The use of adjunctive hemostatic agents for tubeless percutaneous nephrolithotomy

Is Totally Tubeless Percutaneous Nephrolithotomy a Safe and Efficacious Option for Complex Stone Disease?

Background: Percutaneous nephrolithotomy is the gold standard treatment for large, complex intrarenal stones. Historically, this was performed using a nephrostomy tube (PCN) and/or internalized ureteral stent at the end of the procedure. However, totally tubeless nephrolithotomy (tt-PCNL) is a novel technique where no tubes (no stent nor nephrostomy tube) are left post-operatively. We review the literature on this subject regarding peri-operative outcomes, post-operative outcomes, and potential complications of the procedure, discuss our technique, and make recommendations on implementation for centers not currently utilizing the procedure. Materials and methods: We performed a comprehensive search of the literature on totally tubeless nephrolithotomy using MEDLINE database search. Our search included prior review articles, meta-analyses, systematic reviews, primary research articles, case reports, and case studies. Results: In comparison to prior approaches where a stent or nephrostomy tube is placed, tt-PCNL has a similar complication rate and better post-operative outcomes. Totally tubeless PCNL has similar operative times and similar changes in hemoglobin. However, it had shorter length of stays across all studies. The mean difference in length of stay in the studies reviewed was 1.96 days. Additionally, tt-PCNL had decreased post-operative analgesic requirements and pain scores. Conclusions: This review highlights totally tubeless percutaneous nephrolithotomy as a safe and feasible surgical technique with improved outcomes in properly selected patients.

Comparison of outcomes in totally tubeless percutaneous nephrolithotomy according to nephrostomy tract sealing with fibrin versus gelatin matrix: a propensity score matching study

To investigate and compare surgical outcomes in totally tubeless percutaneous nephrolithotomy (ttPCNL) patients according to the type of sealant during nephrostomy tract closure, the records of 158 patients who underwent ttPCNL were retrospectively reviewed. Fibrin sealant [Tisseel^®; n = 107, fibrin-only sealant (FS)] or gelatin matrix hemostatic sealant [FloSeal^®; n = 51, gelatin matrix sealant (GS)] was applied during tract closure according to surgeon's preference. On the first postoperative day, computed tomography (CT) was scanned for all patients. Unsatisfactory radiological outcome (URO) was defined as any postoperative hematoma or urinoma (≥ 2 cm) on the CT. Unsatisfactory clinical outcome (UCO) was defined as any adverse event requiring additional intervention. Both UROs and UCOs were sub-classified as either hemorrhage or drainage related. 2:1 propensity score matching was applied according to clinical parameters. Median age was 58 (19-78) years and a mean stone size was 2.1 ± 1.1 cm. The treatment success rate (stone free or < 4 mm residual) among all patients was 91.1% (144/158). UROs and UCOs occurred in 35.4% (86/158) and 11.4% (18/158) of all cases, respectively. Neither of the frequency of URO nor hemorrhage-related UCO was different according to sealant type. However, drainage-related UCOs were more prevalent among the GS group, mainly due to the higher postoperative ureter stenting rate. The postoperative pain severity and the length of hospitalization were comparable between groups. In summary, using GS rather than FS during tract closure did not worsen hemorrhage-related outcomes. However, the clinical risk of ureter occlusion requiring additional temporary ureteral stenting was increased.

Day care PNL using 'Santosh-PGI hemostatic seal' versus standard PNL: A randomized controlled study

INTRODUCTION

To compare the outcomes of tubeless day care PNL using hemostatic seal in the access tract versus standard PNL.

MATERIAL AND METHODS

It was a prospective randomized controlled study. Cases were randomized to either the day care group with hemostatic seal (DCS) or the control group where patients were admitted and a nephrostomy tube was placed at the conclusion of surgery.

RESULTS

A total of 180 cases were screened and out of these, 113 were included in the final analysis. The stone clearance rates were comparable in both the groups. The mean drop in hemoglobin was significantly lower in DCS group than the control group (1.05 ±0.68 vs. 1.30 ±0.58 gm/dl, p = 0.038).Mean postoperative pain score, analgesic requirement (paracetamol) and duration of hospital stay were also significantly lower in the DCS group (3.79 ±1.23 vs. 6.12 ±0.96, 1.48 ±0.50 vs. 4.09 ±1.11 grams and 0.48 ±0.26 vs. 4.74 ±1.53 days respectively; p <0.05). The incidence of urine leakage through the access tract site was significantly lower in the DCS subgroup when compared to the controls (3.6% vs. 21.1%, p <0.05). Cases in the DCS group resumed their normal activities in a significantly shorter time (8.05 ±3.05 vs.18.42 ±4.42 days; p <0.05). Higher proportion of cases in the DCS group got re-admitted, although it was not a statistically significant number (7.1% vs. 1.8%; p = 0.21).

CONCLUSIONS

Tubeless day care PNL with composite hemostatic tract seal is considered safe. It resulted in a significant reduction of blood loss and analgesic requirement with significantly reduced hospital stay, nephrostomy tube site morbidity and time required to resume normal activity when compared to the standard PNL. However, patients must be compliant with the given instructions and should have access to a health care facility, as few of them may need re-admission.

Hemostatic agents for access tract in tubeless percutaneous nephrolithotomy: Is it worth?

INTRODUCTION

The role of hemostatic agents as an adjunct for closure of the nephrostomy tract in tubeless percutaneous surgery (tubeless percutaneous nephrolithotomy [tPNL]) has been previously evaluated, observing a potential benefit in terms of reduced bleeding and urinary leakage. We assessed the rate of postoperative complications after the use of hemostatic agents for sealing the nephrostomy tract in patients undergoing tPNL at our institution.

SUBJECTS AND METHODS

We performed a retrospective analysis of 52 consecutive patients undergoing tPNL at our center between January 2010 and December 2013. No substance was placed within the tract in 25 patients (Group 1). A cylinder of Surgicel(®) in addition to 1 unit of Gelita(®) were placed within the access tract in 27 patients (Group 2). We accounted for demographic variables, stone size, operative time, postoperative pain, development of hematoma, postoperative hematocrit drop, urinary leakage, residual lithiasis, and hospital stay length.

RESULTS

Age and sex differed significantly between the two groups (P = 0.0002 and P = 0.048 respectively). However, there were no significant differences in terms of body mass index and stone burden. No significant differences between groups were found with regards to operative time, postoperative hematocrit drop, postoperative pain and presence of residual lithiasis.

CONCLUSION

The use of Gelita(®) and Surgicel(®) as hemostatic agents in tPNL is safe, but we were not able to demonstrate any significant benefit in terms of postoperative morbidity after comparing the use of these agents in tPNL. We concluded that the uses of hemostatic agents needed to be evaluated in prospective randomized trials to define its benefits.

The management of the access tract after percutaneous nephrolithotomy

PURPOSE

To describe the evolution of the current technique in percutaneous nephrolithotomy (PCNL) with a special focus on access tract closure techniques.

METHODS

A systematic review of outcomes and complications of tubeless PCNL was conducted using the MEDLINE and Pubmed databases between 1976 and 2014.

RESULTS

During the past decade, PCNL underwent fundamental modifications due to miniaturization of the instruments and advancements in technique. The routine use of the nephrostomy tube after PCNL has been subsequently questioned. Currently, the nephrostomy tube is increasingly omitted, and the access tract is usually sealed by haemostatic agents. An additionally ureteric stent is commonly inserted at the end of the procedure. However, the application of haemostatic sealants increases the immediate costs significantly. Still there are inconsistent data because of small study populations, lack of randomization, retrospective character and further more heterogeneous surgical techniques.

CONCLUSION

The current body of literature does not provide high-level evidence for the preferred treatment of the access tract in PCNL. However, most authors agree that a tract sealing can be omitted without increasing the risk of complication in uncomplicated procedures.

Hemostatic plug: novel technique for closure of percutaneous nephrostomy tract

Percutaneous nephrolithotomy (PCNL) is a standard treatment for patients with large or complex kidney stones. The procedure has traditionally included postoperative placement of a nephrostomy tube to allow for drainage and possible reentry. This practice was first implemented after complications incurred after tubeless PCNL in a small patient population. Recently, tubeless PCNL has reemerged as a viable option for selected patients, resulting in decreased pain and analgesic use, shorter hospitalization, quicker return to normal activity, and decreased urine extravasation. Gelatin matrix sealants are occasionally used in nephrostomy tract closure. Techniques for delivery of these agents have been ill described, and placement may be performed with varying results. We present a literature review comparing tubeless PCNL to its traditional variant with indications for use of each, as well as a comparison of agents used in closure. Finally, we outline a novel, reproducible technique for closure of the dilated percutaneous renal access tract.

Hemostatic agents used for nephrostomy tract closure after tubeless PCNL: a systematic review and meta-analysis

To evaluate the role of hemostatic agents used for nephrostomy tract closure after tubeless percutaneous nephrolithotomy (PCNL). A systematic review of Pubmed, Embase and Cochrane was performed. All studies that compared hemostatic agents with common methods (silk stitch or pressure dressing) were included. The analyzed outcomes were hospital stay, operative time, blood loss, transfusion rate, fever rate, and complication rate. A total of eight articles including six RCTs met our criteria. Hemostatic agents showed short hospital stay (MD -4.54, 95 % CI -6.78 to -2.36, p < 0.0001). There was no difference between hemostatic agents and common methods on operative time (MD 2.00, 95 % CI -17.32 to 21.33, p = 0.84), blood loss (MD -0.19, 95 % CI -0.41 to 0.03, p = 0.08), transfusion rate (OR 1.42, 95 % CI 0.34-5.96, p = 0.63), fever rate (OR 1.02, 95 % CI 0.33-3.12, p = 0.97) and complication rate (OR 1.02, 95 % CI 0.33-3.12, p = 0.97). Eight studies including six RCTs showed that use of hemostatic agents was safe. Hemostatic agents showed short hospital stay. There were no difference between hemostatic agents and common methods on blood loss, transfusion rate, fever rate, and complication rate.

WITHDRAWN: Editorial Comment

The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.urology.2013.02.086. The duplicate article has therefore been withdrawn.

TachoSil(®) sealed tubeless percutaneous nephrolithotomy to reduce urine leakage and bleeding: outcome of a randomized controlled study

PURPOSE

We determined the efficacy and safety of TachoSil(®) in sealing the tract after percutaneous nephrolithotomy compared to nephrostomy tube placement.

MATERIALS AND METHODS

A total of 100 consecutive patients scheduled for percutaneous nephrolithotomy were randomized 1:1 to receive a 16Fr nephrostomy tube (group 1) or TachoSil in the tract (group 2). All patients received a mono-J ureteral catheter. The primary study end points were bleeding and urinary leakage rates. The secondary end points were pain as assessed by the 0 to 10-point visual analog scale, analgesic requirement and hospital stay.

RESULTS

The groups were comparable for preoperative and operative variables. In group 1, 3 patients were excluded intraoperatively because of relevant bleeding, and in group 2, 1 patient was excluded intraoperatively because of hydrothorax. Tract complications were significantly more frequent in group 1 than in group 2 (25.5% vs 2%, p <0.001). However, the difference in urinary leakage reached statistical significance (19.1% vs 2%, p = 0.007), whereas that in perirenal hematoma formation did not (6.4% vs 0%, p = 0.113). There was no difference between the groups in mean ± SD number of analgesic doses (1.17 ± 1.56 vs 1.20 ± 1.69, p = 0.791) and visual analogue scale scores (4.77 ± 2.28 vs 4.24 ± 2.32, p = 0.270). Postoperative hospital stay was significantly shorter in group 2 than in group 1 (5.15 ± 1.74 vs 2.75 ± 1.78 days, p <0.0001).

CONCLUSIONS

Although failing to reduce pain and analgesic requirement, TachoSil provided better tract control and a shorter hospital stay than nephrostomy tube placement, thus allowing the extension of indications for tubeless percutaneous nephrolithotomy to most procedures.

Evolution of hemostatic agents in surgical practice

Objective:

Topical hemostatic agents are used in a wide variety of surgical settings, and the evolution of this class of surgical tools is an interesting topic. We reviewed and outlined the historical progress of topical hemostats into present day surgery and urology, and highlight opportunities for future research.

Materials and Methods:

A MEDLINE search of all available literature concerning several classes of topical hemostatic agents was performed. Fibrins sealants, Gelatin sponge hemostatics, cyanoacrylate adhesives, oxidized regenerated cellulose, and microfibrillar collagen were included. References were chosen from a broad range of surgical literature.

Results:

Topical hemostatic agents have historically taken advantage of a wide variety of mechanisms for hemostasis. Fibrin sealants have a rich history and large potential for further applications. Gelatin sponge hemostatics have been widely used since their introduction, but have changed little. Cyanoacrylate adhesives have a unique mechanism and opportunity for novel applications of existing products. Oxidized cellulose was original in the use of plant-based components. Microfibrillar collagen hemostats have evolved to a wide variety of formats.

Conclusions:

A review of the evolution of topical hemostatic agents highlights opportunities for potential novel research. Fibrin sealants may have the most opportunity for advancement, and understanding the history of these products is useful. With the drive in urology for minimally invasive surgical techniques, adaptation of topical hemostatic agents to this surgical approach would be valuable and offers an opportunity for novel contributions.

New instrumentation in percutaneous nephrolithotomy

Percutaneous nephrolithotomy (PCNL) is the procedure of choice for removing large, complex, and/or multiple renal calculi. Since its first description in 1976, PCNL techniques and equipment have evolved to maximize procedural efficacy, safety, and reproducibility. We reviewed current literature from January 2004 to November 2009 using Medline search regarding PCNL instrumentation and technology. Additional equipment discovered during the review process without published Medline evidence was summarized from manufacturer brochures and data. Included in this review are summaries of intracorporeal lithotriptors and accessory equipment, stone manipulation devices, PCNL tract sealants, and a digital rigid nephroscope. The evolution of these devices from their predecessors has increased the instrumentation options for the treating urologist and may represent more effective technology for the percutaneous treatment of large renal stones.

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.

Evolution of hemostatic agents in surgical practice

OBJECTIVE

Topical hemostatic agents are used in a wide variety of surgical settings, and the evolution of this class of surgical tools is an interesting topic. We reviewed and outlined the historical progress of topical hemostats into present day surgery and urology, and highlight opportunities for future research.

MATERIALS AND METHODS

A MEDLINE search of all available literature concerning several classes of topical hemostatic agents was performed. Fibrins sealants, Gelatin sponge hemostatics, cyanoacrylate adhesives, oxidized regenerated cellulose, and microfibrillar collagen were included. References were chosen from a broad range of surgical literature.

RESULTS

Topical hemostatic agents have historically taken advantage of a wide variety of mechanisms for hemostasis. Fibrin sealants have a rich history and large potential for further applications. Gelatin sponge hemostatics have been widely used since their introduction, but have changed little. Cyanoacrylate adhesives have a unique mechanism and opportunity for novel applications of existing products. Oxidized cellulose was original in the use of plant-based components. Microfibrillar collagen hemostats have evolved to a wide variety of formats.

CONCLUSIONS

A review of the evolution of topical hemostatic agents highlights opportunities for potential novel research. Fibrin sealants may have the most opportunity for advancement, and understanding the history of these products is useful. With the drive in urology for minimally invasive surgical techniques, adaptation of topical hemostatic agents to this surgical approach would be valuable and offers an opportunity for novel contributions.