A randomized trial evaluating type of nephrostomy drainage after percutaneous nephrolithotomy: small bore v tubeless

Comparative analysis of standard, tubeless and total tubeless percutaneous nephrolithotomy: A prospective study

INTRODUCTION

This study was done to review and compare safety, effectiveness and advantages of total tubeless percutaneous nephrolithotomy (PCNL), tubeless PCNL with standard PCNL.

METHODOLOGY

This prospective comparative study involving 30 patients in each total tubeless PCNL, tubeless PCNL and standard PCNL group from Feb 2021 to June 2022.

RESULT

Significant difference was found in mean duration of surgery (p < 0.01), mean hospital stay (p < 0.01), mean VAS post op score (p < 0.01), mean time to return to normal activity (p < 0.01) in total and tubeless PCNL group as compared with standard PCNL. While no significant difference found in mean haemoglobin drop (p = 0.1417), blood transfusion (p = 3721), incidence of urine leak (p = 0.13), need of accessory secondary procedure (p = 0.1322) and associated complications (p = 0.5939) among three groups.

CONCLUSION

Study observed that total tubeless, tubeless PCNL is a safe and efficient technique. It is significantly associated with the advantages of shorter hospital stay, shorter time to return to normal activity, lower postoperative pain scores. Total tubeless PCNL obviates need of second procedure of removing DJ stent. Standard, tubeless and total tubeless PCNL have similar post op complication rate. Study thus concludes that total tubeless, tubeless PCNL can be used as a substitute for traditional standard PCNL.

Comparing Tubeless and Tubed Approaches in Percutaneous Nephrolithotomy for Moderate Renal Calculi: Outcomes on Safety, Efficacy, Pain Management, Recovery Time, and Cost-Effectiveness

Introduction This study focuses on investigating the effect of routine nephrostomy tube placement in patients with moderate renal calculi of size 2.5 cm or less who undergo uncomplicated percutaneous nephrolithotomy (PCNL) procedures. Previous studies have not specified whether only uncomplicated cases were included in the analysis, which may affect the results. This study aims to provide a clearer understanding of the effect of routine nephrostomy tube placement on blood loss in a more homogeneous patient population. Materials and methods A prospective randomized controlled trial (RCT) was conducted at our department over 18 months, dividing 60 patients with a single renal or upper ureteric calculus of size ≤2.5 cm into two groups: 30 patients in each group (group 1: tubed PCNL, group 2: tubeless PCNL). The primary outcome was the drop in perioperative hemoglobin level and the number of packed cell transfusions necessary. The secondary outcome included the mean pain score, analgesic requirement, length of hospital stay, time to return to normal activities, and the total cost of the procedure. Results The two groups were comparable in age, gender, comorbidities, and stone size. The postoperative hemoglobin level was significantly lower in the tubeless PCNL group (9.56 ± 2.13 gm/dL) compared to the tube PCNL group (11.32 ± 2.35 gm/dL) (p = 0.0037), and two patients in the tubeless group required blood transfusion. The duration of surgery, pain scores, and analgesic requirement were comparable between the two groups. The total procedure cost was significantly lower in the tubeless group (p = 0.0019), and the duration of hospital stay and time to return to daily activities were significantly shorter in the tubeless group (p < 0.0001). Conclusions Tubeless PCNL is a safe and effective alternative to conventional tube PCNL, with the advantages of shorter hospital stay, faster recovery, and lower procedure costs. Tube PCNL is associated with less blood loss and the need for transfusions. Patient preferences and bleeding risk should be considered when choosing between the two procedures.

Complications and outcomes of tubeless versus nephrostomy tube in percutaneous nephrolithotomy: a systematic review and meta-analysis of randomized clinical trials

We aimed to perform a systematic review of randomized trials to summarize the evidence on the safety and stone-free rate after Tubeless percutaneous nephrolithotomy (PCNL) (ureteral stent/catheter, no nephrostomy) compared to Standard PCNL (nephrostomy, with/without ureteral stent/catheter) to evaluate if the tubeless approach is better. The inverse variance of the mean difference with a random effect, 95% Confidence Interval (CI), and p values was used for continuous variables. Categorical variables were assessed using Cochran-Mantel-Haenszel method with the random effect model, and reported as Risk Ratio (RR), 95% CI, and p values. Statistical significance was set at p < 0.05 and a 95% CI. 26 studies were included. Mean operative time was significantly shorter in the Tubeless group (MD-5.18 min, 95% CI - 6.56, - 3.80, p < 0.00001). Mean postoperative length of stay was also significantly shorter in the Tubeless group (MD-1.10 day, 95% CI - 1.48, - 0.71, p < 0.00001). Incidence of blood transfusion, angioembolization for bleeding control, pain score at the first postoperative day, the number of patients requiring postoperative pain medication, fever, urinary infections, sepsis, perirenal fluid collection, pleural breach, hospital readmission, and SFR did not differ between the two groups. Incidence of postoperative urinary fistula was significantly lower in the Tubeless group (RR 0.18, 95% CI 0.07, 0.47, p = 0.0005). This systematic review shows that tubeless PCNL can be safely performed and the standout benefits are shorter operative time and hospital stay, and a lower rate of postoperative urinary fistula.

The feasibility of one-day length of hospital stay after pediatric percutaneous nephrolithotomy

PURPOSE

To evaluate the safety of one-day length of hospital stay (LOS) after pediatric percutaneous nephrolithotomy (PNL), and to study the predictors of LOS.

METHODS

A retrospective study included pediatric patients who PNL for renal calculi more than 1 cm between January 2016 and October 2019. PNL was performed in prone position. The nephrostomy tubes and ureteric catheters were removed on the second day and patients were discharged if there was no perforation or significant residual stones. The stone free rate, LOS and the surgical complications were reported. Bivariate and multivariate analysis were used to predict the LOS.

RESULTS

220 patients were identified. The median age (range) was eight (Range: 3-17) years. Stone free rate was achieved in 200 patients (91%) of patients, while residual fragments were detected in 20 patients (9%). Complications, they were reported in 50 (22.7%) patients. 184 (83.6%) of patients stayed at the hospital for only 1 day, while 36 (16. 4%) stayed more than 1 day. Of 36 patients who stayed more than one-day, 34 had complications (p value <0.001).On multivariate analysis, surgical complications was found to be the only predictor of longer LOS (p value <0.001).

CONCLUSION

Early nephrostomy tube removal and 1-day length of hospital stay could be a safe option after pediatric PNL. Surgical complications is a statistically significant predictor of longer LOS.

Comparison of tubeless percutaneous nephrolithotomy and standard percutaneous nephrolithotomy for kidney stones: A meta-analysis of randomized trials

This systematic review was designed to evaluate the efficacy of tubeless percutaneous nephrolithotomy (PCNL) versus standard percutaneous nephrolithotomy (PCNL) for kidney stones. Computerized search was performed for randomized clinical trials (RCTs) from PubMed, EMBASE, CENTRAL and Cochrane Database of Systematic Reviews databases. The included studies were randomized trials investigating tubeless PCNL versus standard PCNL in patients with kidney stones. Outcomes measured included postoperative pain, postoperative analgesia, hospital stay, drop in hemoglobin, stone free, urine leakage, blood transfusion, or pyrexia per randomized patients. In all, 15 RCTs involving 947 subjects were included. With regard to postoperative pain, analgesia, hospital stay and urine leakage, it was significantly reduced in tubeless PCNL group. In respect of drop in hemoglobin, stone free, blood transfusion and pyrexia, tubeless PCNL group appeared to be equivalent with standard PCNL group. Tubeless PCNL technology is associated with shorter hospitalization time, lower incidence of postoperative pain and less analgesia requirement after nephrolithotony. Tubeless PCNL can be used as a substitute for traditional standard PCNL of the first-line treatment. Nevertheless, further research in this field is urgently needed to confirm it.

Choosing the appropriate size of Amplatz sheath during percutaneous nephrolithotomy-a novel method

Objective

To choose appropriate size Amplatz sheath during percutaneous nephrolithotomy (PCNL) based on retrograde pyelogram.

Material and methods

We performed standard PCNL in prone position in 20 patients. All these patients had placement of appropriate size of Amplatz sheath based on retrograde pyelogram images. All patients had nephrostomy tubes postoperatively. The preoperative and postoperative renal parameters, hemoglobin, mean operating time and mean hospitalisation stay were measured.

Results

There was no significant difference between the pre-operative and postoperative hemoglobin and creatinine levels. Median operating time was 60.5 mins (45 to 98 mins). The median hospitalisation stay was 4.6 days (3 to 7 days). There was no intraoperative pelvic wall or infundibular injury.

Conclusion

Choosing correct size of Amplatz sheath lowers the incidence of kidney hemorrhage and renal function impairment.

Tubeless Pediatric Percutaneous Nephrolithotomy: Assessment of Feasibility and Safety

Introduction

Tubeless pediatric percutaneous nephrolithotomy (TL-PCNL) is evolving and adult criteria are being safely applied to children. We examine the feasibility, safety, and outcomes of pediatric TL.

Materials and Methods

A retrospective review of pediatric (≤18 years) PCNL patients at our institute was done. Patients eligible for TL but underwent tube (T) PCNL due to surgeon choice or protocol were compared with TL. Only children with 100% stone clearance were included, and those receiving nephrostomy for intraoperative complications were excluded from the study. Demographic, baseline, and stone characteristics were matched. Safety, outcome, and complications were assessed. Group T was classified into large bore (22F-LB) and small bore (16F-SB) based on nephrostomy size. Statistical analysis was done.

Results

A total of 46 children were eligible - TL in 17 (37%) and T in 29 (63%). Among T, SB was performed in 6/29 (20.7%) and LB in 23/29 (79.3%). TL had fewer complications. Urinary leak developed in 2 (6.9%) patients in T. Eight (27.6%) patients in T and 3 (17.7%) patients in TL had supracostal access with complications similar to infracostal access. SB had significantly lesser and analgesic requirement than LB. SB and TL had similar LOH and analgesic requirement. Adult expanded criteria such as supracostal access, 2 punctures, prior renal surgery, and larger tract size were feasible.

Conclusions

TL is safe, feasible, and less morbid alternative to T in uncomplicated pediatric nephrolithiasis. TL is feasible with supracostal access, 2 punctures, adult tract size (24F), and anomalous kidneys. SB nephrostomy is reasonable when tube is indicated.

Tubeless versus standard percutaneous nephrolithotomy: an update meta-analysis

Background

To update a previously published systematic review and meta-analysis on the efficacy and safety of tubeless percutaneous nephrolithotomy (PCNL).

Methods

A systematic literature search of EMBASE, PubMed, Web of Science, and the Cochrane Library was performed to confirm relevant studies. The scientific literature was screened in accordance with the predetermined inclusion and exclusion criteria. After quality assessment and data extraction from the eligible studies, a meta-analysis was conducted using Stata SE 12.0.

Results

Fourteen randomized controlled trials (RCTs) involving 1148 patients were included. Combined results demonstrated that tubeless PCNL was significantly associated with shorter operative time (weighted mean difference [WMD], −3.79 min; 95% confidence interval [CI], −6.73 to −0.85; P = 0.012; I² = 53.8%), shorter hospital stay (WMD, −1.27 days; 95% CI, −1.65 to −0.90; P < 0.001; I² = 98.7%), faster time to return to normal activity (WMD, −4.24 days; 95% CI, −5.76 to −2.71; P < 0.001; I² = 97.5%), lower postoperative pain scores (WMD, −16.55 mm; 95% CI, −21.60 to −11.50; P < 0.001; I² = 95.7%), less postoperative analgesia requirements (standard mean difference, −1.09 mg; 95% CI, −1.35 to −0.84; P < 0.001; I² = 46.8%), and lower urine leakage (Relative risk [RR], 0.30; 95% CI 0.15 to 0.59; P = 0.001; I² = 41.2%). There were no significant differences in postoperative hemoglobin reduction (WMD, −0.02 g/dL; 95% CI, −0.04 to 0.01; P = 0.172; I² = 41.5%), stone-free rate (RR, 1.01; 95% CI, 0.97 to 1.05; P = 0.776; I² = 0.0%), postoperative fever rate (RR, 1.05; 95% CI, 0.57 to 1.93; P = 0.867; I² = 0.0%), or blood transfusion rate (RR, 0.79; 95% CI, 0.36 to 1.70; P = 0.538; I² = 0.0%). The results of subgroup analysis were consistent with the overall findings. The sensitivity analysis indicated that most results remained constant when total tubeless or partial tubeless or mini-PCNL studies were excluded respectively.

Conclusions

Tubeless PCNL is an available and safe option in carefully evaluated and selected patients. It is significantly associated with the advantages of shorter hospital stay, shorter time to return to normal activity, lower postoperative pain scores, less analgesia requirement, and reduced urine leakage.

Tubeless versus standard percutaneous nephrolithotomy: an update meta-analysis

BACKGROUND

To update a previously published systematic review and meta-analysis on the efficacy and safety of tubeless percutaneous nephrolithotomy (PCNL).

METHODS

A systematic literature search of EMBASE, PubMed, Web of Science, and the Cochrane Library was performed to confirm relevant studies. The scientific literature was screened in accordance with the predetermined inclusion and exclusion criteria. After quality assessment and data extraction from the eligible studies, a meta-analysis was conducted using Stata SE 12.0.

RESULTS

Fourteen randomized controlled trials (RCTs) involving 1148 patients were included. Combined results demonstrated that tubeless PCNL was significantly associated with shorter operative time (weighted mean difference [WMD], -3.79 min; 95% confidence interval [CI], -6.73 to -0.85; P = 0.012; I² = 53.8%), shorter hospital stay (WMD, -1.27 days; 95% CI, -1.65 to -0.90; P < 0.001; I² = 98.7%), faster time to return to normal activity (WMD, -4.24 days; 95% CI, -5.76 to -2.71; P < 0.001; I² = 97.5%), lower postoperative pain scores (WMD, -16.55 mm; 95% CI, -21.60 to -11.50; P < 0.001; I² = 95.7%), less postoperative analgesia requirements (standard mean difference, -1.09 mg; 95% CI, -1.35 to -0.84; P < 0.001; I² = 46.8%), and lower urine leakage (Relative risk [RR], 0.30; 95% CI 0.15 to 0.59; P = 0.001; I² = 41.2%). There were no significant differences in postoperative hemoglobin reduction (WMD, -0.02 g/dL; 95% CI, -0.04 to 0.01; P = 0.172; I² = 41.5%), stone-free rate (RR, 1.01; 95% CI, 0.97 to 1.05; P = 0.776; I² = 0.0%), postoperative fever rate (RR, 1.05; 95% CI, 0.57 to 1.93; P = 0.867; I² = 0.0%), or blood transfusion rate (RR, 0.79; 95% CI, 0.36 to 1.70; P = 0.538; I² = 0.0%). The results of subgroup analysis were consistent with the overall findings. The sensitivity analysis indicated that most results remained constant when total tubeless or partial tubeless or mini-PCNL studies were excluded respectively.

CONCLUSIONS

Tubeless PCNL is an available and safe option in carefully evaluated and selected patients. It is significantly associated with the advantages of shorter hospital stay, shorter time to return to normal activity, lower postoperative pain scores, less analgesia requirement, and reduced urine leakage.

Improving Drainage After Percutaneous Nephrolithotomy Based on Health-Related Quality of Life: A Prospective Randomized Study

PURPOSE

The impact of drainage type after percutaneous nephrolithotomy (PCNL) on the health-related quality of life (HRQoL) has been rarely studied. We conducted a prospective randomized study to evaluate the differences in HRQoL among patients who received different drainage types.

METHODS

A total of 90 patients who underwent PCNL were randomized into three groups to receive a nephrostomy tube (Group 1), a Double-J (JJ) stent (Group 2), and an open-ended ureteral catheter (Group 3) after PCNL, respectively. We compared the perioperative characteristics, surgical outcomes, and HRQoL using Wisconsin Stone Quality of Life (WiSQoL) questionnaire among three groups.

RESULTS

There were no significant differences in patients' characteristics such as age, gender ratio, body mass index, stone burden, and so on. Majority of the surgical outcomes (operative time, estimated blood loss, hemoglobin drop, postoperative complications, and stone-free rate) were also comparable, except for the duration of hospitalization, visual analog scale, and analgesic required. The preoperative WiSQoL scores were similar among the three groups, but significant differences occurred postoperation (Groups 1, 2, and 3, 122.0 vs 105.6 vs 124.4, p < 0.001). Besides, patients in Group 2 had lower willingness (Groups 1, 2, and 3, 86.7% vs 70.0% vs 96.7%, p = 0.02) to undergo the same procedure as future treatment, if needed.

CONCLUSIONS

Our study suggested that the drainage types after PCNL using a nephrostomy tube or a JJ stent or an open-ended ureteral catheter were equally safe and efficacious, but patients who received a nephrostomy tube or an open-ended ureteral catheter had better HRQoL.

Intraoperative and postoperative feasibility and safety of total tubeless, tubeless, small-bore tube, and standard percutaneous nephrolithotomy: a systematic review and network meta-analysis of 16 randomized controlled trials

BACKGROUND

Percutaneous nephrolithotomy (PCNL) is performed to treat relatively large renal stones. Recent publications indicate that tubeless and total tubeless (stentless) PCNL is safe in selected patients. We performed a systematic review and network meta-analysis to evaluate the feasibility and safety of different PCNL procedures, including total tubeless, tubeless with stent, small-bore tube, and large-bore tube PCNLs.

METHODS

PubMed, Cochrane Central Register of Controlled Trials, and EMBASE™ databases were searched to identify randomized controlled trials published before December 30, 2013. One researcher examined all titles and abstracts found by the searches. Two investigators independently evaluated the full-text articles to determine whether those met the inclusion criteria. Qualities of included studies were rated with Cochrane's risk-of-bias assessment tool.

RESULTS

Sixteen studies were included in the final syntheses including pairwise and network meta-analyses. Operation time, pain scores, and transfusion rates were not significantly different between PCNL procedures. Network meta-analyses demonstrated that for hemoglobin changes, total tubeless PCNL may be superior to standard PCNL (mean difference [MD] 0.65, 95% CI 0.14-1.13) and tubeless PCNLs with stent (MD -1.14, 95% CI -1.65--0.62), and small-bore PCNL may be superior to tubeless PCNL with stent (MD 1.30, 95% CI 0.27-2.26). Network meta-analyses also showed that for length of hospital stay, total tubeless (MD 1.33, 95% CI 0.23-2.43) and tubeless PCNLs with stent (MD 0.99, 95% CI 0.19-1.79) may be superior to standard PCNL. In rank probability tests, small-bore tube and total tubeless PCNLs were superior for operation time, pain scores, and hemoglobin changes.

CONCLUSIONS

For hemoglobin changes, total tubeless and small-bore PCNLs may be superior to other methods. For hospital stay, total tubeless and tubeless PCNLs with stent may be superior to other procedures.

Intraoperative and postoperative feasibility and safety of total tubeless, tubeless, small-bore tube, and standard percutaneous nephrolithotomy: a systematic review and network meta-analysis of 16 randomized controlled trials

Background

Percutaneous nephrolithotomy (PCNL) is performed to treat relatively large renal stones. Recent publications indicate that tubeless and total tubeless (stentless) PCNL is safe in selected patients. We performed a systematic review and network meta-analysis to evaluate the feasibility and safety of different PCNL procedures, including total tubeless, tubeless with stent, small-bore tube, and large-bore tube PCNLs.

Methods

PubMed, Cochrane Central Register of Controlled Trials, and EMBASE™ databases were searched to identify randomized controlled trials published before December 30, 2013. One researcher examined all titles and abstracts found by the searches. Two investigators independently evaluated the full-text articles to determine whether those met the inclusion criteria. Qualities of included studies were rated with Cochrane’s risk-of-bias assessment tool.

Results

Sixteen studies were included in the final syntheses including pairwise and network meta-analyses. Operation time, pain scores, and transfusion rates were not significantly different between PCNL procedures. Network meta-analyses demonstrated that for hemoglobin changes, total tubeless PCNL may be superior to standard PCNL (mean difference [MD] 0.65, 95% CI 0.14–1.13) and tubeless PCNLs with stent (MD -1.14, 95% CI -1.65–-0.62), and small-bore PCNL may be superior to tubeless PCNL with stent (MD 1.30, 95% CI 0.27–2.26). Network meta-analyses also showed that for length of hospital stay, total tubeless (MD 1.33, 95% CI 0.23–2.43) and tubeless PCNLs with stent (MD 0.99, 95% CI 0.19–1.79) may be superior to standard PCNL. In rank probability tests, small-bore tube and total tubeless PCNLs were superior for operation time, pain scores, and hemoglobin changes.

Conclusions

For hemoglobin changes, total tubeless and small-bore PCNLs may be superior to other methods. For hospital stay, total tubeless and tubeless PCNLs with stent may be superior to other procedures.

Is it Necessary to Perform Nephrostography before Tube Removal after Percutaneous Nephrolithotomy

BACKGROUND

The aim of this study is the caparison of the complications rate among the patients which underwent nephrostomy removal with and without performing nephrostography.

MATERIALS AND METHODS

Between October 2010 and November 2011, 200 patients who underwent standard percutaneous nephrolithotomy (PCNL) procedures were included in this study. The patients were randomly assigned into two groups, Group A (n = 100) did not undergo the antegrade nephrostography on postoperative day 2 and the patients were discharged keeping the nephrostomy until postoperative day 3, while in Group B (n = 100) the nephrostomy tube was removed on postoperative day 3 after antegrade nephrostography demonstrating ureteral drainage down to the bladder. Postoperative complications in both groups were recorded and compared between two groups.

RESULTS

A total of 200 patients were treated with standard PCNL. The persistent leakage of urine after removal of the nephrostomy tube was encountered in 5 (5.0%) and 3 (3%) of patients in Groups 1 and 2, respectively. Urinary leakage was resolved with conservative management in 3 and 2 patients of Groups 1 and 2, respectively, but a double-J stent was inserted in 2 and 1 patients in each group because of persistent leakage of urine more than 1-week. The two groups show comparable complications such as prolonged urinary leakage which managed in a similar manner, however, postoperative hospital stay was lesser in Group 1.

CONCLUSION

Our results revealed postoperative performing nephrostogramy before tube removal changed the planning of complications such as prolonged urinary leakage and could be omitted in cases.

Modified totally tubeless percutaneous nephrolithotomy: Is it an effective and safe treatment option for renal and upper ureteral stones?

Introduction

We hypothesized that modified totally tubeless percutaneous nephrolithotomy (PNL) without indwelling ureteral stent would minimize postoperative discomfort without complications.

Aim

To evaluate the safety, efficacy, and morbidity of standard, tubeless, and modified totally tubeless PNL as well as the usefulness of modified totally tubeless PNL.

Material and methods

From November 2011 to February 2015, 211 patients who underwent PNL consecutively were enrolled in this study and divided into 3 groups (group 1: standard, group 2: tubeless, group 3: modified totally tubeless PNL). Patient and stone characteristics, operation time, hemoglobin change, length of hospitalization, stone-free rate, analgesic requirement, and perioperative complications were analyzed and compared among the 3 groups.

Results

There were no significant differences in preoperative patient characteristics among the three groups. In the postoperative analysis, the three groups had similar operation time, stone-free rate, perioperative fever and transfusion rate, but group 2 showed superior results in terms of length of hospitalization (p = 0.001). Group 2 and group 3 had a lower analgesic requirement (p = 0.010). Immediate postoperative hemoglobin change (p = 0.001) and tube site complications (p = 0.001) were more common in group 1.

Conclusions

Modified totally tubeless PNL was not inferior in terms of postoperative outcomes and safety compared with the standard and tubeless PNL, and avoided the postoperative stent-related symptoms and cystoscopy for double-J stent removal. Modified totally tubeless PNL could be an alternative treatment of choice for management of renal or upper ureteral stones in selected patients.

The Circle Nephrostomy Tube: An Attractive Nephrostomy Drainage System Following Complex Percutaneous Nephrolithotomy

OBJECTIVE

To describe our experience with the circle nephrostomy tube (NT) (Cook Medical), a drainage system uniquely designed for use after multiple-access percutaneous nephrolithotomy (PNL).

METHODS

A retrospective review of 1317 consecutive patients undergoing 1599 PNLs at IU Health Methodist Hospital was performed. All multiple access cases utilizing circle NTs were reviewed and analyzed. The method of insertion of circle NT was demonstrated.

RESULTS

A total of 1843 accesses were obtained in 1599 renal units (RUs): 380 upper pole, 129 interpolar, and 1334 lower pole. Multiple accesses in this series were required in 282 RUs (17.6%). Following multiple-access PNL, circle NTs, Cope loop, and reentry Malecot NTs were inserted in 91 RUs (32.3%), 208 RUs (73.8%), and 31 RUs (11%), respectively. None of the patients who had circle NT experienced clogging, dislodgement, or obstruction of the tube. The cost of circle, Cope loop, and Malecot NTs are 121.73 USD, 95.20 USD, and 81 USD, respectively.

CONCLUSION

Circle NTs are easy to insert, secure, cost-effective compared with inserting two NTs. Circle NTs provide excellent drainage and facilitate secondary procedures.

Are we fearful of tubeless percutaneous nephrolithotomy? Assessing the need for tube drainage following percutaneous nephrolithotomy

OBJECTIVE

The objective was to demonstrate that percutaneous nephrolithotomy (PCNL) can be safely performed with a tubeless or totally tubeless drainage technique.

INTRODUCTION

Standard PCNL includes nephrostomy tube placement designed to drain the kidney and operative tract at the conclusion of the procedure. Modern technique trend is tubeless PCNL and totally tubeless PCNL, which are performed without standard nephrostomy drainage. We aim to reinforce current literature in demonstrating that PCNL can be safely performed using a tubeless technique. With compounded supportive data, we can help generate a trend toward a more cost-effective procedure with improved pain profiles and patient satisfaction, as previously shown with the tubeless technique.

METHODS

Retrospective analysis of 165 patients who underwent PCNL treatment was performed. Of this group, 127 patients underwent traditional nephrostomy drainage following PCNL. A tubeless procedure was performed in the remaining 38 patients. Patient's postoperative stone size and burden as well as complication profiles were analyzed. Largest stone size and total stone burden was similar between the groups.

RESULTS

Patient characteristics and demographic information were compared and no significant statistical difference was identified between the groups. Complication rates between the groups were compared and no statistical difference was noted. A total of 23 patients had at least one postoperative complication.

CONCLUSION

Tubeless and totally tubeless PCNL demonstrates equivalent outcomes in the properly selected patient group when compared to PCNL performed with a nephrostomy tube. Although this is not the first study to demonstrate this, a large majority of urologists continue standard nephrostomy placement after PCNL. More studies are needed that demonstrate safety of this practice to shift the pendulum of care. Thus, tubeless and totally tubeless PCNL can be performed safely and effectively, which has previously been shown to improve cost, patient pain profiles, and length of hospitalization.

Mini percutaneous nephrolithotomy in the treatment of renal and upper ureteral stones: Lessons learned from a review of the literature

The aim of this review is to present the most recent data regarding the indications of mini percutaneous nephrolithotomy (PCNL), the results and the complications of the method. Medline was searched from 1997 to January 2014, restricted to English language. The Medline search used a strategy including medical subject headings and free-text protocols. PCNL is a well-established treatment option for patients with large and complex renal calculi. In order to decrease morbidity associated with larger instruments like blood loss, postoperative pain and potential renal damage, a modification of the technique of standard PCNL has been developed. This is performed with a miniature endoscope via a small percutaneous tract (11–20 F) and was named as minimally invasive or mini-PCNL. This method was initially described as an alternative percutaneous approach to large renal stones in a pediatric patient population. Furthermore, it has become a treatment option for adults as well, and it is used as a treatment for calculi of various sizes and locations. However, the terminology has not been standardized yet, and the procedure lacks a clear definition. Nevertheless, mini-PCNL can achieve comparable stone-free rates to the conventional method, even for large stones. It is a safe procedure, and no major complications are reported. Although less invasiveness has not been clearly demonstrated so far, mini-PCNL is usually related to less blood loss and shorter hospital stay than the standard method.

Comparison of complications associated with standard and totally tubeless percutaneous nephrolithotomy according to modified Clavien grading: a multicenter retrospective study

The aim of this study was to compare the complications of standard and totally tubeless percutaneous nephrolithotomy (PCNL) based on the modified Clavien complication grading system. We retrospectively evaluated the complications of 290 consecutive patients who had undergone standard or totally tubeless PCNL at four institutes between January 2010 and August 2012 based on the modified Clavien scale. The totally tubeless cases were classified as Group 1 and the cases to which a Malecot re-entry catheter was applied were classified as Group 2. The postoperative complications were recorded according to the modified Clavien complication grading system. Statistically significant differences were observed only in the first-degree injury class between the two groups based on the modified Clavien classification. The requirement for blood transfusion and prolonged percutaneous access site leakage were more frequent in Group 2, but these differences were not statistically significant. We also performed a pain evaluation by monitoring postoperative analgesia demands. In Group 1, the analgesic demand rates in the 1(st) and 6(th) postoperative hours were 64.6% and 31.5%, respectively. In Group 2, the analgesic demand rates were 87.5% and 58.75% in the 1(st) and 6(th) postoperative hours, respectively. The mean ± standard deviation of analgesic doses in the first 6 hours was 0.96 ± 0.7 and 1.46 ± 0.6 in Groups 1 and 2, respectively. These differences were statistically significant. Based on our results, we can conclude that the tubeless technique has fewer complications, improved postoperative patient comfort, shorter hospitalization times, and a reduced need for analgesics, suggesting that tubeless PCNL should be the standard approach. For suitable cases, this technique may be used safely as the standard PCNL approach.

The use of the amplatz sheath in percutaneous nephrolithotomy: does amplatz sheath size matter?

OBJECTIVES

To evaluate the effect of Amplatz sheath size used in percutaneous nephrolithotomy (PCNL) on postoperative outcome, bleeding, and renal impairment rates.

MATERIALS AND METHODS

One-hundred and ten patients who underwent uneventful percutaneous nephrolithotomy between November 2011 and October 2012 were included in the study. The patients were divided into 5 groups based on Amplatz sheath size (22, 24, 26, 28 and 30 Fr). Groups were comppared in terms of pre- and post-operative mean hemoglobin, creatinine, nephrostomy time, nephrostomy tube diameter, operative time, and fluoroscope time.

RESULTS

Mean operative time, preoperative hemoglobin and creatinine values were similar in all groups. Postoperative mean hemoglobin level was significantly lower and postoperative mean creatinine level was significantly higher in patients who were treated with a larger Amplatz sheath when compared to a smaller size (p < 0.05). It was observed that nephrostomy time and nephrostomy tube size significantly increased as the Amplatz sheath size increased. Seven patients presented with postoperative infection (1, 2, 1, 0 and 3 patients in Group I, II, III, IV, and V respectively), 13 patients presented with bleeding requiring blood transfusion (2, 4, and 7 patients in Group III, IV, and V respectively), and residual stone was observed in 9 patients (5, 2, 0, 1, and 1 patients in Group I, II, III, IV, and V respectively).

CONCLUSION

Although the use of a larger Amplatz sheath for larger stones seems to be suitable, this is not the case for smaller stones. For smaller stones, a smaller Amplatz sheath size would be useful to decrease the bleeding and renal impairment rates.

Percutaneous nephrolithotomy: Large tube, small tube, tubeless, or totally tubeless?

The role of percutaneous nephrostomy tube for drainage after percutaneous nephrolithotomy (PCNL) procedure has come under scrutiny in recent years. The procedure has been modified to use of small diameter tubes, ‘tubeless’ PCNL, and even ‘totally tubeless’ PCNL. A review of the available literature confirms that the chosen method of drainage after PCNL has a bearing upon the post-operative course. It is generally recognized now that small tubes offer benefit in terms of reduced post-operative pain and morbidity. Similarly, nephrostomy-free or ‘tubeless’ PCNL, using a double-J stent or ureteric catheter as alternative form of drainage, can be used with a favorable outcome in selected patients with the advantage of decreased postoperative pain, analgesia requirement, and hospital stay. Although the tubeless technique has been applied for extended indications as well, the available evidence is insufficient, and needs to be substantiated by prospective randomized trials. In addition, ‘totally tubeless’ approach has also been shown to be feasible in selected patients.

The comparison of standard and tubeless percutaneous nephrolithotomy procedures

PURPOSE

To compare totally tubeless and standard percutaneous nephrolitotomy procedures on many parameters.

MATERIALS AND METHODS

Percutaneous nephrolitotomy was performed on 195 patients between June 2009 and May 2012. The data of those patients were evaluated retrospectively. Totally tubeless cases were enrolled to Group 1, and Group 2 consisted of non-tubeless cases (re-entry or Foley catheter).

RESULTS

Group 1 included 85 cases and group 2 a total of 110 patients. Paper tracing values for the kidney stones were 321.25 ± 102.4 mm(2) and 324.10 ± 169.5 mm(2) respectively. Mean fluoroscopy time was 4.9 ± 1.9 min and 5.08 ± 2.7 min, mean operation time was 78.8 ± 27.9 min and 81.9 ± 28.77 min and mean decrease in hematocrit was 2.6 ± 1.6 and 3.74 ± 1.9 respectively. All these comparisons were statistically significant. Length of hospitalization was 1.6 ± 1.1 and 3.5 ± 1.5 days for Groups 1 and 2 respectively. Mean superficial pain score was 5.8 ± 1.6 and 6.7 ± 1.2 respectively for both groups after 1 hour. At 6 hours, the scores changed to 3.87 ± 1.22 and 4.84 ± 1.3 respectively. The analgesic dose was 1.00 ± 0.7 and 1.53 ± 0.6 for the groups respectively at 6 hours. All the statistical differences were significant for these three parameters.

CONCLUSIONS

We believe that, because of their post operative patient comfort and decreased length of hospital stay, totally tubeless procedures should be considered as an alternative to standard percutaneous nephrolitotomy.

Tubeless procedure reduces hospitalization and pain after percutaneous nephrolithotomy: results of a multivariable analysis

The objective of the study was to assess the efficacy and safety of tubeless percutaneous nephrolithotomy (t-PCNL) in comparison with standard PCNL (s-PCNL). We retrospectively evaluated 317 consecutive PCNL and compared perioperative results, time of hospitalization and analgesic requirement of t-PCNL (114; 36.0 %) to s-PCNL (203; 64.0 %). The decision to perform a tubeless PCNL was made at the end of the procedures depending on the surgeon's preference and according to the following inclusion criteria: (a) no serious bleeding or perforation in the collecting system during the procedure; (b) patients with no more than one access; and (c) residual stone burden needing a second-stage nephroscopy. Staghorn stones and anatomic anomalies were not considered as exclusion criteria for t-PCNL. Univariate analyses were conducted with one-way ANOVA, Fisher's exact test, Pearson's Chi-square and linear-by-linear association test as appropriate. Stepwise multivariable regression analyses were used to assess the independent correlation between demographics and clinical variables and the clinical outcomes. There were no significant differences between the two groups in terms of stone-free rate, hemoglobin decrease, blood transfusion and complication rate. Mean hospital stay was significantly shorter in the t-PCNL group (3.3 vs. 4.6 days; P < 0.001). Tubeless PCNL was associated with less analgesia requirement (68.4 vs. 86.7 %; P < 0.001) and with lower analgesic dose requirement (1.6 vs. 2.1 mean doses; P = 0.010). Multivariable analyses showed that t-PCNL (P < 0.001), postoperative fever (P < 0.001), transfusions (P < 0.001), operative time (P = 0.002), postoperative hydronephrosis (P = 0.005) and residual fragment dimension (P = 0.024) were independently correlated with duration of hospitalization, while analgesic dose requirement was independently influenced by hemoglobin decrease (P < 0.001), t-PCNL (P = 0.005) and stone number (P = 0.044). Our study confirmed that t-PCNL has similar outcomes to s-PCNL in terms of stone-free rate without increasing complications in selected cases. t-PCNL is a factor independently associated with shorter hospitalization and lower analgesic requirement.

Total tubeless versus standard percutaneous nephrolithotomy: a meta-analysis

OBJECTIVE

The aim of this meta-analysis was to evaluate the efficacy and safety of total tubeless percutaneous nephrolithotomy (PCNL) versus standard PCNL.

METHOD

MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and the Chinese Biomedical Literature Database were researched. Randomized controlled trials (RCTs) and clinically controlled trials (CCTs) comparing total tubeless PCNL (tubeless and stentless) versus standard PCNL were included in this review. The related studies that met the inclusion criteria were included in the meta-analysis. Two reviewers independently assessed the quality of each included studies and extracted data. RevMan 5.1. was used for meta-analysis.

OUTCOME

Five RCTs and four CCTs were included, involving a total of 652 patients. All patients were divided into the total tubeless PCNL group and the standard PCNL group. The pooled results showed that the total tubeless PCNL group significantly reduced the hospital stay [weighted mean difference (WMD) -1.09 (95% confidence intervals, 95% CI -1.33, -0.85)] and analgesic requirement [standardized mean difference (SMD) -0.59 (95% CI -0.96, -0.23)]. There was no statistically significant difference in the operation time [WMD -4.14 (95% CI -8.27, -0.01)], mean hemoglobin decrease [-0.07 (95% CI -0.20, 0.06)], fever [relative risk (RR) 0.53 (95% CI 0.16, 1.69)], transfusion [RR 0.86 (95% CI 0.40, 1.85)], prolonged urinary drainage [RR 0.58 (95% CI 0.08, 4.09)], and ancillary procedure [extracorporeal shockwave lithotripsy, RR 0.84 (95% CI 0.29, 2.41), second-look PCNL RR 1.18 (95% CI 0.49, 2.89)]. According to the study design, the subgroup analyses were performed; most results were consistent with the overall findings, except the one that evaluated the analgesic requirement in the CCT subgroup.

CONCLUSION

Total tubeless PCNL is a safe and effective procedure. It significantly reduced the hospital stay, analgesic requirement, and the time to return to normal activity without increasing complications. However, further randomized trials are needed to confirm these findings.

Is an overnight stay after percutaneous nephrolithotomy safe?

OBJECTIVES

To establish a clinical care pathway that plans for hospital discharge the day after percutaneous nephrolithotomy (PCNL), to evaluate the safety, effectiveness and feasibility of this pathway, and to identify factors associated with a postoperative length of hospital stay (LOS) of >1 day. PCNL is the treatment of choice for patients with large kidney stones and those in whom extracorporeal shockwave lithotripsy has failed, and the mean LOS is typically 2-5 days.

PATIENTS AND METHODS

We retrospectively reviewed the charts of 109 patients (mean age 57.4 years; 58 men, 53%) who had PCNL between 2006 and 2009. All had nephrostomy tubes placed after surgery. The patients' demographics, LOS, incidence of complications, clinical outcomes, stone-free rates, number of early postoperative emergency-room visits, need for subsequent admission and/or other procedures, were noted and analysed. The modified Clavien classification was used to describe the postoperative complications. Bivariate analyses were used to test for associations between LOS and other variables.

RESULTS

The mean (range) stone size was 2.2 (0.9-5.9) cm, and the mean (SEM) LOS was 1.7 (0.13) days. Of the 109 patients, 20% had a LOS of >1 day for surgical, 3% for medical and 5% for social reasons. The stone-free rate was 89%. There was no difference in the number of subsequent hospital visits or ancillary procedures for patients discharged after one or more postoperative nights. No variables were associated with a longer LOS.

CONCLUSIONS

An overnight hospital stay after PCNL is safe and represents an effective strategy for improved bed use in selected patients. A longer LOS was not affected by patient age or body mass index, stone size or operative time. We continue to use our clinical care pathway, as supported by these data.

Nephrostomy in percutaneous nephrolithotomy (PCNL): does nephrostomy tube size matter? Results from the Global PCNL Study from the Clinical Research Office Endourology Society

PURPOSE

To explore the relationships between nephrostomy tube (NT) size and outcome of percutaneous nephrolithotomy (PCNL).

METHODS

The Clinical Research Office of the Endourological Society (CROES) prospectively collected data from consecutive patients treated with PCNL over a 1-year period at 96 participating centers worldwide. This report focuses on the 3,968 patients who received a NT of known size. Preoperative, surgical procedure and outcome data were analyzed according to NT size, dividing patients into two groups, namely small-bore (SB; nephrostomy size ≤ 18 Fr) and large-bore (LB; nephrostomy size > 18 Fr) NT.

RESULTS

Patients who received a LB NT had a significantly lower rate of hemoglobin reduction (3.0 vs. 4.3 g/dL; P < 0.001), overall complications (15.8 vs. 21.4%; P < 0.001) and a trend toward a lower rate of fever (9.1 vs. 10.7%). Patients receiving a LB NT conversely had a statistically, though not clinically significant, longer postoperative hospital stay (4.4 vs. 4.2 days; P = 0.027). There were no differences in urinary leakage (0.9 vs. 1.3%, P = 0.215) or stone-free rates (79.5 vs. 78.1%, P = 0.281) between the two groups.

CONCLUSIONS

LB NTs seem to reduce bleeding and overall complication rate. These findings would suggest that if a NT has to be placed, it should better be a LB one.

Randomized prospective trial of tubeless versus conventional minimally invasive percutaneous nephrolithotomy

PURPOSE

To evaluate the effectiveness and safety of minimally invasive percutaneous nephrolithotomy (mPCNL) without nephrostomy drainage tubes.

METHODS

We prospectively enrolled 32 eligible patients with kidney stones at our hospital. Patients were randomly assigned to a conventional mPCNL group (ureteric Double-J stents and nephrostomy drainage tubes) or a tubeless mPCNL group (ureteric catheter but no drainage tubes). A single experienced surgeon performed all operations.

RESULTS

At baseline, the two groups had similar age, maximum stone diameter, and gender distribution. There were no significant differences in operation time, presence of postoperative fever, stone clearance, and level of postoperative serum hemoglobin. However, the tubeless mPCNL group had significantly shorter hospital stays (3 vs. 4 days, p = 0.032) and significantly less back pain (5 patients vs. 14 patients, p = 0.003) than the conventional mPCNL group.

CONCLUSIONS

No significant differences were found between conventional and tubeless mPCNL in safety issues and stone clearance rate. However, patients treated with tubeless mPCNL had shorter hospitalization stays and were less likely to experience back pain.

Standard versus tubeless percutaneous nephrolithotomy: a systematic review

OBJECTIVE

This article systematically analyses comparative studies to evaluate the efficacy and safety of tubeless percutaneous nephrolithotomy (PCNL) versus standard PCNL.

METHODS

The Medline, EMBASE, PsycINFO, Cochrane and DARE databases were searched from 1997 to February 2011. Comparative studies evaluating outcomes from standard versus tubeless PCNL were included. Primary outcome measures were post-operative pain scoring, analgesic requirements, duration of hospitalisation/convalescence, operation time, major/minor complications and stone-free rates.

RESULTS

Twenty-four studies were included (11 randomised control trials and 13 retrospective or prospective studies). Levels of pain recorded, analgesic requirements, duration of inpatient stay and convalescence time were all significantly reduced in the tubeless PCNL group. Cost was reduced in two studies. Morbidity was not significantly different between the groups. There was no significant difference between groups regarding stone-free status.

DISCUSSION

This systematic review has demonstrated that tubeless PCNL is a viable alternative to tubed PCNL in uncomplicated cases. Benefits are as described above. There is no evidence suggesting that patient safety is compromised by the absence of post-operative nephrostomy. The tubeless method has been reported in challenging cases such as stag-horn stones, horseshoe or ectopic kidneys. Promising outcomes have been demonstrated in elderly patients and when clinical needs demand a supracostal approach. Multi-centre randomised controlled trials are needed to fully establish the effectiveness of the tubeless method.

Nephrostomy tube-free versus nephrostomy tube for renal drainage after percutaneous nephrolithotomy: a systematic review and meta-analysis

BACKGROUND

Historically, percutaneous nephrostomy drainage following percutaneous nephrolithotomy (PNL) has been considered the standard of care. More recently, however, an increasing number of centers are performing tubeless (with insertion of JJ ureteric stent) or totally tubeless (with no internal or external drainage) PNL with impressive outcome data.

OBJECTIVE

This systematic review is to compare the clinical therapeutic efficacy and safety of nephrostomy tube-free (NT-free) and standard PNL.

MATERIALS AND METHODS

We searched PubMed (1966 to April 2011), Embase (1966 to April 2011), and the Cochrane Library without language restriction. All randomized controlled trials that compared NT-free PNL (using a double-J stent) with standard PNL were enrolled in this review. The Cochrane Collaboration's RevMan5.0.2 software was used for statistical analysis.

RESULTS

Nine studies involving 547 patients were included. Patients were divided into 4 groups: NT-free group, small tube group (8-9 Fr), middle tube group (16-18 Fr), and large tube group (20-24 Fr). Meta-analysis showed that: (1) with regard to hospital stay (h) and visual analog scale scores for postoperative pain on day 1, there was no significant difference between the NT-free group and the small tube group, but there were differences between the NT-free group versus the middle and large tube groups; (2) for puncture site urinary leakage, no significant difference was found between the NT-free group and the small and middle tube groups; (3) no significant difference was found with regard to transfusion, fever or infection, operative time between the NT-free group and the 3 tube groups.

CONCLUSIONS

The clinical efficacy and safety of NT-free and small tube are similar in all measurements. Compared with the middle and large tubes, NT-free PNL could reduce hospital stay and postoperative analgesia requirement without increasing other complications.

Nephrostomy tube placement after percutaneous nephrolithotomy: critical evaluation through a prospective randomized study

OBJECTIVE

To evaluate the hemostatic and drainage functions of the nephrostomy tube after percutaneous nephrolithotomy through a prospective randomized study. Additionally, the effect of nephrostomy tube placement on postoperative pain, hospital stay, and the success and complication rates was assessed.

METHODS

The present study was designed to include 100 patients with upper urinary tract calculi who were prospectively randomized to tubeless (group 1) and standard (group 2) PCNL using closed envelopes. The hemoglobin and hematocrit deficits, development of hematuria and hematoma, and blood transfusion rate were compared to assess the hemostatic effect. The drainage effect was evaluated by comparing the incidence of postoperative urinary leakage, urinoma, and/or hydrothorax development.

RESULTS

A total of 123 patients were assessed for eligibility, and 100 fulfilled the study requirements. The hemoglobin and hematocrit deficits were comparable. Significant hematuria and/or hematoma were recorded in 5 and 4 patients in groups 1 and 2, respectively. Blood transfusion was required in 5 and 6 patients in groups 1 and 2, respectively. One patient with chronic kidney disease in the tubeless group required abdominal exploration because of respiratory embarrassment and a large hematoma. Transient urinary leakage was recorded in 2 and 31 patients in groups 1 and 2, respectively (P < .05). No urinoma developed. Hemothorax developed in 1 patient in the tubeless group with supracostal puncture. Postoperative pain was significantly less in the tubeless group. No statistically significant difference was found in the success rate, morbidity, or hospital stay between the 2 groups.

CONCLUSION

The hemostatic and drainage functions of the nephrostomy tube were modest. However, the tubeless approach might be not suitable for the patients with chronic kidney disease or a supracostal approach.

Percutaneous nephrolithotomy: keeping the bridge for one night

This study was conducted to compare nephrostomy-free percutaneous nephrolithotomy (PCNL) with early nephrostomy tube removal (after 1 day). A prospective study started from January 2008 through December 2009 and included patients who underwent non-complicated PCNL through a single tract without intra-operative residual stones. Nephrostomy-free technique was performed during 2008 (nephrostomy-free group). During 2009, a nephrostomy tube was placed for 1 day (1-day nephrostomy group). Both groups were compared for post-operative events, dose of analgesia, hemoglobin deficit and hospital stay. The study included 55 patients (27 in nephrostomy-free group and 28 in 1-day nephrostomy group). There were no statistically significant differences between patients, renal and stone characteristics of both groups. Post-operative events were significantly more in nephrostomy-free group (26 vs. 14.3%, p = 0.039). They include hematuria in three (11.1%) of nephrostomy-free patients and one (3.6%) of 1-day nephrostomy patient, severe renal colic in four patients of nephrostomy-free group (14.8%), and temporary urinary leakage via the nephrostomy site in three patients of 1-day nephrostomy group (10.7%). Mean dose of post-operative analgesia, mean hemoglobin deficit and hospital days were comparable for both groups (p = 0.946, 0.541, 0.807, respectively). A second look PCNL was performed through the already present tract to retrieve residual stones in two patients with nephrostomy. In conclusion, 1-day nephrostomy technique after PCNL showed significantly better post-operative course. It was comparable to nephrostomy-free technique in analgesic requirements and hospital stay. The nephrostomy tube provided a bridge for second look nephroscopy.

Incidence, prevention, and management of complications following percutaneous nephrolitholapaxy

CONTEXT

Incidence, prevention, and management of complications of percutaneous nephrolitholapaxy (PNL) still lack consensus.

OBJECTIVE

To review the epidemiology of complications and their prevention and management.

EVIDENCE ACQUISITION

A literature review was performed using the PubMed database between 2001 and May 1, 2011, restricted to human species, adults, and the English language. The Medline search used a strategy including medical subject headings (MeSH) and free-text protocols with the keywords percutaneous, nephrolithotomy, PCNL, PNL, urolithiasis, complications, and Clavien, and the MeSH terms nephrostomy, percutaneous/adverse effects, and intraoperative complications or postoperative complications.

EVIDENCE SYNTHESIS

Assessing the epidemiology of complications is difficult because definitions of complications and their management still lack consensus. For a reproducible quality assessment, data should be obtained in a standardized manner, allowing for comparison. An approach is the validated Dindo-modified Clavien system, which was originally reported by seven studies. No deviation from the normal postoperative course (Clavien 0) was observed in 76.7% of PNL procedures. Including deviations from the normal postoperative course without the need for pharmacologic treatment or interventions (Clavien 1) would add up to 88.1%. Clavien 2 complications including blood transfusion and parenteral nutrition occurred in 7%; Clavien 3 complications requiring intervention in 4.1.%; Clavien 4, life-threatening complications, in 0.6%; and Clavien 5, mortality, in 0.04%. High-quality data on complication management of rare but potentially debilitating complications are scarce and consist mainly of case reports.

CONCLUSIONS

Complications after PNL can be kept to a minimum in experienced hands with the development of new techniques and improved technology. A modified procedure-specific Clavien classification should be established that would need to be validated in prospective trials.

Tubeless vs standard percutaneous nephrolithotomy: a meta-analysis

OBJECTIVE

To systematically review and compare tubeless percutaneous nephrolithotomy (PCNL) with standard PCNL.

MATERIALS AND METHODS

We conducted a review of the English language literature on studies involving randomized controlled trials for PCNL. The studies chosen to be included in our review compared tubeless PCNL with standard PCNL and described the advantages of each in the outcomes. Two reviewers independently screened the studies for eligibility, evaluated their quality and extracted the data from the eligible studies, with confirmation by cross-checking. Data were processed using RevMan 5.0.

RESULTS

Seven studies involving 1365 cases met the inclusion criteria, and these were included in the meta-analysis. The patients' baseline characteristics were comparable in all the studies. By comparing the four common characteristics, we found no difference in efficacy between the two surgical approaches in terms of mean operation duration and postoperative haematocrit change (P > 0.05). We found that the mean analgesic requirement and number of days in hospital were lower for tubeless PCNL (P < 0.05).

CONCLUSIONS

Our results show that tubeless PCNL is a good option in non-complicated cases, with the advantages of reduced hospital stay and little need for postoperative analgesia. There was no difference between the two approaches in operation duration, or haematocrit change after surgery. As only few studies with small study populations were available, more high quality larger trials with longer follow-up are recommended.

[Benign prostatic hyperplasia and urolithiasis]

The Academy Spring Forums held as part of the Southwest German Congress in Tübingen and the Congress of North Rhine-Westphalia in Aachen offer urologists in private practice and likewise hospital urologists a compact overview of new developments. This article summarizes the newest work on e.g. interventional therapy, uroliths, and extracorporeal shock wave lithotripsy for benign prostatic hyperplasia and urolithiasis.

Tubeless percutaneous nephrolithotomy

Introduction and Objective:

Placement of a percutaneous nephrostomy tube for drainage has been an integral part of the standard percutaneous nephrolithotomy (PCNL) procedure. However, in recent years, the procedure has been modified to what has been called ‘tubeless’ PCNL, in which nephrostomy tube is replaced with internal drainage provided by a double-J stent or a ureteral catheter. The objective of this article is to review the evidence-based literature on ‘nephrostomy-free’ or ‘tubeless’ PCNL to compare the safety, effectiveness, feasibility, and advantages of tubeless PCNL over standard PCNL.

Materials and Methods:

We performed a MEDLINE database search to retrieve all published articles relating to ‘tubeless’ PCNL. Cross-references from retrieved articles as well as articles from urology journals not indexed in MEDLINE, were also retrieved.

Results:

The majority of the studies have shown ‘tubeless’ PCNL to be a safe and economical procedure, with reduced postoperative pain and morbidity and shorter hospital stay. tubeless PCNL has been found to be safe and effective even in patients with multiple stones, complex staghorn stones, concurrent ureteropelvic junction obstruction, and various degrees of hydronephrosis. The technique has been successful in obese patients, children, and in patients with recurrent stones after open surgery.

Conclusion:

Tubeless PCNL can be used with a favorable outcome in selected patients (stone burden <3 cm, single tract access, no significant residual stones, no significant perforation, minimal bleeding, and no requirement for a secondary procedure), with the potential advantages of decreased postoperative pain, analgesia requirement, and hospital stay. However, for extended indications, like supine PCNL, multiple, complex and staghorn stones, and concurrent PUJ obstruction, the evidence is insufficient and should come from prospective randomized trials.

Postoperative morbidity of tubeless versus conventional percutaneous nephrolithotomy: a prospective comparative study

Percutaneous Nephrolithotomy (PNL) is an established technique for the treatment of renal calculi. Some reports have challenged the need for a nephrostomy tube at the end of the procedure, arguing that it accounts for a longer hospital stay and increased postoperative pain. During the last years, several series have addressed the feasibility and safety of tubeless PNL, where a double-J ureteral stent is left in place after the end of intervention instead of a nephrostomy tube. The aim of our study was to compare conventional versus tubeless PNL in terms of postoperative morbidity. Eighty-five patients who underwent PNL at a single center met the inclusion criteria (complete intraoperative stone clearance, no evidence of active intraoperative bleeding, single percutaneous access, and operative time shorter than 2 h) and were randomized at the end of the procedure to have placed either a nephrostomy tube (group 1) or a double-J ureteral stent (group 2). Outcomes assessed were postoperative pain, bleeding complications, leakage complications, and length of hospital stay. The patients in the tubeless group had a shorter hospital stay (3.7 vs. 5.8 days; P < 0.001), and less postoperative pain at postoperative days 2 and 3 (P < 0.001). No significant difference in bleeding or leakage complications was observed. This study supports the feasibility and safety of tubeless PNL in a selected group of the patients, suggesting some intraoperative criteria to be considered when performing it. However, further controlled studies will have to determine its impact on stone-free rates prior to be considered the standard technique in these selected cases.

The efficacy and safety of tubeless percutaneous nephrolithotomy: a systematic review and meta-analysis

The objective of this study was to conduct a systematic review and meta-analysis to evaluate the efficacy and safety of tubeless versus standard percutaneous nephrolithotomy (PCNL). Relevant randomized or quasi-randomized controlled trials studies were identified from electronic database (Cochrane CENTRAL, Medline and EMBASE et al.). The retrieval time ended in August 2010. The quality of the included trials was assessed and the data were extracted independently by two reviewers. We divided the participants who received standard PCNL into two subgroups: small tube (4-10 F) group and big tube (14-24 F) group to reduce heterogeneity and bias. Efficacy (hospital stay time, operative time, stone-free rate) and safety (postoperative pain and analgesia requirement, postoperative fever, blood transfusion, urine leakage) were explored by using review manager v5.0. Fourteen randomized controlled trials comprising 776 subjects met the inclusion criteria. Our meta-analysis showed that there were statistically significant differences in hospital stay, postoperative analgesic requirement and urine leakage between tubeless and standard PCNL. In operative time, significant difference was found between tubeless and big tube group. No statistically significant differences were found in stone-free rate, postoperative fever, and blood transfusion between tubeless and standard PCNL. In conclusion, Tubeless PCNL was an effective and safe procedure for treatment of renal stones in selected patients, with shorter hospital stay, less analgesic requirement, lower urine leakage and without increased complications. Patients can receive great benefit from tubeless PCNL and it will become more palatable to patients as well as more cost-effective than standard PCNL in the future.

Tubeless percutaneous nephrolithotomy is associated with less pain and shorter hospitalization compared with standard or small bore drainage: a meta-analysis of randomized, controlled trials

OBJECTIVES

To assess the efficacy and safety of tubeless percutaneous nephrolithotomy (PCNL) compared with standard or small-bore PCNL with a meta-analysis of randomized, controlled trials.

METHODS

All eligible studies were searched on MEDLINE, Embase, and the Cochrane Library databases. Risk ratio (RR), mean difference, or standardized mean difference (SMD), with its 95% CI, was used to evaluate the size effect.

RESULTS

Ten and 3 trials were identified for comparison I (tubeless PCNL vs standard PCNL, 320 cases and 323 controls) and comparison II (tubeless PCNL vs small-bore PCNL, 55 cases and 54 controls), respectively. Tubeless PCNL required significantly less analgesia relative to standard PCNL (SMD -1.72; 95% CI -2.30 to 1.13; P(heterogeneity) = 0.04) and small-pore PCNL (SMD -0.69; 95% CI -1.13 to 2.05; P(heterogeneity) = 0.94). Furthermore, there was a remarkably shorter hospital stay in comparison I (SMD -1.35; 95% CI -1.40 to 1.30; P(heterogeneity) = 0.60) and comparison II (SMD -0.49; 95% CI -0.76 to 0.21; P(heterogeneity) = 0.15). The return to normal activity days was also significantly decreased in comparison I (SMD -4.34; 95% CI -6.28 to 2.41; P(heterogeneity) = 0.02). However, no significant difference was observed in the analyses concerning stone-free blood transfusion and complications rate in both comparisons. In subgroup analyses by nephrostomy diameter (22-Fr) and drainage methods, most results were consistent with the overall findings except for that to evaluate the operative time in the double-J stent subgroup.

CONCLUSIONS

Tubeless PCNL is associated with less pain and quicker recovery compared with standard or small-bore PCNL, in the management of uncomplicated renal calculi.

Do patients benefit from miniaturized tubeless percutaneous nephrolithotomy? A comparative prospective study

BACKGROUND AND PURPOSE

A benefit of miniaturized percutaneous nephrolithotomy (MPCNL) compared with conventional percutaneous nephrolithotomy (PCNL) has not been demonstrated as yet. Thus, the aim of this study was to evaluate the outcome of conventional vs MPCNL and to determine if MPCNL offers an advantage for the patient.

PATIENTS AND METHODS

A prospective, nonrandomized series of 50 consecutive patients with solitary calculi (lower pole or the renal pelvis) were treated either by conventional PCNL (26F) or MPCNL (18F). Ultrasound or holmium laser were used for lithotripsy. Patients were treated tubeless after uncomplicated MPCNL, with thrombin-matrix tract closure and antegrade Double-J catheter placement. After PCNL, all patients received 22F nephrostomies. Demographic data, stone characteristics, perioperative course, and complication rates were assessed.

RESULTS

Patients characteristics were comparable in both groups, except for stone size, which was 18 +/- 8 mm (MPCNL) and 23 +/- 9 (PCNL; P = 0.042). Operative time was comparable in both groups (48 +/- 17 vs 57 +/- 22 min, not significant [NS]). After MPCNL, 96% were stone free at day 1 vs 92% after PCNL (NS). Significant complications did not occur in both groups. Minor complications were: Fever, 12% (MPCNL) vs 20% (PCNL; NS); bleeding, 4% vs 8%; perforations, 0% vs 4% (all NS). Overall outcome was not influenced by body mass index. Calcium oxalate stones were predominant with 75%. Patients after tubeless MPCNL had less pain (visual analogue score, 3 +/- 3 vs 4 +/- 3; P = 0.048.) and needed slightly less additional pain medication (25 +/- 12 mg/d vs 37 +/- 10 mg/d piritramid; NS). Hospital stay was significantly shorter after MPCNL (3.8 +/- 28 vs 6.9 +/- 3.5 d; P = 0.021.).

CONCLUSIONS

Both techniques were safe and effective for the management of renal calculi. While stone-free rates were comparable in our series, MPCNL showed advantages in terms of shorter hospital stay and postoperative pain. The lower stone burden and the tubeless fashion of MPCNL, however, might have influenced these results.

Systematic Review and Meta-Analysis of Nephrostomy Placement Versus Tubeless Percutaneous Nephrolithotomy

Abstract Purpose: We performed a systemic review with meta-analysis to compare tubeless vs conventional percutaneous nephrolithotomy (PCNL) and assess the effectiveness and safety of this innovative procedure. Materials and Methods: A systematic review of PUBMED, EMBASE, LILACS, and Cochrane Library was performed to identify all randomized controlled trials (RCTs) that compared tubeless PCNL vs conventional PCNL. The analyzed outcomes were stone-free rate, pain assessment, analgesic medication requirements, operative time, hospitalization time, blood loss, and complications. Results: A total of 10 RCTs were identified that reported 621 patients. Seven studies analyzed stone-free rates. Meta-analysis of the data resulted in no difference between tubeless and conventional PCNL. Operative time, blood transfusion, hemoglobin drop and postoperative fever did not differ between the groups. Meta-analysis of length of hospitalization and prolonged urinary drainage was analyzed and favored the tubeless PCNL group. Conclusions: Tubeless PCNL is a safe and effective procedure with a stone clearance rate comparable to that of conventional PCNL. Tubeless PCNL presented a shorter hospital stay and less postoperative urinary leakage. Pain reduction and minimization of analgesic requirements also were demonstrated.

Tubeless percutaneous nephrolithotomy--the new standard of care?

PURPOSE

Traditionally the placement of a nephrostomy tube at the conclusion of percutaneous nephrolithotomy is considered the standard of care. However, the need for nephrostomy tube placement has been questioned by numerous authors. We evaluated the literature regarding tubeless percutaneous nephrolithotomy, and determined potential candidates for tubeless percutaneous nephrolithotomy and whether this procedure can be considered the new standard of care for complex stone removal.

MATERIALS AND METHODS

A MEDLINE search was conducted between May 1997 and January 2010 to detect studies reporting tubeless percutaneous nephrolithotomy. "Nephrolithiasis," "percutaneous nephrolithotomy," "tubeless" and "lithotripsy" were used as medical subject headings (MeSH) key words. Additional citations were identified by reviewing the reference lists of the included articles. All relevant articles were reviewed for indications, outcomes and complications.

RESULTS

The data obtained from 50 reports document comparable complication rates between tubeless and standard percutaneous nephrolithotomy. Tubeless percutaneous nephrolithotomy demonstrated advantages such as less pain, less debilitation, less costs and a shorter hospital stay. Mean stone-free rates for tubeless percutaneous nephrolithotomy were as high as 89%.

CONCLUSIONS

Tubeless percutaneous nephrolithotomy appears to be safe and efficacious in uneventful procedures, in children, in obese patients, in simultaneous bilateral procedures, in supracostal access and in renal units with coexisting anatomical anomalies. Nephrostomy tube placement should still be considered in certain cases such as those with more than 2 nephrostomy access tracts, those necessitating a second look and those with intraoperative complications such as significant bleeding or collecting system perforation.

Renal drainage after percutaneous nephrolithotomy

Exit strategy after percutaneous nephrolithotomy (PCNL) is an area of continuing innovation to improve postoperative morbidity and operative outcomes for patients. The two important components of an exit strategy after PCNL are hemostasis and renal drainage. We review the different techniques of renal drainage after PCNL-ie, nephrostomy tube, ureteral stents, and totally tubeless strategy with critical discussion of available evidence for and against each of these techniques. We conclude that the optimal renal drainage method depends on patient characteristics and the operative course; hence, it should be individualized. To simplify this, we group patients undergoing PCNL as routine, problematic, and complicated, based on increasing complexity of the procedure and procedural complications. In routine PCNLs, we favor placement of an ureteral stent or a small-bore nephrostomy tube. In problematic and complicated PCNLs, we think the evidence directs toward placement of a nephrostomy tube, small bore being an option in problematic PCNLs.

Tubeless percutaneous nephrolithotomy: 3 years of experience with 454 patients

OBJECTIVE

To present our experience with 454 patients who had tubeless percutaneous nephrolithotomy (TPCNL) over last 3 years.

PATIENTS AND METHODS

From September 2004 to August 2007, all patients aged >14 years and undergoing PCNL were considered for TPCNL. Exclusion criteria were the presence of pyonephrosis, matrix calculi, significant bleeding or residual stone burden and need for three of more percutaneous accesses. These patients had a nephrostomy tube placed after PCNL (control group). The remaining patients undergoing TPCNL (study group) had antegrade ureteric stenting. Demographic and perioperative data were compared retrospectively.

RESULTS

Of 840 patients who had PCNL during the study period, 454 had TPCNL. The two groups had comparable demographic data except for a smaller stone burden (322.8 vs 832.2 mm(2)) and fewer staghorn calculi (94 vs 154) in patients undergoing TPCNL (P < 0.001). The mean number of tracts per renal unit and operative duration were statistically higher in patients undergoing standard PCNL (1.5 vs 1.1, and 68.8 vs 52.2 min, respectively). The decrease in haemoglobin, complication and stone-free rates were comparable. TPCNL was associated with less postoperative pain, analgesia requirement and earlier discharge (P < 0.001).

CONCLUSIONS

TPCNL can be used with a favourable outcome and no increase in complications in selected patients, with the potential advantages of decreased postoperative pain, analgesia requirement and hospital stay. Its application can be extended to patients with a solitary kidney, previous ipsilateral open surgery, raised serum creatinine level, in the presence of three renal accesses or supracostal access, and in patients undergoing bilateral synchronous PCNL or contralateral endourological stone treatment.