Editing AUA: Stone Surgery (2016) (section)

== PCNL ==

* '''<span style="color:#ff0000">Relative contraindications to PCNL (2):</span>'''
*# '''<span style="color:#ff0000">Use of anti-coagulation or anti-platelet therapy that cannot be discontinued</span>'''
*# '''<span style="color:#ff0000">Anatomic derangements (e.g. contractures, flexion deformities) that may preclude positioning for PCNL</span>'''
** '''In patients not considered candidates for PCNL, clinicians may offer staged URS'''
* '''Clinicians must use normal saline irrigation for PCNL and URS'''
* '''A safety guide wire should be used for most endoscopic (URS or PCNL) procedures'''
** '''Situations where a safety guidewire cannot be placed, may not be necessary, or may even be harmful (2):'''
**# '''Severely impacted ureteral stones''' where even a hydrophilic guidewire cannot safely be negotiated proximal to the stone.
**# '''When a ureteral access sheath is being used''' to facilitate treatment of intra-renal stones with the flexible ureteroscope.
* '''Flexible nephroscopy should be a routine part of standard PCNL'''
** In an RCT, stone-free rate was higher in patients that underwent concomitant flexible endoscopy with rigid nephroscopy during PCNL, compared to without concomitant flexible nephroscopy, 92.5% vs 70%.
* '''In patients undergoing uncomplicated PCNL who are presumed stone-free, placement of a nephrostomy tube is optional'''
** '''<span style="color:#ff0000">Purpose of the nephrostomy tube following PCNL (4):</span>'''
**# '''<span style="color:#ff0000">Aid in healing of the nephrostomy tract</span>'''
**# '''<span style="color:#ff0000">Promote hemostasis</span>'''
**# '''<span style="color:#ff0000">Prevent extravasation of urine</span>'''
**# '''<span style="color:#ff0000">Allow for re-entry into the collecting system should a secondary procedure be necessary</span>'''
** '''In the appropriately selected patient, "tubeless" PCNL can result in similar stone-free and complication rates as standard PCNL.'''
*** '''“Tubeless” PCNL is a term used to describe the scenario when no nephrostomy tube is inserted at the end of the procedure. Renal drainage can be established with an indwelling or externalized stent, or the patient can be left without a stent.'''
*** Indwelling nephrostomy tubes following PCNL is associated with increased postoperative pain with greater narcotic requirements and increased length of hospitalization compared to tubeless PCNL.
*** '''The tubeless approach should not be undertaken if there is active hemorrhage or it is likely that another PCNL will be needed to remove residual stones'''