Percutaneous nephrolithotomy (PNL) is used to treat the large or complex
calculi (1). Following Fernstrom and Johansson has been reported the extraction
of renal calculus through a nephrostomy tract (2), the operation techniques showed
development with increasing success rate and decreasing complication and
There is a considerable debate about the anesthesia technique for PNL.
Although regional anesthesia gradually gains popularity, the procedure is
usually performed under general anesthesia which provides safety in patient’s
airway during prone position and tidal volume control during the puncture to
minimize pleural injury. It also maintains patient and surgeon comfort in
prolonged anesthesia duration and facilitates the removal of large stones (4).
Our hospital is a referral center for urinary stones and PNL operations
have been performed for a long time period with a high success rate. The primary
goal of this study was to document the PNL operations and evaluate the
perioperative management of these patients in anesthesiologist perspective.
Materials and Method
The study group was composed of patients admitted to our hospital for
urinary stones and scheduled for PNL between 2015 and 2017. Routine
preoperative evaluation included total blood count, coagulation, renal and
hepatic function tests, chest x-ray and electrocardiogram was performed by
anesthesiologists and additional assessment was needed if any pathologic
finding was detected. A written informed consent was obtained from all
After premedication with 0.01-0.02 mg/kg midazolam and 1-2 µg/kg fentanyl,
anesthesia was induced by 5-7 mg/kg thiopental sodium or 2-3 mg/kg propofol.
Neuromuscular relaxation was provided by 0.6 mg/kg rocuronium in all patients
and following endotracheal intubation, mechanical ventilation with tidal volume
of 8-10 ml/kg and a respiratory rate adjusted to normocapnia was conducted.
Anesthesia maintenance was provided by sevoflurane or desflurane in 60% O2-air
mixture. All patients were routed with 18-gauge peripheral venous line and
infused crystalloid solutions based on 4/2/1 rule. All procedures were carried
out in the prone position.
Standard monitoring including continuous electrocardiogram, pulse
oxymetry and end-tidal CO2 was applied to all patients. Right or left radial
artery cannula was inserted for monitoring invasive blood pressure and blood
sampling during the intraoperative period.
PNL was performed as a standard procedure. The kidney was punctured under
Data was collected in 3 steps and recorded to pre-prepared forms. Firstly
we searched the hospital electronic database to find the patients having PNL operation.
After that, we reviewed the patients’ anesthesia records to extract the data
including age, gender, ASA physical status, duration of operation, blood
transfusion requirements and any adverse situation during the intraoperative
period. On the last step, patients’ hemoglobin levels, the total amount of
blood transfused, duration of hospitalization and stone characteristics were
recorded from the hospital electronic database.
The study protocol was by Scientific Research Ethics Committee of our hospital
and conducted according to ethical principles outlined in the Helsinki Declaration.
Recently, a large number of studies about the effect of anesthesia type
on the PNL were taken attention. Regional anesthesia was firstly reported by
Ballestrazzi et al (5) in 112 patients who underwent PNL with epidural
anesthesia in 88% satisfactory result. In a randomized controlled trial
comparing the efficacy of general and regional anesthesia intraoperative hemodynamics
was found comparable in both groups where as visual analog score (VAS) and
analgesic requirement were comparatively less in regional group (6). Kuzgunbay
et al indicated that there was no significant difference regarding operation
time, amount of irrigation fluids, intraoperative complications, hemoglobin
levels and hospital stay between general and combined spinal-epidural
anesthesia (7). It’s also suggested that because of maintenance of better
hemodynamic state and disposing of the complications of general anesthesia,
spinal anesthesia might be a better choice (8). In our
general anesthesia series, no complication related with general anesthesia was
In literature, the most emphasized point of regional anesthesia is the
decreasing in analgesic requirements. On the other hand, Mehrabi et al
indicated that this advantageous was valid in a short time period and on the 2nd
day of operation there was no significant difference between general and
regional anesthesia(9). We used multimodal analgesia
with paracetamol and tramadol for postoperative pain.
Predictable and unpredictable complications of PNL includes hemorrhage,
injuries of collecting system, technical complications, hypothermia, fluid
overload, sepsis, stricture formation, nephrocutaneous fistula, renal damage
and even death(10-12). These complications are divided into two as major and
minor complications. Pain (49%),fever (30%), urinary tract infections (11%) and
renal colic (4%) was reported as minor, septicemia (4.1%), and severe
hemorrhage (2.7%) was reported as major complications (13). Lee et al. reported
12%of transfusion rate in 500 PNL patients as the most frequent complication
(14). This rate was reported as high as 23.8% (10). In case of excessive
bleeding, clamping of nephrostomy tube,placement of larger nephrostomy tubes or
balloon tamponade may be necessary (15). In some conditions, angiographic
embolization may be a treatment of choice (16). In our
study transfusion rate was_________________
In all comparative studies between general and regional anesthesia,
mostly emphasized issue is the hazards of general anesthesia in the prone
position. These are accidental extubation, kinking of the endotracheal tube,
torsion of the neck veins leading to fascial or ocular edema, ecchymosis and
peripheral nerve injuries on pressure points (4). Prone position has been
widely used in a variety of surgical procedures and possible complications were
well defined (17, 18). Due to abdominal muscle paralysis during general anesthesia,
functional residual capacity and arterial partial pressure of oxygen are
increased, in contrast chest wall and lung compliance remain unchanged. This physiological
respiratory change may be advantageous in many conditions (19-20). All
procedures were conducted in prone position in our patients and no position
related complication was recorded.
Anesthetics affect thermoregulation and this is an underestimated issue.
During general anesthesia hypothermia develops in three phases. Rapid heat loss
develops within first hour (Phase I). Heat loss exceeds the production in Phase
II after 2-4 hours. In third phase named thermal steady state occurs after 3-4
hours and peripheral vasoconstriction is triggered (21, 22). Thermoregulation
is also affected during regional anesthesia. Because of the disruption of
thermal input in the blocked region, patient can’t distinguish warm or cold.
Supplementation of sedatives or analgesics makes the hypothermic condition
worse (22). Due to large amount of irrigation fluid used during procedure body
core temperature may decrease more than expected. Hypothermia is a limitation
of our study. Because of the missing data statistical analysis could not be conducted.
Further studies about hypothermia during PNL may
provide more definite data.
There is predictable and unpredictable complications of PNL such as
hemorrhage, collecting system injuries, contiguous organ injuries, technical
complications, hypothermia, fluid overload, sepsis, stricture formation,
nephrocutaneous fistula, renal damage and even death (x,xx,xxx). These
complications are divided as major or minor complications. Havel et al
indicated pain (49%), fever (30%), urinary tract infections (11%), renal colic
(4%) as minor complications. Most important major complication was reported as
seprticemia (4.1%) and severe hemorrhage (2.7%) (xxxx). In literature, transfusion
rate in PNL patient represents variability. Lee et all reported 12% transfusion
rate in 500 PNL patients as most frequent complication (5x). This ratio was as
high as 23.8% (x). Excessive bleeding may require additional maneuvers such as
placement of larger nephrostomy tube, nephrostomy tube clamping, hydration and
balloon tamponade (6x). In some conditions, angiographic embolization may be