Initial experiences with percutaneous nephrolithotomy in a resource-poor setting: a case series from northern Ghana

¹Department of Surgery, Tamale Teaching Hospital, Tamale, Ghana, ²Department of Pathology, University for Development Studies, Tamale, Ghana

^&Corresponding author
Benjamin Akinkang, Department of Pathology, University for Development Studies, Tamale, Ghana

Introduction    

Percutaneous nephrolithotomy (PCNL) is the gold-standard intervention for managing large (>2 cm). Complex renal stones, offering superior stone clearance compared with extracorporeal shock wave lithotripsy (ESWL) and retrograde intrarenal surgery (RIRS) [1]. Over the past two decades, the evolution of PCNL has led to refinements such as miniaturised access tracts, tubeless techniques, and image-guided renal puncture, improving safety and reducing morbidity [2]. However, in low- and middle-income countries (LMICs), including Ghana, the adoption of PCNL remains limited by infrastructural, technical, and human-resource constraints. The global incidence of urolithiasis is increasing, partly due to lifestyle and dietary transitions associated with urbanisation [3]. In sub-Saharan Africa, population-based data remain sparse. Still, emerging hospital reports suggest that an increasing number of patients present with symptomatic nephrolithiasis, often at advanced stages, with greater stone burdens [4]. Access to minimally invasive urologic surgery is restricted to a few tertiary centres with functional endourology units and fluoroscopy or ultrasound guidance systems. In Ghana, where most urologic centres operate under resource constraints, open stone surgery is still performed for large or complex stones in many hospitals [5].

Percutaneous nephrolithotomy requires specialised instruments (nephroscopes, dilators, lithotripters), imaging for renal access, and trained personnel. In many low- and middle-income countries (LMICs), shortages of fluoroscopy units, limited availability of disposable access kits, and unreliable equipment maintenance hinder routine PCNL procedures [6]. Additionally, the limited number of trained endourologists and anaesthesia support services further restrict access. These barriers underscore the need for context-specific adaptation of PCNL techniques and resource optimisation. Several centres in Asia and Africa have demonstrated feasible modifications of PCNL under constrained conditions. Ultrasound-guided renal puncture, used either as a primary modality or in combination with fluoroscopy, has been shown to achieve safe access with reduced radiation exposure [7]. Mini-PCNL and tubeless PCNL approaches have been associated with reduced bleeding, shorter hospital stays, and lower postoperative analgesic requirements [2], making them particularly suitable in settings with limited blood transfusion capacity and hospital bed shortages. Moreover, spinal anaesthesia and supine positioning have been successfully adopted in resource-limited centres to overcome anaesthetic and patient positioning challenges [8].

The most frequent complications include transient fever and minor bleeding, whereas major complications such as sepsis or organ injury are uncommon when strict perioperative protocols are used [9]. These findings suggest that PCNL can be safely implemented in low-resource settings, provided adequate training, equipment maintenance, and patient selection are in place. Despite the increasing burden of renal calculi in Ghana, published local data on PCNL outcomes are virtually nonexistent. Anecdotal reports suggest that only a few tertiary hospitals, such as Korle-Bu Teaching Hospital, Komfo Anokye Teaching Hospital, and Tamale Teaching Hospital, regularly perform PCNL, often under modified protocols using ultrasound guidance or mini-PCNL kits, owing to limited fluoroscopic access and instrument availability. Systematic documentation of the clinical characteristics, procedural adaptations, outcomes, and complications of PCNL in Ghana would provide valuable local evidence to inform national surgical policy, resource allocation, and endourology training priorities.

This proposed case series aims to bridge the evidence gap by documenting the experiences and outcomes of PCNL procedures performed in peri-urban settings in Ghana. The specific objectives of this series include the following: 1) to describe the demographic and clinical characteristics of patients who underwent PCNL. 2) To determine the mean operative time, mean stone size, mean blood loss, mean number of nephrostomy days, and duration of hospital stay among patients treated with PCNL. 3) To document the intraoperative and postoperative complications associated with PCNL. The findings provide an evidence base for resource allocation, capacity building, and the standardisation of endourologic practice in Ghana and similar low-resource settings. Additionally, this study contributes to regional data on innovations and adaptations that make advanced urological care feasible and sustainable in sub-Saharan Africa.

Methods     

This case series was conducted at the Department of General Surgery of the Upper East Regional Hospital, Bolgatanga, a regional referral facility for the Upper East Region of Ghana. Ethical clearance was waived, and signed consent was obtained from the patients. We retrospectively reviewed all cases of renal stones at the Bolgatanga Hospital in which PCNL was performed. Information on age, sex, chief complaint, and laterality of the kidney involved, as well as the imaging modality used in diagnosis, and the location of the stone. These data were compiled as part of the patients´ information and clinical presentation, as shown in Table 1. The variables related to the operative procedure (Table 2) that were extracted included patient positioning during the procedure, size of the tract used, type of lithotripter, procedure duration, estimated blood loss, and the number of days the nephrostomy tube remained in situ. We also extracted information on tone characteristics such as stone size, number of stones, chemical composition, length of stay postoperative before discharge, and complications, as shown in Table 3. The data were entered into and analysed via Microsoft Excel. Simple descriptive statistics, such as proportions, means, and standard deviations, were used to present the results.

Operative technique: all procedures were carried out under general anaesthesia. A urine culture was obtained before the procedure. Patients with sterile urine were given standard perioperative antibiotic prophylaxis. Those with positive urine cultures were treated before surgery. Insertion of the ureteric catheter and retrograde pyelography, in the lithotomy position, the patient was prepped and draped, a cystoscopy was performed to identify the appropriate ureteric orifice, a guidewire was passed into the kidney, and the ureteric catheter was passed under C-arm guidance to the renal pelvis. Retrograde pyelography was then performed to study the anatomy of the renal pelvis, and a urethral catheter was then passed and fixed to the ureteric catheter. The patient was then positioned prone, and an abdominal cushion was used to elevate the lumbar spine. Under ultrasound guidance with the help of the C-arm, the lower calyx was punctured via the puncture needle. After successful puncture, a guidewire is passed into the renal pelvis, and serial dilatation is performed up to 30 fr. The Amplatz sheath is then inserted under C-arm guidance. The microscope was placed under vision, and nephroscopy was performed until the stone was visualised via irrigation fluid. Stone disintegration and fragmentation were carried out via a pneumatic lithotripter. The stone fragments were removed with stone forceps and preserved for stone analysis; small fragments were removed via the irrigation fluid. After complete extraction, a new nephroscopy was performed to ensure total clearance of the stone. A 16 fr nephrostomy tube was then inserted and connected to a urine bag. At the end of the procedure, the ureteral catheter was removed, and the transurethral catheter was left in place until postoperative days 1 or 2, when it was removed. Postoperatively, patients were monitored closely for bleeding, fever and pain. The nephrostomy tube was removed between postoperative days 2 and 4.

Results     

Patient and clinical features: for the entire year 2025, we performed PCNL on 5 patients, 3 of whom were male and 2 of whom were female. The mean age of the patients was 43 years (SD, 9.35), and the range was 32-55 years. All 5 patients complained chiefly of flank pain, 3 of whom had pain in the left flank. Ultrasonography (USG) and noncontrast computed tomography (NCCT) were performed for all 5 patients. Three (3) of the patients had stones located in the renal pelvis, 1 each in the lower pole and ureteropelvic junction.

Operative procedure: all 5 patients were placed in the prone position. A tract size of 30 Fr was used for all the patients. A pneumatic lithotripter was used for all our patients. The mean blood loss was 80 (SD, 44.72) mL, with some losing as little as 50 mL and some as much as 150 mL. The mean duration of the surgery was 144 (SD 25.09) minutes. The mean number of days the nephrotomy tube was left in situ was 2.6 (SD 0.89) days.

Stone characteristics and postcomplications: all patients had one stone, which was completely removed, with a mean stone size of 2.1 cm (SD, 0.42 cm). The chemical composition of all 5 stones was calcium oxalate. The mean duration of stay postoperatively was 3.6 (SD, 0.89) days. Only one patient had a low-grade fever as the only complication. All patients were followed up for 6 weeks post-operatively.

Discussion     

Patients and clinical features: percutaneous nephrolithotomy (PCNL) is the gold standard for treating large renal stones (≥ 20 mm) because it offers a creative and effective substitute for open surgery and laparoscopic pyelolithotomy in situations with limited resources. Because it is dependable, repeatable, and less complicated, it is a great option for therapy in sub-Saharan Africa [1,10]. Many cases of renal stones have been recorded at the Upper East Regional Hospital, but very few of those who qualify for PCNL can afford the cost, which is one of the main challenges over the period under consideration. Most of the people within the catchment area of the Upper East Regional Hospital are farmers and petty traders who may not be able to afford the cost of a PCNL. The remaining patients underwent open surgery. Therefore, this accounted for the low number of patients (5) who had PCNL. Many studies and case series have revealed that males are more likely to develop kidney stones than females [11]. This is in keeping with the 3 out of 5 patients with renal stones in this series, although the sample size is extremely small for adequate comparison to be made. People exposed to hot temperatures and warmer climates are more likely to develop kidney stones [12].

Owing to their major occupation as farmers, the male population in the Upper East region of Ghana, the catchment area of the study site, is usually exposed to very high temperatures and sometimes inadequate water intake, resulting in dehydration. This dehydration can cause urine crystallisation. Women are mostly engaged in indoor work, thus minimising their exposure to hot temperatures and dehydration. It has also been shown that sex differences exist in the relationship between heat and stone formation risk, with men having more risk than women [11]. The mean age of the patients in this series was 43 years, with a standard deviation of 9.355, which is in accordance with the literature [5,6]. Depending on the location of the stone and its size, the patient may be asymptomatic or present with symptoms. These symptoms could be obstructive symptoms or renal colic, which is a sharp, sudden pain that may fluctuate in intensity over several minutes to become steady [13]. Flank pain is usually the most common symptom, as seen in a study of urolithiasis in a multiethnic population at a tertiary hospital in Nairobi, Kenya, by Wathigo et al [4]. All our patients in this series complained of renal colic (flank pain). The imaging modality of choice used in most of the literature is a noncontrast CT scan, as it is able to localise the stone as to whether it is located in the renal parenchyma, pelvis, poles, etc [13]; however, it is not readily available and costly for a peasant population such as the study site. Ultrasonography can also be used to detect the presence of a stone, but not the precise location and size of the stone. Although it is inexpensive and readily available, it is operator-dependent [13]. Even though a noncontrast CT scan is the gold standard, its high cost and nonavailability allowed us to use USG as our screening tool. Once a stone is detected, a CT scan is performed to characterise the stone and to study renal anatomy. Based on these findings, both USG and noncontrast CT were performed for all 5 patients. While lower pole stones are the most common [14], 3 out of 5 patients had stones located in the renal pelvis. Notably, this is an extremely small sample size for comparison.

Operative procedure: while the preoperative preparations for PCNL may differ depending on the geographical location and institution, one commonality among all PCNL preparations, which was also performed in our patients, is ensuring sterile urine before the procedure. To achieve this, urinalysis is performed, and if the reports point to a urinary tract infection, urine cultures are performed; if bacteria are present, treatment is given via appropriate antibiotics; otherwise, prophylactic antibiotics are given [1]. Another common thing or recommendation is to obtain a full blood count, looking for an indication of potential haemorrhage [1]. For our patients, there was no evidence of urinary tract infections, so only prophylactic antibiotics were given. The full blood count reports were unremarkable. All 5 patients were given general anaesthesia and placed in the prone position supported by a cushion. There are two main positions in which the patient can be placed for the procedure: supine and prone. The prone position has been shown to have a higher stone-free rate than the supine position. However, complications are more common in the prone position than in the supine position [15]. Based on these findings and our endourologist's experience, we adopted the prone position for all our patients. However, we did not encounter any complications.

A lithotripter is required to fragment the stone during PCNL. Many approaches exist, depending on the energy source. These include ultrasonic, pneumatic, combined ultrasonic-pneumatic and laser methods [16]. While other approaches or modalities have good results but are laden with complications, the laser has very good results with minimal complications. However, it requires high energy and high maintenance costs, making its use in a resource-limited country expensive [16]. The mean blood loss volume was 80 ml (SD, 44.12), with a range of 50 to 150 ml. This is not very different from what has been reported in many articles. The amount of blood loss did not require hemotransfusion or renal angioembolization. The mean operation duration was 144 minutes, with a standard deviation of 25.09 minutes and a range of 120 to 180 minutes. This is quite close to the 130 minutes stated by Kamadjou et al. [10] but far greater than the 74.9-minute time estimate by Guler et al. [17] and 49.44 by Zeid et al. [18]. Various opinions exist about drainage insertion [10]. Tubeless PCNL has been shown to have better outcomes in terms of a short hospital stay, fewer requirements for analgesia, etc., but drains (nephrostomy tubes) are still considered standard procedures since they act as a tamponade for bleeding and provide access for possible re-exploration in addition to their drainage functions [19]. The mean number of days the nephrotomy tube was left in situ was 2.6 (SD 0.89) days, with a range of 2 to 4 days, which is greater than the 24 hrs estimated by Kamadjou et al. [10].

Stone characteristics and postoperative complications: all 5 stones are composed mainly of calcium oxalate, which is in keeping with the fact that calcium oxalate stones are the most common [5,13]. Other types of stones, especially in Ghana, include calcium apatite, amorphous calcium phosphate carbonate, carbonate apatite, ammonium urate, cystine, xanthine, struvite, etc [5]. The number of days a patient spends on admission after surgery depends on many factors, such as the recovery rate, complications encountered, and the need for further close monitoring. In our case, the patient spent between 3 and 5 days, with a mean of 3.6 days (SD, 0.89). This is in keeping with the 3.06 reported by Kamadjou et al. [10] but shorter than the 4.29 reported by ElSheemy et al. [20] and longer than the 2.4 Zeid et al. [18]. The small sample size of our patients does not allow proper comparisons. However, it is worth noting that the lack of complications among our patients may have been responsible for the short mean time compared with that reported by ElSheemy et al. who reported an appreciable level of complications [20]. The effect of complications on the length of stay can be explained by the fact that the longest stay in our study was for patients who had a low-grade fever. Even though we did not record any complication level higher than Clavien-Dindo grade 1, which is low-grade fever, the extremely small sample size must be taken into consideration.

Limitations: the strength of the comparison of the findings with literature data is limited by the small sample sizes.

Conclusion     

Percutaneous nephrolithotomy can be safely and effectively performed in resource-limited regional hospitals and has favourable outcomes and minimal complications. This study demonstrates the feasibility of implementing minimally invasive endourological procedures in Ghana and highlights the need for larger multicenter studies to strengthen local evidence and guide the expansion of endourological services.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

All authors were involved in the conceptualisation, analysis, and writing up of this work. They have read and approved the final version of this manuscript.

Tables     

Table 1: patient information and clinical presentation of patients who underwent PCNL at Upper East Regional Hospital for renal stones from January 2025 to December 2025

Table 2: summary of operative procedure for patients who underwent PCNL at Upper East Regional Hospital for renal stones from January 2025 to December 2025

Table 3: stone characteristics and postcomplications of patients who underwent PCNL at Upper East Regional Hospital for renal stones from January 2025 to December 2025

References