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Anaesthetic Consideration for Percutaneous Nephrolithotomy (PCNL): A Review and Exposition on Modalities
*Corresponding author: Bashir Garba Aljannare, Department of Anesthesiology and Intensive Care, Usmanu Danfodiyo University Teaching Hospital Sokoto, Sokoto. Nigeria bashiraljannare@yahoo.com
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Received: ,
Accepted: ,
How to cite this article: Aljannare BG, Abdullahi Y, Khalid A. Anaesthetic Consideration for Percutaneous Nephrolithotomy (PCNL): A Review and Exposition on Modalities. Karnataka J Surg. 2025;2:51–54. doi: 10.25259/KJS_6_2025
Abstract
Objectives:
The objective of this review article is to describe the Anaesthetic Consideration for Percutaneous Nephrolithotomy. It also describes the difference anaesthetic techniques, their advantages and disadvantages, as well as their complications.
Material and Methods:
A Google and PubMed search yielded several articles on anaesthesia management for Percutaneous nephrolithotomy (PCNL). From these articles, the most relevant ones were selected for writing this review. The objective of this review article is to describe the anaesthetic management of PCNL using different modalities. This review describes the indications, contraindications, advantages, disadvantages, and challenges of each technique.
Results:
The successful outcome of PCNL depends on proper patient selection and good and effective communication between the surgical and anaesthesia teams.
Conclusion:
General Anaesthesia is considered the safest anaesthesia technique and effective communication between the anaesthesia and surgical teams is essential for a successful outcome.
Keywords
Anaesthetic consideration
Percutaneous nephrolithotomy
Review
INTRODUCTION
Percutaneous nephrolithotomy (PCNL) is a minimally invasive procedure for renal stone surgery. It gives a direct approach to the kidney stone. Therefore, PCNL is associated with minimal injury to both the kidneys and other surrounding structures as compared to the open surgery.
The surgical skills and experience are required for this procedure to avoid injury to the surrounding structures. Over the years, modifications have been made to reduce the associated morbidity, analgesic requirements, and duration of hospitalisation, including the use of regional blocks.[1,2] Currently, PCNL is the procedure of choice for managing renal stones of 2 cm and above. The procedure continues to evolve, and it has largely replaced the removal of kidney stones via the open approach.
The first description of PCNL was in the 1950s, and later, in 1976, more popularity was achieved by Fernström and Johansson, and it is currently the preferred modality for renal stone removal at most kidney centres. Advances in surgical technique and technology enabled the anaesthetists and urologists to further modify this procedure, thereby improving safety and efficacy and reducing associated morbidity and mortality.[3]
The indications for PCNL include renal calculi larger in size (>2 cm), renal stones in the upper part of ureters, staghorn calculi, and stones in abnormally located or ectopic kidneys.[4]
The anaesthesia for PCNL can be done under general anaesthesia (GA) or regional anaesthesia (RA) [spinal or epidural anaesthesia (SA or EA)]. The search for the ideal anaesthetic technique for PCNL still continues. However, the procedure can safely be carried out under general anaesthesia or regional anaesthesia, namely SA, EA, or combined spinal. Each anaesthesia technique has its advantages and disadvantages. The local anaesthetic agent, intravenous sedatives and analgesics have been used for PCNL. According to the available literature, the data concerning the use of regional anaesthesia for percutaneous nephrolithotomy is sparse.[5] Over the years, both GA and regional anaesthesia techniques have been used, and they have their advantages and disadvantages.
Several studies have found no significant difference between the modalities. Moawad et al.[6] in a randomised controlled trial including 200 patients, compared the efficacy of GA versus RA in PCNL patients and concluded that both groups had comparable intraoperative haemodynamics. Kuzgunbay et al.[7] found no significant difference between the GA and RA groups in terms of operative time, success rate, haemoglobin level, hospital stay, and complications. However, patients’ satisfaction was better in the regional anaesthesia group. Other authors have previously compared the two techniques and found that while RA provided the advantage of better analgesia and shorter recovery times, GA was more comfortable for the patients in the prone position and also safer in case the procedure was prolonged.[8]
The specific anaesthesia consideration in this procedure requires coordination between the anaesthesia and surgical teams for effective results. The choice of anaesthesia depends on the patient’s and surgeon’s preferences. The surgical expertise and the estimated time of the procedure determined by the stone size, number, and location are also factors. The anaesthetist should be fully aware of all the possible complications, irrespective of the choice of anaesthetic technique, which may occur during the surgery and also postoperatively.
MATERIAL AND METHODS
During the literature search, a systematic inquiry was conducted on PubMed and Google Scholar to identify relevant articles concerning the anaesthetic management of PCNL. This search approach contained terms such as “Anaesthetic Management,” “Percutaneous Nephrolithotomy,” and “review and exposition on modalities.” Studies examining the anaesthetic management of PCNL were included in this review. About 25 randomised controlled trials and observational studies were reviewed and formed this article. And articles published in peer-reviewed journals that were used also included in this review.
The exclusion criteria include articles not relevant to the anaesthetic management of PCNL. The conference abstracts, editorials, and letters to the editor were excluded from this review.
The extraction of data from eligible studies encompassed study design, outcomes, and key findings. The analysis was conducted to synthesise the findings from individual studies and provide a quantitative and qualitative summary of the safety and efficacy outcomes.
DISCUSSION
The anaesthetic management for percutaneous nephrolithotomy is challenging to both anaesthetists and urologists. Therefore, the patient’s current physiological status and comorbidities, as well as the peculiarity of the procedure, must be taken into consideration during the perioperative period. The common medical conditions in patients with kidney stones include obesity, diabetes and hypertension. These medical conditions may complicate anaesthesia and surgery if special concerns are not taken. Both general anaesthesia and regional anaesthesia (spinal, epidural, and combined spinal epidural) have been used with success. Therefore, it is important to be familiar with these various anaesthesia techniques and their associated complications; some of these complications may be life-threatening, and the anaesthetist must be able to treat them successfully.
General Anaesthesia (GA)
The advantages of GA for PCNL include safety, as the patient’s airway is secured in the prone position. The feasibility of controlling tidal volume minimise renal mobility secondary to respiration, and also, during percutaneous access puncture, it minimises injury to the pleura and lung tissues. The prolonged anaesthesia duration in GA allows the surgeon to make multiple and higher punctures with minimal patient discomfort, especially in cases with large stones and extensibility of anaesthesia time. And again, GA is more comfortable for the patients and anaesthetists.[4,5] The following are drawbacks of GA for PCNL: increased rate of complications (example: pulmonary, vascular and neurologic problems with endotracheal tubes, postoperative nausea and vomiting). Other disadvantages of GA are more postoperative pain as compared to regional anaesthesia, prolonged recovery and hospital stays, higher cost, cognitive dysfunction and delirium.
The contraindications include patient refusal, severe uncontrolled medical conditions, potentially difficult airway patients, adverse reactions and anaphylaxis to anaesthetic agents.[5] Moawad et al.,[6] in their study, observed the incidence of postoperative nausea and vomiting was significantly higher in the GA group in comparison to the RA group, but the overall patients and surgeons satisfaction was better in the GA group. In a large retrospective study involving 1004 patients, complications were graded according to Clavien classification, and a comparison of the two groups was done which revealed that the overall rate of complications was greater in the GA group compared to the RA group.[9]
Regional Anaesthesia (RA)
In 1988, the first RA for PCNL was first described.[10] This consists of subarachnoid block or SA, EA or combined spinal and EA. The indications for regional anaesthesia for cases of PCNL are patient preferences, when GA has potential risks, pulmonary conditions like Chronic Obstructive Pulmonary Disease (COPD), and difficult airway conditions. Whereas the contraindications are patient refusal, severe uncontrolled hypovolaemia, infection at the site of regional anaesthesia, allergy to local anaesthetic agents, coagulopathies, neurological deficit, spinal deformities and increased intracranial pressure.
The following includes advantages of regional anaesthesia: less postoperative pain, less postoperative analgesics consumption, reduced blood loss, and early recovery and discharge, thereby reducing hospital stay. It is also associated with minimal side effects from multiple medications as compared to GA.[11]Other advantages are that it’s associated with better haemodynamic stability, it’s cost-effective, it’s suitable for high-risk patients, and overall patient satisfaction is better with regional anaesthesia compared to GA. However, the disadvantages of regional anaesthesia are block failure, rebound pain, neurologic injury, hypotension, and conversion to GA. If the procedure is prolonged, it’s not suitable for prone position surgery, and local anaesthetic toxicity may complicate the procedure.[11]
In the study by Moawad et al.[6] they found that the postoperative Visual Analogue Scale (VAS) scores were comparatively less after one hour postoperatively in the RA group when compared to the GA group. They added that the GA group patients received analgesics within the first postoperative hour itself. Therefore, the consumption of systemic analgesics was greater in the patients who underwent GA. The same study also noted patients who received RA had an increased incidence of shivering, but the procedures were completed successfully without conversion to GA. Mehrabi and Shirazi[12] evaluated the intraoperative and postoperative anaesthetic and surgical outcomes in patients who underwent PCNL under SA in the prone position and concluded that SA is not only safe and effective for performing PCNL but is also a good alternative for GA in adult patients. Borzouei et al.[13] did a large study regarding the use of SA in PCNL and reported that SA is feasible, safe, and well tolerated, especially in elderly patients with significant comorbidities such as pulmonary disease.
Intraoperative and Safety Consideration
GA has been reported to be the safest technique for PCNL worldwide[12], However, it may be associated with complications like accidental extubation and kinking of the endotracheal tube (ETT) during positioning of the patient; hence, it is better to use a reinforced or non-kickable ETT or an oral airway along with a regular ETT, and the tube should be firmly secured. The position of bolsters should be carefully checked to allow normal ventilation. Facial oedema may result from the torsion of the neck veins, and ocular oedema and ecchymosis may also occur.
The pressure on the eyeballs may cause postoperative visual loss, especially when the external pressure on the globe exceeded the Mean Arterial Pressure; this may cause reduced perfusion to the optic nerve, leading to postoperative visual loss. Therefore, the eyeball should be protected to avoid external pressure. The pressure on the pinna should be avoided in order to prevent reduced blood supply and necrosis. Pressure on the female breast may cause necrosis; therefore, the breast should be positioned medially. Injury to the brachial plexus should be prevented by placing the arms in an abducted and upward position to avoid overstretching the nerves. The elbows, wrists, knees, and ankles should be adequately padded to prevent peripheral nerve injuries. Regional anaesthesia is not associated with all these problems related to pressure effect and positioning. However, patients may be complaining of discomfort when the duration of the surgery is prolonged.
The type of anaesthesia technique depends on patient choice, the associated co-morbidities and the agreement between the Surgeon and Anaesthetist. General anaesthesia provides more flexibility in terms of time. It also allowed Anaesthetist to control patient’s ventilation. However, it has its own disadvantages as mentioned earlier.
For patients that refuses general anesthesia, regional anaesthesia is an option. It provides more postoperative analgesia and reduces other complications of general anaesthesia.
Both general anaesthesia and regional anaesthesia can be used for PCNL depending on patient preferences, clinical conditions of patients and agreement between surgical and anaesthesia teams.
Limitations
The number of articles reviewed are few; the more the articles reviewed, the better the outcome of this review. Therefore, more research with more number of articles reviewed is needed to achieve a final conclusion regarding which anaesthesia technique is better for PCNL. Again, the patients preference of the type of anaesthesia technique and surgeon preference are also limitations of this review
CONCLUSION
PCNL is a routinely performed, minimal-access surgery. However, it has both anaesthetic and surgical complications which may be life-threatening. Patient selection is paramount in reducing morbidity and mortality following PCNL. It is important to know all the various modalities of anaesthesia for PCNL, their complications and the management of complications. Good and effective communication between the surgical and anaesthesia teams is crucial to formulate the correct perioperative management plan for each patient. In terms of safety, and based on the various articles reviewed, GA is considered to be the safest anaesthesia technique, provided there is no contraindications to it.
Acknowledgement:
We acknowledged all the staff of our Hospital who contributed in one way or the other towards the successful production of this manuscript.
Author contributions:
KA: Conceived the review and design; ABG: Initial draft of the manuscript and design; YA: Additional literature searches on the subject and contributed to the initial draft of this work. The authors critically revised the initial draft of this manuscript. All authors read and approved the final manuscript.
Ethical approval:
Institutional Review Board approval is not required.
Declaration of patient consent:
Patient’s consent not required as there are no patients in this study.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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