Anesthesia for Percutaneous Nephrolithotomy (PCNL) Ureteroscopy (URS),ESWL


1. Introduction

Percutaneous Nephrolithotomy (PCNL) and Ureteroscopy (URS) are commonly performed urological procedures for renal and ureteric stones.

Procedure

Indication

Access

PCNL

Large renal calculi (>2 cm), staghorn stones

Percutaneous access to renal pelvis

URS

Ureteric stones, small renal stones (<2 cm)

Retrograde via urethra/ureter


 2. Preoperative Evaluation

A. History and Clinical Examination

  • Renal colic, hematuria, UTI history
  • Past surgical/stone interventions
  • Comorbidities (DM, HTN, CKD)
  • Check for bleeding disorders

B. Investigations

  • CBC – Anemia, infection
  • RFTs – BUN, creatinine
  • Electrolytes – K⁺ disturbances common
  • Urine culture – Mandatory; treat UTI before procedure
  • Coagulation profile
  • Imaging – USG, NCCT KUB, IVP, or DTPA scan


3. Anesthetic Considerations – PCNL

✅ Anesthetic Technique

  • General Anesthesia (GA) is preferred
  • Airway secured for prone positioning and longer duration
  • Regional anesthesia (RA) may be used in select cases, especially in high-risk patients, but limits airway access in prone


 4. Intraoperative Management – PCNL

A. Positioning

  • Initial lithotomy position: For ureteric catheter placement
  • Then prone position: For renal access

🔴 Positioning Risks

  • Pressure sores, nerve injuries (brachial plexus, ulnar, lateral femoral cutaneous)
  • Eye injury – protect with foam pads

B. Monitoring

  • Standard ASA monitors
  • Temperature probe – Long cases
  • Arterial line – If bleeding risk or comorbidities

C. Fluid Management

  • Maintain euvolemia
  • Risk of fluid overload due to irrigation → monitor UO, vitals
  • Large fluid absorption can → TURP-like syndrome

D. Bleeding Risk

  • PCNL can cause significant venous or arterial bleeding
  • Ensure crossmatched blood is available

E. Pain Management

  • Multimodal analgesia: IV opioids, paracetamol, NSAIDs
  • Consider ESP block, paravertebral block, or wound infiltration


⚠️ 5. Complications of PCNL (Anesthetic Relevance)

Complication

Anesthetic Concern

Bleeding

Hypovolemia, hypotension – prepare for transfusion

Injury to pleura

Pneumothorax, hydrothorax – monitor for desaturation

Injury to colon/liver/spleen

Abdominal tenderness, sepsis

Infection/sepsis

Treat UTI pre-op; monitor for post-op sepsis

Fluid overload

From irrigation; monitor SpO₂, JVP, lung signs



🧠 6. Anesthetic Considerations – Ureteroscopy (URS)

✅ Anesthetic Technique

  • GA or spinal anesthesia both acceptable
  • GA preferred for long, complex cases
  • Spinal useful for short diagnostic or stone fragmentation

A. Positioning

  • Lithotomy position
  • Ensure padding to avoid peroneal nerve injury

B. Airway & Ventilation

  • GA with ETT or LMA (if brief case)
  • Avoid Trendelenburg to reduce aspiration risk

C. Pain Management

  • Short-acting opioids (fentanyl)
  • Diclofenac or IV paracetamol
  • Post-op ureteric spasm may need additional analgesia

D. Complications

  • Ureteral trauma or perforation
  • Sepsis due to pyonephrosis → must sterilize urine pre-op
  • Obstruction post-op due to edema → stenting


Viva Q&A Tips

Q. Why is GA preferred in PCNL?
→ Because of prone position, longer surgery duration, bleeding risk, and airway protection.

Q. What regional techniques can be used?
→ Subarachnoid block, combined spinal-epidural (CSE), paravertebral block, or ESP block.

Q. What is the risk of TURP syndrome in PCNL?
→ Due to excessive absorption of irrigating fluid (if hypotonic fluids used), leading to hyponatremia, fluid overload, cerebral edema.