Questioning the wisdom of tubeless percutaneous nephrolithotomy (PCNL): a prospective randomized controlled study of early tube removal vs tubeless PCNL

Abstract

catheter and a Foley catheter were used, while in group 2 only a 6 F retrograde ureteric catheter and Foley catheter were placed at the end of the procedure. Computed tomography (CT) with no contrast medium was done on the first morning after surgery before removing all catheters/tubes, and patients discharged subsequently. The variables assessed were stone clearance, hospital stay, analgesic requirement, postoperative complications and auxiliary procedures. RESULTSThe mean ( SD ) stone bulk was similar between the groups, at 2737 (946.9) and 2934.2 (2090.7) μ L, respectively. Despite an on-table complete clearance, clearance assessed by CT was nine of 11 vs eight of 11 in groups 1 and 2, respectively. CT showed a 6mm stone in one patient in group 1, while the remaining patients had stones of < 4mm. The mean ( SD ) analgesic requirement, haemoglobin decrease, urine leak and hospital stay in the two groups were 72.7 (51.8) vs 68.2 (46.2)mg of tramadol ( P = 0.25), 1.6 (0.7) vs 1.6 (0.9)g/dL ( P = 0.39), 13.9 (6.3) vs 7.1 (14.2)h ( P = 0.018) and 72.8 (2.1) vs 70.2 (18.5)h ( P = 0.09), respectively. Complications noted were early haematuria in none vs three ( P = 0.21), urinoma none vs one, and fever in two vs one, respectively; one patient in group 1 required a check nephroscopy for a residual fragment. Overall clearance including re-treatment was 10/11 vs eight of 11 ( P = 0.009), respectively.

Outcome of PCNL- Success &Complications

“…Both the procedures are routinely done under general anaesthesia in our set up, so considered as grade 3B complications. These major complications were marginally higher compared to CORES study [19]. Grade 4 and 5 were not noted in our study.…”

“…13.58% of patients.Factors predisposing to fever after PCNL include preexisting untreated UTI, infected urinary stones, duration of surgery (< 90 min), amount and pressure of irrigation fluid.In the literature, fever is reported in up to 32% of cases after PCNL [19]. Both the AUA and EAU guidelines recommend antibiotic prophylaxis for all patients who are undergoing PCNL [20,21].…”

“…In the CROES study, transfusion was administered in 5.7% of patients [19]. Bleedingcan occur in every step of PCNL from percutaneous access to tract dilation to stone disintegration [23].…”

Intraoperative Patient Selection for Tubeless Percutaneous Nephrolithotomy

“…Mishra et al demonstrated that early tube removal after PCNL resulted in an equivalent analgesic requirement, decrease in hemoglobin and hospital stay as tubeless PCNL as well as a significantly lower incidence of early hematuria, and better clearance. 16 Meanwhile, totally tubeless PCNL can be feasible and is a more advanced technique compared to early tube removal after PCNL. A meta-analysis by Zhong et al showed that totally tubeless PCNL is safe and effective and that it significantly reduced the hospital stay, analgesic requirement, and the time to return to normal activity without increased complications.…”

Determinants of Nephrostomy Tube Dislodgment After Percutaneous Nephrolithotomy

“…4 Furthermore, nephrostomy tubes preserve and maintain renal access if a repeat procedure is needed to evacuate residual stone debris. 5 The majority of urologists continue to place nephrostomy tubes after PCNL, especially in complicated cases where the risk of hemorrhage, urinary extravasation, urosepsis, and the need for a repeat procedure is high. 4,6 Accidental nephrostomy tube dislodgment can be a significant complication after PCNL leading to pain or fever from obstructive uropathy because of an obstructing stone or renal pelvic/ureteral edema, urinary extravasation, need for reoperation, renal hemorrhage, or urinary extravasation.…”