‘Nephrostomy-Free’ Percutaneous Nephrolithotomy: Experience in a UK District General Hospital

Abstract

INTRODUCTION Percutaneous nephrolithotomy (PCNL) is the first-line treatment for large and complex renal calculi. Accepted UK practice is to insert a nephrostomy tube at the end of the procedure to drain the kidney and reduce potential complications. ‘Tubeless’ or ‘nephrostomy-free’ PCNL has been advocated in selected patients as it is thought to reduce length of hospital stay, analgesia requirements and pain experienced. We present our outcomes of a consecutive series (n = 101) of ‘nephrostomy-free’ PCNLs compared to standard PCNL over a 4-year period. PATIENTS AND METHODS Between January 2004 and October 2006, we performed 55 standard (with nephrostomy tube) PCNLs (Group 1). From October 2006 onwards, we changed our technique and have performed 46 consecutive ‘nephrostomy-free’ PCNLs (JJ stent inserted), independent of patient and stone factors (Group 2). We have compared the two groups in terms of length of hospital stay (LOS), analgesia requirements, transfusion rates, haemoglobin (Hb) decrease and immediate, early and late complications. RESULTS ‘Nephrostomy-free’ PCNL significantly reduced the length of hospital stay (2.8 vs 5.1 days; P < 0.001), morphine-based analgesia requirements (23% no morphine required vs 2.8%; P < 0.001), transfusion rate (2.5% vs 7%; P < 0.01) and mean Hb decrease (1.89 g/dl vs 2.25 g/dl; P > 0.05). Overall, no patient experienced a serious complication. All attempted ‘nephrostomy-free’ PCNLs were completed (stone clearance 95%) and no patient needed an unplanned nephrostomy. Only 5% in Group 2 needed their ureteric JJ stent removing earlier than planned secondary to pain. Both groups were comparable in terms of immediate, early and late complications, though three patients in Group 1 developed chronic loin pain and one patient in the ‘nephrostomy-free’ group developed a delayed perirenal haematoma. CONCLUSIONS ‘Nephrostomy-free’ percutaneous nephrolithotomy is a safe, effective and feasible procedure independent of patient and stone factors. It decreases the length of hospital stay, the pain experienced and the need for morphine-based analgesia; we feel it should be the standard of care for patients undergoing a PCNL.

Standard versus Tubeless Percutaneous Nephrolithotomy: A Systematic Review

“…In 22 studies [2,3,4,5,6,7,8,9,10,11,12,13,14,18,19,21,22,23,24,27,28,29], the range of analgesia needs post-operatively was less for tubeless patients, and this was significant in 13 studies [2,3,4,6,7,8,9,10,11,13,18,22,27]. …”

“…In the case of Yates et al [29], although clearance for tubeless groups was 95 versus 71% in standard PCNL, the authors postulated that this was coincidental rather than reflecting true differing case complexity. Without giving an actual figure, in the majority of patients requiring further treatment, ESWL was the modality of choice.…”

A non-inferiority study to analyze the safety of totally tubeless percutaneous nephrolithotomy

“…All those studies were superiority trials with the aim to prove that experimental treatment is superior to standard treatment. [18][19][20] In statistical language, the aim was to reject null hypothesis (experiment is not better than standard) and adopt an alternative one (experiment is better than standard). In the above-mentioned trials, statistical significance was not shown (p > 0.05); hence, the authors stated that ttPCNL are equally safe as cPCNL.…”

Truly tubeless percutaneous nephrolithotomy

“…1 In a recent series of 170 patients in whom a stent was placed post PCNL, five required a postoperative emergency nephrostomy insertion for obstruction. 2 In the series of Yates et al, 3 immediate and early complication rates were higher in the stented group including haematuria requiring re-admission, clot colic, stent pain and stent migration. They also described a delayed presentation of perinephric haematoma and abscess formation.…”

“…They also described a delayed presentation of perinephric haematoma and abscess formation. 3 True tubeless PCNL has been evaluated by Crook and colleagues 4,5 and found to be safe and well-tolerated. No differences were seen in stone free rates, transfusion, and complication or re-admission rates.…”