a minimally invasive surgical procedure that allows a surgeon to reach the kidney through a small incision in the back and remove stones using specialized instruments.

PCNL is commonly considered for kidney stones larger than 2 cm, multiple stones, branching stones and selected stones that are difficult to treat with other procedures. The most suitable treatment depends on stone size, location, anatomy, infection status and the patient's overall health. (European Association of Urology, NIDDK)

At Prabhakar Bhurke Clinic, Dr. Sandip Prabhakar Bhurke, super specialist nephrologist and transplant physician, provides kidney evaluation and medical management for patients with kidney stones and associated kidney-function concerns. When stone removal is required, assessment and treatment planning may involve coordination with an appropriately qualified urologist.

When Is PCNL Recommended?

PCNL is not necessary for every kidney stone. Small stones may pass naturally, while some stones can be managed with observation, shock wave lithotripsy or ureteroscopy.

A specialist may consider PCNL in situations such as:

• Large kidney stones: Particularly stones measuring more than 2 cm.

• Staghorn calculi: Branching stones that occupy a substantial part of the kidney's collecting system.

• Multiple renal stones: When removing several stones through other methods may be less suitable.

• Complex stone anatomy: When the stone's location makes alternative procedures less effective.

• Persistent stone burden: When previous treatment has not adequately cleared the stones.

• Selected cases of obstruction: When stone removal is needed to restore or protect urinary drainage.

The decision should be based on imaging and clinical assessment, not stone size alone.

How Does PCNL Remove a Kidney Stone?

PCNL provides direct access to the kidney rather than relying on stone fragments to pass through the urinary tract.

The procedure generally involves the following stages.

1. Preoperative Assessment

The treating team reviews imaging, medical history, kidney function, current medicines and any signs of urinary infection. Blood and urine tests help identify problems that may need attention before surgery.

2. Anaesthesia

PCNL is usually performed under general anaesthesia in a hospital setting.

3. Creating Access to the Kidney

The surgeon makes a small incision in the back and creates a controlled passage into the kidney's collecting system, using imaging guidance.

4. Locating and Breaking the Stone

A specialized viewing instrument called a nephroscope is passed through the access tract. Depending on the stone, instruments using laser, ultrasonic or other energy may break it into smaller pieces.

5. Removing Stone Fragments

The surgeon removes accessible fragments through the tract and checks the kidney for remaining stone material.

6. Providing Drainage When Needed

A temporary nephrostomy tube or ureteral stent may be placed to support urine drainage or provide access for further treatment. These are not required in every case.

The precise technique varies according to the stone's complexity and the surgeon's assessment. (Mayo Clinic)

What Size Kidney Stone Needs PCNL?

There is no single size cutoff that determines the procedure in every patient, but PCNL is commonly recommended as a first-line option for large renal stones, particularly those greater than 2 cm.

This table is a general guide. A CT scan, stone location, density, kidney anatomy and medical history can change the recommended approach. (EAU Guidelines on Urolithiasis)

PCNL Compared With Laser Treatment and ESWL

Several procedures can treat kidney stones, but they work differently.

PCNL: Reaches the kidney through a small incision in the back. It is often preferred for large or complex renal stones.

Ureteroscopy or RIRS with laser lithotripsy: Uses an instrument passed through the urinary tract to reach and fragment the stone. Some large stones can be treated this way, but staged procedures may be needed.

ESWL or shock wave lithotripsy: Uses externally generated shock waves to break selected stones into smaller pieces that pass through urine. It may be less suitable for some large, hard or anatomically difficult stones.

The best choice balances the likelihood of stone clearance, treatment risks, the need for repeat procedures and the patient's health.

What Tests Are Needed Before PCNL Surgery?

Before recommending PCNL, the treating team generally assesses the stone and checks whether the patient can safely undergo the procedure.

Imaging

A CT scan is often used to establish stone size, location, number and surrounding anatomy. Ultrasound or X-ray may also be useful in selected circumstances.

Blood Tests

Depending on the patient's condition, these may include:

• Serum creatinine and eGFR

• Complete blood count

• Electrolytes

• Blood-clotting tests when indicated

• Other tests based on medical history

Urine Testing

Urinalysis and urine culture may be recommended to identify infection.

An infected, obstructed urinary tract requires urgent medical attention. In such cases, the priority may be drainage using a ureteral stent or nephrostomy tube and appropriate infection treatment before definitive stone removal.

Medication and Medical History Review

The team reviews blood thinners, diabetes medicines, allergies and other prescriptions. Medicines should only be paused or adjusted according to the treating clinician's instructions.

Is PCNL a Major Operation?

PCNL is less invasive than traditional open kidney stone surgery, but it remains a surgical procedure that requires careful planning and monitoring.

It is performed in a hospital under anaesthesia, and some patients need an overnight stay or longer observation depending on their recovery and medical condition.

The length of the procedure, hospital stay and recovery varies with stone burden, bleeding risk, infection, kidney function and whether additional treatment is required.

What Are the Risks of PCNL?

PCNL can remove substantial stone material, but no procedure is entirely risk-free.

Possible complications include:

• Bleeding, sometimes requiring a transfusion or additional treatment

• Urinary tract infection or sepsis

• Injury to the kidney or nearby structures

• Urine leakage

• Residual stone fragments

• Temporary discomfort from a stent or drainage tube

• Need for a second procedure

• Anaesthesia-related complications

The individual risk depends on the patient's health, stone complexity and surgical circumstances. The treating surgeon should explain the relevant risks and expected benefits before consent. (Mayo Clinic)

Recovery After PCNL Surgery

Recovery is different for every patient. The care team will provide instructions based on the procedure and any drainage devices used.

During recovery, patients may experience mild discomfort around the incision, temporary blood in the urine or irritation associated with a stent or nephrostomy tube.

Follow-up care may include:

• Taking prescribed medicines as directed

• Keeping the incision and any drainage device clean according to instructions

• Avoiding heavy lifting and strenuous activity until cleared

• Following individualized fluid advice

• Attending appointments for tube or stent removal

• Completing follow-up imaging to check for residual stones

• Reviewing stone analysis and prevention measures

Do not assume the stone has been completely removed just because pain has improved. Follow-up testing helps confirm the result.

How Long Does It Take to Recover From PCNL?

Many patients resume light daily activities gradually after discharge, but full recovery can take several weeks. The timeline depends on the complexity of surgery, physical demands of work, complications and the presence of drainage tubes.

Do not return to strenuous activity or heavy lifting until the treating team says it is safe. Contact the surgical team if recovery is not progressing as expected.

What Symptoms After PCNL Need Urgent Attention?

Contact your treating team promptly or seek urgent medical care if you experience:

• Fever or chills

• Increasing or severe pain

• Heavy bleeding or large blood clots in urine

• Very little or no urine

• Persistent vomiting

• Increasing redness, swelling or discharge around the incision

• A drainage tube that stops working or becomes displaced

• Severe breathlessness or sudden deterioration

Fever and chills after stone surgery can indicate infection and should not be ignored.

Can Kidney Stones Return After PCNL?

Yes. PCNL removes existing stones but does not necessarily eliminate the reason they formed.

Prevention depends on stone composition and individual risk factors. After treatment, the care team may recommend stone analysis, blood tests or a 24-hour urine assessment, particularly for people with recurrent or high-risk stones.

Prevention may include:

• Appropriate fluid intake based on kidney function and medical advice

• Reducing excessive dietary sodium

• Following a stone-specific dietary plan

• Treating metabolic abnormalities when identified

• Taking prescribed preventive medicines when appropriate

• Attending follow-up appointments

People with advanced kidney disease, heart failure or fluid restrictions should not increase water intake without medical guidance.

Can PCNL Affect Kidney Function?

PCNL is intended to remove stones while preserving kidney function, but the outcome depends on the condition of the kidney before treatment and the complexity of the procedure.

Long-standing obstruction, repeated infection or extensive stone disease can already affect kidney function. Bleeding, infection or other complications can also influence recovery.

For this reason, patients may need creatinine and eGFR monitoring before and after treatment, particularly if they have pre-existing kidney disease or only one functioning kidney.

Kidney Stone Evaluation at Prabhakar Bhurke Clinic

At Prabhakar Bhurke Clinic, Dr. Sandip Prabhakar Bhurke, super specialist nephrologist and transplant physician, provides individualized kidney assessment for patients with kidney stones and related kidney-function concerns.

Depending on the patient's needs, evaluation may involve:

• Reviewing CT scans and ultrasound reports

• Assessing creatinine and eGFR

• Evaluating urinary obstruction and infection

• Reviewing medical conditions and current medicines

• Assessing kidney function before and after stone treatment

• Planning follow-up kidney monitoring

• Discussing stone recurrence prevention

• Coordinating with a qualified urologist for procedural treatment when required

PCNL is a surgical procedure, and suitability must be determined by the treating surgical team after reviewing the patient's complete clinical situation.

Frequently Asked Questions About PCNL Treatment

Is PCNL the best treatment for a large kidney stone?

PCNL is commonly recommended for large renal stones, especially those larger than 2 cm, but the best treatment depends on stone location, anatomy, complexity, infection status and overall health.

Is PCNL surgery painful?

The procedure is usually performed under general anaesthesia, so the patient is not awake during surgery. Some discomfort may occur afterward and can be managed according to the treating team's plan.

Does PCNL remove the entire kidney stone?

PCNL aims to remove the stone burden, but residual fragments may remain. Follow-up imaging determines whether further treatment is needed.

Is a stent always required after PCNL?

No. A ureteral stent or nephrostomy tube may be used when needed for drainage or recovery, but the decision depends on the procedure and the patient's condition.

Can PCNL be performed if a urine infection is present?

A suspected or confirmed infection must be assessed carefully. If a stone is obstructing an infected urinary tract, urgent drainage and infection treatment may be needed before definitive stone removal.

Can PCNL be performed in patients with reduced kidney function?

It may be possible, but the decision requires individualized assessment of kidney function, stone burden, bleeding risk and other health conditions.

Will PCNL prevent future kidney stones?

No. It removes existing stones but does not guarantee that new stones will not form. Stone analysis and preventive management can help reduce recurrence risk.

Conclusion

PCNL treatment for kidney stones is an established minimally invasive surgical option for large, multiple or complex stones that may not be suitable for other procedures. By providing direct access to the kidney, it allows the surgical team to fragment and remove stones through a small incision.

The right treatment depends on stone size, location, kidney anatomy, infection status and the patient's overall health. Careful preparation, appropriate infection management, postoperative monitoring and follow-up imaging are important parts of treatment.

If you have been advised to undergo PCNL, discuss the expected benefits, possible complications, recovery plan and alternative procedures with a qualified urologist. Kidney-function assessment and long-term prevention are also important, especially for people with existing kidney disease.

For individualized kidney evaluation and related medical care, consult Dr. Sandip Prabhakar Bhurke at Prabhakar Bhurke Clinic.

Medical Disclaimer

This article is intended for general educational and informational purposes only and is not a substitute for professional medical advice, diagnosis or treatment. PCNL is a surgical procedure, and its suitability depends on stone size, location, anatomy, kidney function, infection status and overall health. Not every patient with a large kidney stone requires the same procedure. Do not start or stop medicines, change fluid intake or delay treatment for suspected urinary obstruction or infection based on this article. Fever or chills with a known obstructing stone, very little or no urine, severe pain, heavy bleeding or sudden deterioration requires prompt medical assessment. Consult a qualified urologist and Dr. Sandip Prabhakar Bhurke or another qualified nephrologist for individualized evaluation and treatment planning.