Role of Pyelolithotomy in modern era

65 yr Male with normal renal function came with bilateral flank pain. This was his X-ray KUB. 

Respected seniors, I would like to know what would be your line of management for this case in the modern era? Will you opt for PCNL or Pyelolithotomy for him?

Role of Pyelolithotomy in modern era


  • Dr. Anil Takvani
    Dr. Anil Takvani
    18 Feb 2020 03:01:41 PM

    Utsav Shah, 

    First of all, let me congratulate you.
    You are the first trainee to post on
    Is this patient has history of renal stone surgery in past?
    As his renal function is normal, please provide IVU or CT IVU films...
    Also USG details of amount of HN and details of cortical thickness on either side.

  • Utsav Shah
    Utsav Shah
    18 Feb 2020 05:25:51 PM

    Ok sir. I shall get back to u with the details in a day

  • Dr. Md. Mazedur Rahman
    Dr. Md. Mazedur Rahman
    19 Feb 2020 12:17:15 AM

    I think, Bilateral standard PCNL will be most beneficial stone clearance management for this patient, in addition preventive measure according to analysis.

  • Utsav Shah
    Utsav Shah
    19 Feb 2020 09:38:57 AM

    Attaching the images of CT KUB(P). Excretory imaging not done.

    Severe cortical thinning in both the kidneys with maximum measurable parenchymal thickness 8.5-9mm

  • Pankaj N Maheshwari
    Pankaj N Maheshwari
    19 Feb 2020 12:46:45 PM

    Interesting case

    Right PCNL is easy: may need two tracks
    Left very difficult to make stone free both by open or by PCNL. In view of intra-renal pelvis, i would prefer PCNL
    Few precautions for the left PCNL:
    Will need a supra-costal access
    Look for spleen (in one coronal image, it appears in the line of the PCNL tract)

  • Sunil Moteria
    Sunil Moteria
    19 Feb 2020 01:06:11 PM

    Interesting case Utsav,

    will like to have some more additional information 
    Sr Creatinine ??.. though you have put Normal Renal function but looking to the CT findings it should not be expected to be normal get it Checked again
    Second any previous surgery ?? 
    and lastly answer to your main query ..Definitely YES if you have a Good Mentor go ahead with Open Surgery, Rt Side it will require a Pyelonephrolithotomy which is likely to clear in a SIngle Stage but for  Lt side a Multiple Nephrotomies 
    I personally  would not recommend an Open Surgery for Lt side as this the morbidity of Multiple tract PCNL would be definitely less than Open Upper Pole Nephrolithotomy and presence of multiple secondary stone in Mid andLower calyces .
    hope this will help you 

  • Utsav Shah
    Utsav Shah
    19 Feb 2020 07:55:17 PM

    Thanks sirs !!

  • Ajay Bhandarkar
    Ajay Bhandarkar
    19 Feb 2020 11:23:56 PM

    Dear Utsav,

    Nice case for discussion. 
    Management for such case needs proper planning. No PCNL plan can be final without proper RGU picture. Like, Pankaj said two punctures can clear Right side, but, left PCS looks tricky. Is there a history of previous intervention on left side ? Anyways more then two punctures, careful supracostal access can offer clearance. We need to think of proper drainage of left PCS post clearance.

    With availability of many efficient energy sources, large bulk of stone volume is not a deterrent to PCNL. Open surgery can be avoided, provided you have good experience of  PCNL and able to puncture desired calyx in aggressive PCNL.

  • Gyanendra Sharma
    Gyanendra Sharma
    20 Feb 2020 09:15:47 AM

    First of all Kudos to Utsav for bring fore the topic of pyelolithotomy

    With the widespread availability of expertise & instrumentation for endourology--open surgery  for stone disease is getting  less & less common
    In general surgery the residents do not get a chance to see Pyelolithotomy  ( in many centers) leave aside doing one
    In Urology residency--such challenging cases are done by the seniors & again residents get to assist or see such cases
    There are certain other concerns which I would like to raise
    1. The overall fitness of the patient to undergo a major procedure  in prone position
    2. If PCNL is planned-- care taken to prevent sepsis, RGP before the procedure, Which side to be addressed first, explanation to the patient that even on one side a two stage PCNL may be needed. Time interval  between the one side & then the other side PCNL
    3. If the surgeon feels that he can have good clearance with open surgery--I feel there is no shame in doing an open surgery for such cases, especially if the anesthetic concerns are addressed
    The reason I am raising the anesthesia issue is that duration of anesthesia in a 65 year old patient who may be having associated ailments should be considered by the surgeon as it can have significant implications in post op period
    This becomes even more important if the surgeon is in a nursing home & not in gig institutes

    As regards PCNL I fully agree with what Dr. Pankaj & Dr. Ajay have written

  • Utsav Shah
    Utsav Shah
    20 Feb 2020 01:53:24 PM

    Thank you for your opinion sirs..

  • Nitesh Jain
    Nitesh Jain
    20 Feb 2020 08:58:42 PM

    Looking at CT and plain X-ray it doesnot look like this patient is having a normal renal function 

    Will put a PCN bilaterally and assess the kidney function to plan any thing definitive 

    Regarding the role of pyelolithotomy at present - indications are hardly any except 
    1. When needs to be combined with Pyeloplasty
    2. Combined with any other open surgical procedure or partial Nephrectomy for a tumor 
    3. I feel the current generation is more used to PCNL than pyelolitjotomy and probably will be more comfortable in doing that rather than struggling with once a blue moon procedure 

    **** request you to recheck the RFT again 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    21 Feb 2020 12:51:56 PM

    Please re-check RFT

    Right side I am very much comfortable with extended(Gilvernet) pyelolithotomy.
    That will be almost bloodless and as rightly said by Sunil can be a single stage solution for complete clearance. Left side is tricky, put the PCN as Nitesh has mentioned. Decompress the system. Check how much urine left kidney is producing. Do the nephrostogram if kidney is functioning well and decide punctures. We have to explain multi puncture , multi sitting PCNL.

  • Ravindra Sabnis
    Ravindra Sabnis
    24 Feb 2020 09:11:18 AM

    Likely that cr may be raised.  Left side - why is hydronephrosis is not clear.  Is there stone in puj? I could not see that. Bilat pcn first will be safer.   Dilated system pcnl is easy. Both sides can be managed by endourology.  

    Your specific question - role of pyelolitjotomy in modern era ( which means all expertise & all equipments are available)  - if I have to answer - then answer is "NO"

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