PCNL: Percutaneous Surgery for Large Kidney Stones
A method in which the kidney is reached through an entry of about one centimetre in the flank and large stones are cleared in a single sitting. It is the standard approach for staghorn stones.
Last medically reviewed: October 4, 2026 — Assoc. Prof. Dr. Müslüm Ergün
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- Procedure time
- 60–120 minutes
- Anesthesia
- General anaesthesia
- Hospital stay
- 2–3 nights
- Stay in Türkiye
- 7–10 days
- Return to work
- 1–2 weeks
- Flight clearance
- 7–10 days
About the condition
PCNL (percutaneous nephrolithotomy) clears large kidney stones through a small entry made in the flank. Under imaging guidance the kidney is reached with a fine needle, this tract is widened in stages to create a channel of about one centimetre, and a device called a nephroscope is passed through it into the kidney.
The stone is seen directly and broken up with laser or pneumatic energy, and the fragments are removed through the same channel. This is the most important difference from RIRS: rather than waiting for the fragments to pass with the urine, they are taken out directly. For a large stone burden the chance of clearing everything in one sitting is therefore higher.
PCNL is regarded as the standard approach particularly for staghorn stones — branched stones that fill the collecting system of the kidney. Left in place, these stones can lead to recurrent infection and permanent loss of kidney function.
Procedures carried out through a narrower tract are called mini-PCNL. A smaller channel means less damage to the kidney tissue and generally less bleeding; on the other hand, removing the fragments can take longer. Which calibre is chosen depends on the size of the stone.
THE MOST IMPORTANT RISK IS BLEEDING. The kidney is an organ rich in blood vessels, and access is gained by passing through it. Most bleeding stops on its own; rarely, a blood transfusion or closing the bleeding vessel under radiological guidance (embolisation) may be needed. For this reason the medication schedule of patients on blood thinners is planned before surgery.
At the end of the procedure a drain called a nephrostomy may be placed between the kidney and the skin, or in selected patients a tubeless approach may be preferred. This decision is taken during the operation according to how completely the stone has been cleared, how much bleeding there has been and the condition of the kidney.
Who is it suitable for?
May be suitable
- Patients with a large stone inside the kidney
- Patients with a staghorn stone that fills the collecting system
- Patients with a large, hard stone sitting in the lower pole
- Patients in whom shock wave lithotripsy (ESWL) or RIRS has been tried without success
- Patients with multiple stones where clearance in a single sitting is the aim
- Situations where the stone causes obstruction and recurrent infection and kidney function is under threat
May not be suitable
- Patients with a small stone — RIRS or ESWL are less invasive options
- Patients with an untreated urinary tract infection — this must be treated before the procedure
- Patients with an uncontrolled bleeding disorder — this is corrected first
- Patients whose blood-thinning treatment cannot be interrupted — RIRS may be more appropriate
- Patients for whom general anaesthesia is unsuitable
- Anatomical situations in which no safe tract to the kidney can be found
Technology used
- Access to the kidney under ultrasound and/or fluoroscopic guidance
- Standard or mini-calibre nephroscope
- Laser or pneumatic lithotripsy system
- Confirmation of stone clearance by imaging during and after the operation
- Chemical analysis of the stone and metabolic assessment aimed at preventing recurrence
Surgeon's experience
Verifiable information
- Surgeon's experience
- Assoc. Prof. Dr. Müslüm Ergün121270
Step-by-step journey
- Before surgery
Assessment and preparation
A non-contrast CT scan establishes the volume and distribution of the stone, the anatomy of the kidney and a safe route of entry. A urine culture is taken; if there is infection the procedure is postponed. The schedule for blood-thinning medication is arranged.
- Day of surgery
Access and clearing the stone
Under general anaesthesia and imaging guidance the kidney is reached through the flank. The channel is widened, the stone is broken up and the fragments removed. The procedure usually takes 60–120 minutes.
- Day 1
Drain and observation
If a nephrostomy drain has been placed, the colour of the urine and any bleeding are monitored. Pain is brought under control and getting up early is encouraged.
- Days 2–3
Drain removal and discharge
Once the bleeding settles and the urine clears, the drain is removed. Imaging establishes whether any stone remains and the patient is discharged.
- Weeks 1–2
Recovery
Tenderness at the entry site in the flank lessens. A return to desk work is possible; heavy lifting and strenuous exercise are not done during this period.
- Months 1–3
Check-up and prevention
Imaging confirms that the kidney is stone-free. According to the stone analysis, a protective plan covering fluids, diet and, where needed, medication is put into practice.
Method comparison
| Criterion | PCNL | RIRS |
|---|---|---|
| Route of entry | About 1 cm in the flank | Through the urinary passage, no incision |
| Suitable stone size | Large and staghorn | Small to moderate |
| What happens to the fragments | Removed directly | Mostly left to pass with the urine |
| Stone-free in one sitting | Higher chance for large stones | High for small stones |
| Bleeding risk | Higher | Lower |
| Hospital stay | 2–3 nights | Day case or 1 night |
| Return to work | 1–2 weeks | 3–7 days |
The two methods are not alternatives to one another but solutions to different stone burdens. The larger the stone, the more PCNL comes to the fore; the smaller it is, the more RIRS does. In some patients both are used within the same treatment plan.
Risks
- BLEEDING: the most important risk. Most bleeding stops on its own; rarely, a blood transfusion or closing the bleeding vessel under radiological guidance (embolisation) may be needed
- Infection and blood poisoning (urosepsis) — this is why a urine culture before the procedure and treatment of any infection are compulsory; fever and shivering require immediate medical attention
- Entering the lining of the lung (pleura) — only relevant when access is through the upper pole of the kidney; a chest drain is placed if needed
- Injury to neighbouring organs — bowel, liver or spleen; very uncommon
- Fragments of stone left behind, requiring a second sitting or a further procedure
- Urine leakage and the drain having to stay in longer
- Recurrence of the stone — stone disease can come back if preventive measures are not taken
Alternatives
- RIRS (the closed method with a flexible endoscope) — for small and moderately sized stones
- Mini-PCNL — through a narrower tract, for moderately sized stones
- Shock wave lithotripsy (ESWL) from outside the body — for stones of suitable size and position
- Planning more than one method together — for very heavy stone burdens
- Laparoscopic or open stone surgery — very rarely, in special anatomical situations
Recovery
First 24 hours
The patient stays in hospital under observation. Blood in the urine is an expected finding. Pain is controlled with medication and getting up early is encouraged.
Days 2–3
Once the bleeding settles the drain is removed. There may be tenderness at the entry site. Discharge takes place during this period.
Week 1
Gentle walking is allowed. Heavy lifting, strenuous exercise and straining are not. Plenty of fluids are advised.
Week 2
A return to desk work is possible. The tenderness at the entry site has largely gone.
Months 1–3
Imaging confirms that the kidney is stone-free. The preventive plan based on the stone analysis is put into practice.
Frequently asked questions
How big an incision is made for PCNL?
A single entry of about one centimetre is made in the flank. This is incomparably smaller than the large incision of open surgery and leaves a small mark once healed. In mini-PCNL the calibre is smaller still.
Why is PCNL being recommended rather than RIRS?
Because of the size and structure of the stone. In PCNL the fragments are removed directly, so for a large stone burden the chance of clearing everything in one sitting is higher. For staghorn stones this method is regarded as standard. For small stones RIRS is preferred because it is less invasive.
What is the most important risk?
Bleeding. The kidney is an organ rich in blood vessels and access is gained by passing through it. Most bleeding stops on its own; rarely, a transfusion or closing the bleeding vessel under radiological guidance may be needed. This is why, if you take blood thinners, your medication schedule is planned before surgery.
Could my lung be harmed?
This risk only arises when access has to be made through the upper pole of the kidney, and it means entering the lining of the lung. The route of entry is planned under imaging guidance so as to minimise this risk. A temporary chest drain is placed if needed.
What is a nephrostomy drain — is one always placed?
It is a tube placed between the kidney and the skin that carries urine out. It is not placed in every patient; if the stone has been completely cleared, bleeding is minimal and the kidney is suitable, a tubeless approach may be preferred. The decision is made during the operation.
Will my stone be cleared completely in one sitting?
For large stones the chance of clearance in one sitting is higher than with other methods, but it is not guaranteed. For very heavy or highly branched stones a second tract, a second sitting or completion with RIRS may be planned. This is discussed from the outset.
Is blood in my urine after the operation normal?
Yes, it is an expected finding in the first few days and steadily lessens. Dark bleeding with clots, fever or steadily increasing pain requires prompt medical attention.
Will it cause lasting harm to my kidney?
The access tract passes through kidney tissue, but this tract heals. Against that, leaving a large stone such as a staghorn in place can lead to recurrent infection and permanent loss of kidney function. In most situations, therefore, the risk of not treating is greater than the risk of treating.
Will my stone come back?
Stone disease can recur if preventive measures are not taken. The retrieved stone is analysed chemically and, according to the result, a protective plan covering fluid intake, diet and, where needed, medication is drawn up.
When can I fly and return to work?
Flying is usually permitted after 7–10 days; a stay of 7–10 days is planned for patients travelling from abroad. A return to desk work is possible within 1–2 weeks; for heavy physical work, waiting 4–6 weeks is advised.
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This page is for general information only and is not a substitute for medical advice.
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