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  • Review Article
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Pain management in percutaneous nephrolithotomy — an approach rooted in pathophysiology

Nature Reviews Urology volume 22, pages 354–365 (2025)Cite this article

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Abstract

Pain related to percutaneous nephrolithotomy (PCNL) is multifactorial and poorly elucidated. However, understanding the pathophysiology of pain can enable a practical approach to pain management, which can be tailored to each patient. A number of potential mechanisms underlie pain perception in PCNL, and these mechanisms can be leveraged at various points on the perioperative care pathway. These interventions provide opportunities for modulation of pain associated with PCNL but must take into account various technical, pharmacological and patient-related considerations. Technical considerations include the influence of percutaneous access, stone removal and drainage techniques. Pharmacological aspects include the use of various analgesics and anaesthesia approaches. Patient factors include consideration of the biopsychosocial model in pain experience to understand each individual’s response to pain. By understanding the contemporary evidence surrounding the physiology of postoperative pain and identifying tangible intervention points, we can seek to mitigate postoperative pain in patients undergoing PCNL.

Key points

  • Surgical pain in percutaneous nephrolithotomy (PCNL) has both somatic and visceral aspects and, therefore, appropriate pain-management strategies must target both of these systems. Both types are important components of postoperative pain and must be considered in formulating a tailored approach to pain control during and after PCNL.

  • Pain following PCNL is a complex experience that is influenced by physiological, behavioural and psychological factors, which are unique to each patient and surgery.

  • The multifaceted nature of pain and nociception presents numerous opportunities to mitigate the patient’s experience of postoperative pain and enhance patient outcomes after PCNL.

  • Postoperative pain control can be improved by modulating operative factors, such as access technique and postoperative drainage.

  • Multimodal analgesia enables synergistic pain control of various targets in the pain experience while minimizing the adverse effects associated with high doses of any single medication, including opioids.

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Fig. 1: Potential anatomical sources of pain during PCNL.
Fig. 2: Pain modulation opportunities along the PCNL care spectrum.
Fig. 3: Biopsychosocial model of pain.

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Authors and Affiliations

  1. Department of Urology, Montefiore Medical Center, Bronx, NY, USA

    Kelli Aibel

  2. Department of Urology, Lenox Hill Hospital/Northwell Health, New York, NY, USA

    Robert Chang & Jared S. Winoker

  3. Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Arinze J. Ochuba

  4. Department of Urology, Mayo Clinic, Rochester, MN, USA

    Kevin Koo

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  1. Kelli Aibel
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  2. Robert Chang
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  3. Arinze J. Ochuba
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  4. Kevin Koo
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  5. Jared S. Winoker
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Contributions

J.S.W., K.A., A.J.O. and K.K. researched data for the article. J.S.W. and K.A. made substantial contributions to discussion of content and wrote the manuscript. All authors reviewed and edited the manuscript before submission.

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Correspondence to Jared S. Winoker.

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Aibel, K., Chang, R., Ochuba, A.J. et al. Pain management in percutaneous nephrolithotomy — an approach rooted in pathophysiology. Nat Rev Urol 22, 354–365 (2025). https://doi.org/10.1038/s41585-024-00973-w

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