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Information about your procedure fromThe British Association of Urological Surgeons (BAUS)This leaflet contains evidence-based information about your proposedurological procedure. We have consulted specialist surgeons during itspreparation, so that it represents best practice in UK urology. You shoulduse it in addition to any advice already given to you.To view the online version of this leaflet, type the text below into your webbrowser:http://www.baus.org.uk/ rther general information about kidney stones can be found on thePatients’ section of the BAUS website under "I think I might have kidneystones".Key Points The aim of this procedure is to fragment stones in the kidneytelescopically using a “keyhole” approach to your kidney through apuncture in the skin of your back It is a major procedure and is usually reserved for larger stones orfor patients with complex kidney anatomy We puncture the kidney with a needle, under ultrasound or X-rayguidance, and stretch up a “track” into the kidney through which wecan pass a telescope The stone is broken up using a laser fibre, a lithoclast (smallpneumatic drill) or an ultrasonic suction probe This procedure has largely eliminated the need for open surgery toremove kidney stones, because there is a similar stone clearancerate and recovery is much fasterWhat does this procedure involve?This involves puncturing your kidney through the skin of your back with aneedle (using X-ray or ultrasound to guide the puncture) and stretching upa track into the kidney through which a telescope can be passed. We mayneed to puncture the kidney at more than one site to reach all your stone(s).Published: July 2017Due for review: April 2020Leaflet No: 16/164 Page: 1 British Association of Urological Surgeons (BAUS) Limited

We then fragment the stone(s) in your kidney using a laser, lithoclast(mechanical fragmenter) or ultrasound probe. We usually leave a drainagetube in your kidney at the end of the procedure and we normally out acatheter in your bladder.What are the alternatives? Observation –stones smaller than 5mm in diameter can pass bythemselves but sometimes get “stuck” within the kidney; largerstones (greater than 7mm diameter) rarely pass Extracorporeal shockwave lithotripsy (ESWL) – by “firing”shockwaves, generated under water, through your skin to break thestone into fragments which you then pass yourself Flexible ureteroscopy – using a thin flexible telescope passed intoyour bladder, up through your ureter and into your kidney, where thestone is broken up using laser energy Open stone removal – although very unusual nowadays, if all theabove techniques fail we may need to resort to open surgery toremove your stone(s)What happens on the day of the procedure?Your urologist (or a member of their team) will briefly review your historyand medications, and will discuss the surgery again with you to confirmyour consent.An anaesthetist will see you to discuss the options of a general anaestheticor spinal anaesthetic. The anaesthetist will also discuss pain relief after theprocedure with you.We may provide you with a pair of TED stockings to wear, and we may giveyou a heparin injection to thin your blood. These help to prevent bloodclots from developing and passing into your lungs. Your medical team willdecide whether you need to continue these after you go home.We may arrange a plain abdominal X-ray for you on the day of theoperation, to be sure that the stone has not changed in any way.Details of the procedure we normally use a full general anaesthetic and you will be asleepthroughout the procedure we usually give you an injection of antibiotics before the procedure,after you have been checked for any allergiesPublished: July 2017Due for review: April 2020Leaflet No: 16/164 Page: 2 British Association of Urological Surgeons (BAUS) Limited

we put a telescope into your bladder through the urethra (waterpipe) and use it to put a fine ureteric catheter up to your kidneyunder X-ray control we put a catheter into your bladder through your urethra (waterpipe) we then turn you on to your face (prone) and puncture the affectedkidney with a needle using X-ray or ultrasound guidance; contrastmedium (dye) can be injected through the ureteric catheter to helpthis process once the needle is correctlypositioned, we replace it with aguide wire over which graduatedmetal or plastic dilators arethreaded to stretch up a “track”into the kidney the diameter of this track isdetermined by the size of telescopewhich we will use to see inside thekidney (normal, mini or ultra-mini) we pass the telescope(nephroscope) through a sheath,along the track, to see the stone(s)inside the kidney (pictured). the stones are broken up using a laser, a lithoclast or an ultrasoundprobe and the larger fragments are removed using grasping forcepsor suction when smaller nephroscopes (mini or ultra-mini) are used, the stonesare “dusted” to produce tiny fragments which can pass by themselves we usually insert a temporary drainage tube (a nephrostomy tube)into the kidney at the end of the procedure the procedure takes one to three hours to complete, depending on thesize of your stone(s) you can expect to be in hospital for two to five daysOn the day after surgery, we usually carry out an X-ray or CT scan (which ismore sensitive than plain X-ray) to see if all the stones have been cleared.Occasionally, we may X-ray your kidney using contrast medium (dye) putdown the nephrostomy tube (a nephrostogram). If this is satisfactory, thenephrostomy tube and your bladder catheter will be removed.You may get some leakage of urine from the nephrostomy site. This usuallystops within 24 to 48 hours and we will dicharge you when any leakage hasstopped.Published: July 2017Due for review: April 2020Leaflet No: 16/164 Page: 3 British Association of Urological Surgeons (BAUS) Limited

Further information and a short video of percutaneous kidney stoneremoval are available on the BAUS website.Are there any after-effects?The possible after-effects and your risk of getting them are shown below.Some are self-limiting or reversible, but others are not. We have listedsome very rare but important after-effects (occurring in less than 1 in 250patients) individually. The impact of after-effects can vary a lot from patientto patient; you should ask your surgeon’s advice about the risks and theirimpact on you as an individual:After-effectRiskMild bleeding from the kidney into yournephrostomy tube and bladderAll patientsTemporary insertion of a bladder catheterAll patientsRecurrent (new) stone formation over thenext five to 10 years, requiring furthersurgery or other treatment1 in 2 patients(50%)Urinary infection requiring antibiotictreatmentBetween 1 in 2 &1 in 10 patientsNeed for more than one puncture to clearyour stones (depending on the site of thestones)Between 1 in 2 &1 in 10 patientsResidual stones requiring further surgeryor other treatmentBetween 1 in 5 &1 in 20 patientsSepsis (infection) requiring an unexpectedintensive care admissionBetween 1 in 10 &1 in 50 patientsModerately severe bleeding from thekidney requiring radiological interventionto block the blood supply to the damagedarea (embolisation)Between 1 in 50 &1 in 100 patientsPublished: July 2017Due for review: April 2020Leaflet No: 16/164 Page: 4 British Association of Urological Surgeons (BAUS) Limited

Failure to obtain satisfactory access to yourkidney requiring further surgery oralternative treatmentBetween 1 in 50 &1 in 100 patientsInfection in the nephrostomy puncturewound in your back1 in 100 patients(1%)Anaesthetic or cardiovascular problemspossibly requiring intensive care (includingchest infection, pulmonary embolus, stroke,deep vein thrombosis, heart attack anddeath)Between 1 in 50 &1 in 250 patients(your anaesthetistcan estimate yourindividual risk)Major damage to blood vessels in yourkidney requiring emergency surgery toremove the kidney (nephrectomy)Less than 1 in1000 patients(less than 0.1%)What is my risk of a hospital-acquired infection?Your risk of getting an infection in hospital is approximately 8 in 100 (8%);this includes getting MRSA or a Clostridium difficile bowel infection. Thisfigure is higher if you are in a “high-risk” group of patients such as patientswho have had: long-term drainage tubes (e.g. catheters);bladder removal;long hospital stays; ormultiple hospital admissions.What can I expect when I get home? you will be given advice about your recovery at home you will be given a copy of your discharge summary and a copy willalso be sent to your GP any antibiotics or other tablets you may need will be arranged &dispensed from the hospital pharmacy you should drink twice as much fluid as you would normally for thefirst 24 to 48 hours, to flush your system through and reduce the riskof infection or blockage of your urine flow by blood clots it may take at least two weeks to recover from percutaneousnephrolithotomyPublished: July 2017Due for review: April 2020Leaflet No: 16/164 Page: 5 British Association of Urological Surgeons (BAUS) Limited

you may return to work when you are comfortable enough and whenyour GP is satisfied with your progress; this is unlikely to be within10 days, especially if your job is physically demanding if you develop a fever, pain in the area of the affected kidney, severepain on passing urine, inability to pass urine or worsening bleeding,you should contact your GP immediatelyYou can reduce your risk of further stone formation by altering your dietand fluid intake. Ask your urologist or specialist nurse for further detailsabout this or download the BAUS leaflet “Dietary advice for stone formers”.General information about surgical proceduresBefore your procedurePlease tell a member of the medical team if you have: an implanted foreign body (stent, joint replacement, pacemaker,heart valve, blood vessel graft); a regular prescription for a blood thinning agent (warfarin, aspirin,clopidogrel, rivaroxaban or dabigatran); a present or previous MRSA infection; or a high risk of variant-CJD (e.g. if you have had a corneal transplant, aneurosurgical dural transplant or human growth hormonetreatment).Questions you may wish to askIf you wish to learn more about what will happen, you can find a list ofsuggested questions called "Having An Operation" on the website of theRoyal College of Surgeons of England. You may also wish to ask yoursurgeon for his/her personal results and experience with this procedure.BAUS runs a national audit and collects data from all urologists undertakingthis surgery. There are two reasons for this. First, surgeons are requiredby the Department of Health to look at how well the surgery is being doneunder their care and, second, to look at national trends for the procedure.Some basic patient data (e.g. name, NHS number and date of birth) areentered and securely stored. This is required so that members of theclinical team providing your care can go back to the record and add followup data such as length of stay or post-operative complications. This helpsyour surgeon to understand the various outcomes of the procedure.Although BAUS staff can download the surgical data for analysis, theycannot access any patient identifiable data. This information is used togenerate reports on individual surgeons and units; these are available forPublished: July 2017Due for review: April 2020Leaflet No: 16/164 Page: 6 British Association of Urological Surgeons (BAUS) Limited

the public to view in the Surgical Outcomes Audit section of the BAUSwebsite.Before you go homeWe will tell you how the procedure went and you should: make sure you understand what has been done;ask the surgeon if everything went as planned;let the staff know if you have any discomfort;ask what you can (and cannot) do at home;make sure you know what happens next; andask when you can return to normal activities.We will give you advice about what to look out for when you get home.Your surgeon or nurse will also give you details of who to contact, and howto contact them, in the event of problems.Smoking and surgeryIdeally, we would prefer you to stop smoking before any procedure.Smoking can worsen some urological conditions and makes complicationsmore likely after surgery. For advice on stopping, you can: contact your GP; access your local NHS Smoking Help Online; or ring the free NHS Smoking Helpline on 0800 169 0 169.Driving after surgeryIt is your responsibility to make sure you are fit to drive after any surgicalprocedure. You only need to contact the DVLA if your ability to drive islikely to be affected for more than three months. If it is, you should checkwith your insurance company before driving again.What should I do with this information?Thank you for taking the trouble to read this information. Please let yoururologist (or specialist nurse) know if you would like to have a copy foryour own records. If you wish, the medical or nursing staff can also arrangeto file a copy in your hospital notes.What sources have we used to prepare this leaflet?This leaflet uses information from consensus panels and other evidencebased sources including: the Department of Health (England); the Cochrane Collaboration; andPublished: July 2017Due for review: April 2020Leaflet No: 16/164 Page: 7 British Association of Urological Surgeons (BAUS) Limited

the National Institute for Health and Care Excellence (NICE).It also follows style guidelines from: the Royal National Institute for Blind People (RNIB);the Information Standard;the Patient Information Forum; andthe Plain English Campaign.DisclaimerWe have made every effort to give accurate information but there may stillbe errors or omissions in this leaflet. BAUS cannot accept responsibility forany loss from action taken (or not taken) as a result of this information.PLEASE NOTEThe staff at BAUS are not medically trained, a

kidney (normal, mini or ultra-mini) we pass the telescope (nephroscope) through a sheath, along the track, to see the stone(s) inside the kidney (pictured). the stones are broken up using a laser, a lithoclast or an ultrasound probe and the larger fragments are removed using grasping forceps or suction when smaller nephroscopes (mini or ultra-mini) are used, the stones are .

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