Background Information:

What are the other Names for the Procedure?

• Extracorporeal Shock Wave Lithotripsy
• Percutaneous Nephrolithotomy (PCNL)
• Ureterolithotomy (URS)

What is Kidney Stone Removal surgical procedure?

Kidney Stone Removal is a surgical procedure that involves the removal of kidney stones from one of the ureter tubes (the tubes that carry urine from the kidneys to the bladder), or from the kidney itself.

What part of the Body does the Procedure involve?

A Kidney Stone Removal procedure involves a kidney and/or the ureter.

Why is the Kidney Stone Removal surgical procedure Performed?

A Kidney Stone Removal procedure is generally performed to restore proper urine flow, from within the ureter (urinary retention).

What are some Alternative Choices for the Procedure?

• The physician may take a conservative approach to treatment in certain cases, instead of a Kidney Stone Removal surgery
• This involves hydration, watchful waiting, and the use of medication, if there is a possibility that the stone may get flushed-out spontaneously

What are the Recent Advances in the Procedure?

• Kidney Stone Removal surgical procedures may be performed using minimally invasive techniques
• Mini-Percutaneous Nephrolithotomy procedure is performed using a smaller nephroscope

What is the Cost of performing the Kidney Stone Removal surgical procedure?

The cost of Kidney Stone Removal surgical procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

• It is normal for a patient to feel uncomfortable and confused with a sudden inflow of information regarding Kidney Stone Removal surgical procedure and what needs to be done
• If the patient needs further reassurance or a second opinion, a physician will almost always assist in recommending another physician
• Also, if the procedure involves multiple surgeries or has many alternatives, the patient may take a second opinion to understand and choose the best one. They can also choose to approach another physician independently

What are some Helpful Resources?

Urology Care Foundation
1000 Corporate Boulevard, Linthicum, MD 21090
Phone: (410) 689-3700
Toll-Free: 1 (800) 828-7866
Fax: (410) 689-3998
Email: info@urologycarefoundation.org
Website: http://www.urologyhealth.org

http://www.urologyhealth.org/urology/index.cfm?article=32 (accessed on 08/4/2014)

http://www.surgery.com/procedure/nephrolithotomy-percutaneous (accessed on 08/4/2014)

Complete Guide to Symptoms, Illness & Surgery; Written by H Winter Griffith, M.D.; Revised and updated by Stephen Moore, M.D. and Kenneth Yoder, M.D.; The Berkley Publishing Group, 5^th Edition, New York, 2006

Prior to Kidney Stone Removal surgical procedure:

How is the Kidney Stone Removal surgical procedure Performed?

The type of Kidney Stone Removal procedure to be used depends upon factors, such as:

• Location of the stone within the urinary tract
• Size of the stone
• Composition of the stone
• Presence of other medical co-morbidities

The kidney stones may be removed through any one of the following methods:

Percutaneous Nephrolithotomy (PCNL) procedure:

• This procedure is performed for large stones located within the kidney itself
• The surgery is done under general anesthesia. The surgeon makes a skin incision on the flank region, overlying the kidney
• A wire is introduced through this small incision into the kidney up to the ureter. By using instruments that stretch the surrounding tissue (called dilators); the surgeon creates a space (a “track”) around this wire
• An instrument, called the nephroscope, is then introduced through this track. This helps the surgeon visualize the stones directly
• The stones are then removed using special instruments. A large stone may be broken up, before it is removed
• A tube is then left in place to drain fluid from the surgical site for a period of time and the incision closed

Ureteroscopy (URS) procedure:

• This procedure can be used for stones in the ureter (or even in the kidney) and is performed under general anesthesia
• An instrument, called the ureteroscope, is introduced through the urethra (the distant most portion of the urinary tract, through which urine is voided), guided up the bladder and the ureter
• The stones are visualized directly and removed

Shock Wave Lithotripsy:

• This procedure is performed under sedation using a machine, called a lithotripter
• The lithotripter produces ultrasound waves that are transmitted through the skin and body
• These ultrasound waves break-up the stones into smaller pieces
• Multiple sessions may be required with this procedure

Open surgery:

• A Nephrolithotomy (stone removal from the kidney) or Ureterolithotomy (stone removal from the ureter) may be performed using a large skin incision, to expose the kidney or ureter
• The surgeon then enters the affected part of the kidney/ureter, to remove the stone

Where is the Procedure Performed?

• The Kidney Stone Removal procedure is performed in a hospital
• The Shock Wave Lithotripsy procedure may be however, performed on an outpatient basis

Who Performs the Procedure?

An urologist performs a Kidney Stone Removal procedure.

How long will the Procedure take?

The length of the Kidney Stone Removal procedure will depend on the type of chosen technique, for stone removal. It may last from anywhere between a few minutes to a few hours.

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider. This enables your healthcare provider in assessing the risks for the Kidney Stone Removal surgical procedure and helps avoid unnecessary complications.

• Provide a complete list of medications you are currently, taking to your physician. This information is useful for a variety of reasons. For example, it can help your healthcare provider prevent complications due to a drug interaction
• If you are allergic to any specific medication or food items
• If you are taking blood thinners, such as aspirin, warfarin, herbal supplements, or any other such medications
• If you or your family members, have a history of bleeding disorders, or if there is a tendency to bleed more than normal
• If you have diabetes, high blood pressure, chest pains, or have previously suffered from a heart attack
• If you have ever been diagnosed with blood clots in your leg (deep vein thrombosis) or lung (embolism of lung)
• If you have a history of frequent bone fractures (this may affect bone-healing, if bones are involved as part of your procedure)
• A list of all previous surgical procedures you have undergone, like for example: Removal of appendix, gallbladder, or any other part, of your body; surgical repair of any body part, such as hernia repair, perforation of bowel wall, etc.

What Preparations are needed, prior to the Procedure?

• The physician may evaluate the individual’s medical history to gain a comprehensive knowledge of the overall health status of the patient including information related to the medications that are being currently taken
• Some medications increase a person’s chances of bleeding and it may be recommended to discontinue them for a period of time, before the procedure is performed
• Blood tests may be performed to determine if there is a bleeding tendency or any other medical conditions that prevents the person from undergoing the procedure
• Normally local anesthesia is not used; however do inform the physician if you are allergic to any local anesthetics, lidocaine, etc
• Avoid application of any cosmetics, deodorant, or topical medicines on the area, prior to the procedure
• It is advisable to quit smoking and the use of any nicotine based products, for a while, before the surgery
• Consumption of alcoholic drinks must also be avoided for a period of time, as instructed
• The patient must avoid eating or drinking at least 8 hours prior to the surgical procedure, depending on when the procedure is arranged
• For persons suffering from diabetes, it is important that the blood sugar stays within the normal range; if not their diabetologist may have to control blood sugar by recommending insulin and/or a combination of oral medicines

What is the Consent Process before the Procedure?

A physician will request your consent for Kidney Stone Removal procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is your approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

You must sign the forms only after you are totally satisfied by the answers to your questions. In case of minors and individuals unable to personally give their consent, the individual’s legal guardian or next of kin, shall give their consent for the procedure.

What Tests are needed, before the Kidney Stone Removal surgical procedure?

Before a Kidney Stone Removal procedure, the patient has to undergo certain tests, such as:

• Routine blood and urine analysis
• Chest x-ray
• Electrocardiography (ECG)
• Ultrasound imaging
• Cystoscopy
• Intravenous pyelogram (IVP)
• Computerized tomography (CT) scan

What are some Questions for your Physician?

Some of the basic questions that you might ask your physician are as follows:

• What is a Kidney Stone Removal procedure?
• Why is this procedure necessary?  How will it help?
• How soon should I get it done? Is it an emergency?
• Who are the medical personnel involved in this procedure?
• Where is the procedure performed? 
• What are the risks while performing the procedure?
• What are the complications that might take place, during recovery?
• How long will it take to recover? When can I resume normal work?
• How many such procedures have you (the physician) performed?
• Are there any follow-up tests, periodic visits to the healthcare facility required, after the procedure?
• What are the costs involved?

During the Kidney Stone Removal surgical procedure:

What kind of Anesthesia is given, during the Procedure?

• General anesthesia by injection and inhalation is administered, prior to the Kidney Stone Removal procedure
• Shock Wave Lithotripsy procedures are performed under heavy sedation

How much Blood will you lose, during the Procedure?

Significant blood loss is a rare, but possible complication of a Kidney Stone Removal procedure. Some blood in the urine may be present for a few days, after the procedure.

What are the possible Risks and Complications during the Kidney Stone Removal surgical procedure?

There are general factors that increase the risk of getting complications during surgery and they include:

• Obesity: Generally greater the degree of obesity, greater is the surgical risk
• Smoking: Longer the smoking history (in pack years smoked), greater the surgical risk
• Advancing age
• Poorly controlled diabetes, as evidenced by a high hemoglobin A1c and a high fasting glucose
• Poorly functioning kidney, as evidenced by increased BUN (blood urea nitrogen) and blood creatinine
• Poorly functioning liver, as evidenced by increased blood liver function tests
• Hypertension (increased blood pressure), especially if it is poorly controlled
• Poor nutritional status (malnutrition with mineral and vitamin deficiencies)
• Poor lung function, as evidenced by abnormal lung function tests
• History of bleeding disorders
• Longstanding illness, such as autoimmune disorders, chronic infections
• Poor immune system due to a variety of causes

The possible risks or complications that may arise during the Kidney Stone Removal surgery are:

• Excessive bleeding
• Infection in the surgical would
• Damage to adjacent tissues and organs
• Anesthetic complications

What Post-Operative Care is needed at the Healthcare Facility after the Kidney Stone Removal surgical procedure?

• After the Kidney Stone Removal surgical procedure, the patients are sent to an area of the hospital, called a postoperative recovery area (or PACU)
• The patient’s blood pressure, heart rate, and respiration cycle, shall be closely monitored. Any additional pain associated with the procedure are also treated
• The duration of the hospital stay could vary; it depends upon the type of procedure that was adopted

After the Kidney Stone Removal surgical procedure:

What are the possible Risks and Complications after the Kidney Stone Removal surgical procedure?

The possible risks and complications that may arise after a Kidney Stone Removal procedure are:

• Excessive bleeding
• Infection in the surgical wound
• Urine leakage
• Abnormal scarring at the site of the kidney stone, resulting in partial or complete obstruction

What is the Prognosis after the Surgery?

A complete recovery from a Kidney Stone Removal procedure is normally achieved. The prognosis is usually excellent, without any serious complications being noted.

When do you need to call your Physician?

Do contact your physician, if you notice any of the following symptoms:

• Pain that worsens and swelling of the surgical wound
• Bleeding or fluid drainage from the surgical wound
• The occurrence of any symptom that causes uneasiness, such as nausea, vomiting, or constipation
• Experiencing difficultly, while urinating or painful urination
• Signs of an infection
• Fever, feeling sick
• Dizziness
• Muscle aches, headaches
• Complications associated with prescription medications used in treatment

What Post-Operative Care is needed at Home after the Kidney Stone Removal surgical procedure?

At home, the following post-operative care is recommended, after a Kidney Stone Removal procedure:

Slowly resume regular/daily activities as soon as possible, which aids in a faster recovery

• Use a heat pad or warm compress to relieve pain, due to the incision
• Resume showering and keep the wound clean and dry. Avoid taking baths, until the surgical wound is completely healed. Gently wash the surgical wound with an unscented soap
• Elevate legs while resting, to prevent the formation of blood clots and reduce the possibility of swelling
• Complete the course of prescribed medication, as advised by your physician
• Take stool softeners to prevent constipation
• Take antibiotic medications to help combat or prevent infection, as advised by your physician
• Avoid taking nonprescription medications, such as aspirin.  However, individuals may take acetaminophen to relieve pain (under advise from the physician)
• Avoid all activities that are physically strenuous, for about 6 weeks after the surgery
• Resume driving only after 2 weeks of being discharged from the hospital, or when advised by your physician
• Avoid sex, till a complete healing has taken place (under advise by the physician)
• Individuals are advised to have to clear liquids immediately after surgery, until the gastrointestinal tract begins functioning properly. Then, individuals are advised to have a well-balanced diet, which can aid in a faster recovery
• Also, increasing one’s fluid intake may prevent constipation and stress, during bowel movements and urination

How long does it normally take to fully recover, from the Procedure?

It usually takes about 2-3 days to recover from a Shock Wave Lithotripsy procedure, while recovery from other, more invasive Kidney Stone Removal procedures may take 1-2 weeks.

Additional Information:

What happens to tissue (if any), taken out during the Procedure?

The tissue is taken for further examination and later disposed as per the standard medical procedure.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

• The tissue removed is processed in the laboratory under a pathologist's supervision
• Slide(s) are prepared once the tissue is processed and is examined by a pathologist and a pathology report issued
• Depending on the complexity of the case, issue of the report may take anywhere between 72 hours to a week's time

Who will you receive a Bill from, after the Kidney Stone Removal surgical procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes, the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

• The outpatient facility, physician’s office or hospital
• An anesthesiologist (if anesthesia was administered)
• A pathologist (if the tissue was sent for analysis)
• A general surgeon or a urologist

The patient is advised to inquire and confirm the type of billing, before the Kidney Stone Removal procedure is performed.

Thanks and Gratitude:

We sincerely acknowledge and thank Dr. Douglas J. Jones for reviewing the article. His valuable input and feedback has helped enrich the contents of this article.

Douglas J. Jones, MD FACS
Board Certified General Surgeon and Faculty Member
University of Illinois, College of Medicine at Urbana-Champaign
506 S. Mathews Ave., Urbana, IL 61801, USA