Percutaneous nephrolithotomy (PCNL) offers a potentially shorter recovery time for patients but is a challenging procedure to perform. In this interview, Thomas Chi, MD, discusses how he performs PCNL, explains why he uses ultrasound instead of fluoroscopy, and offers advice to urologists looking to gain more experience with the procedure. Dr. Chi is associate professor, associate chair for clinical affairs, and Kutzmann Endowed Professor in Clinical Urology at the University of California, San Francisco. Dr. Chi was interviewed by Urology Times Editorial Consultant Stephen Y. Nakada, MD, the Uehling Professor and founding chairman of urology at the University of Wisconsin, Madison.
What are the indications for PCNL?
If you look at the guidelines, the indications for PCNL are any stone 2 cm to 2.5 cm or larger. We don’t have a lot of guidance for the medium-size stone (1 cm-2 cm). For those stones, I leave it up to the patient and discuss shock wave lithotripsy, ureteroscopy, and PCNL with them. I think the trade-off with PCNL is that even though it’s more invasive, patients recover a little faster and may return to work a little sooner. Some people like the idea of a nephrostomy tube for a short time versus a stent for a longer time.
Do you think patients prefer the percutaneous approach compared to a noninvasive approach?
I think a lot of patients come in with a preconceived notion, but I spend a lot of time describing a stent and the uncertainties associated with having to wear a stent and how much it may impact their life. When they weigh having the stent versus having a nephrostomy tube in the hospital for 1 or 2 days, I think a lot of people change their mind. My experience has been that patients in the short term may prefer a small nephrostomy tube for a day or two compared to a stent for a couple of weeks, but I don’t know that a lot of data exist to guide us either way.
Who do you think should do these procedures? Should it be any urologist versus specialized urologists? Should radiologists be involved?
It’s a complex answer. Every hospital system and practitioner has a different set-up, which makes the relationship between interventional radiology, their own training, and comfort different. PCNL certainly is a challenging procedure, but it’s probably because a lot of the approaches we have are a little bit difficult to learn. There’s a long learning curve to master fluoroscopy. That takes some level of comfort. I think that everybody should be doing PCNL if we can make the procedure easier and more facile on their hands. That way, patients will get the optimum procedure for the stone as opposed to avoiding a procedure because providers feel uncomfortable with it.