This procedure is usually only carried out in the case of large and complex kidney stones, such as staghorn calculi. A staghorn calculus is a stone that fills large sections of the renal pelvis or one or more of the renal calyces. Percutaneous nephrolitholapaxy (PCNL) involves removing kidney stones by creating an artificial opening in the back. To do this, the kidney is punctured from the flank directly through the skin. This allows an endoscope to be inserted into the renal collecting system, where the stone is located. This operation is generally performed under general anesthetic. The urinary tract is prepared for the operation with the patient in the lithotomy position. The patient is then moved onto their stomach so that they are lying face down. This allows the surgery itself to be performed on the back.
The puncture procedure is carried out under visual control using ultrasound and X-ray imaging. Once the endoscope – which can be as thick as a pencil – has been inserted into the kidney, the stone can be broken up with an ultrasonic or laser probe and the pieces can then be removed. To finish off the operation, a catheter is inserted into the kidney (urinary diversion outwards via the flank) or a ureteral stent (internal diversion) is put in to prevent any obstruction of the urine flow.
The patient usually has to stay in hospital for three to five days. If the procedure is performed by an experienced surgeon, the complication rate is usually low. 
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