Extending the Application of Tubeless Percutaneous Nephrolithotomy

doi:10.1016/j.urology.2007.03.082

Urology

Volume 70, Issue 3, September 2007, Pages 412-416

https://doi.org/10.1016/j.urology.2007.03.082 Get rights and content

Abstract

Objectives

Tubeless percutaneous nephrolithotomy (PCNL) has been successfully performed in selected patients. We assessed its applicability for use without imposing preoperative restrictions.

Methods

The study consisted of a prospective and consecutive series of 126 patients. Tubeless PCNL was performed when perforation, residual stones, and significant bleeding had been intraoperatively excluded by fluoroscopy, nephroscopy, and hemodynamic assessment. Staghorn stones, supracostal and/or multiple access, anatomic anomalies, previously operated kidneys, solitary kidneys, and operative time were not considered contraindications. The demographic, clinical, and intraoperative and postoperative data were statistically analyzed.

Results

Using this protocol, we performed 66 (52%) tubeless and 60 (48%) regular PCNLs. The average patient age (54 years versus 52 years), stone burden (924 versus 1044 mm²), operative time (116 versus 130 minutes), complication rate (9% versus 13%), hemoglobin decrease (1.2 versus 1.1 mg/dL), and immediate stone-free rate (92% versus 90%) were similar for the tubeless and regular PCNL groups, respectively (P >0.05). The reasons for performing standard PCNL were an expected second-look procedure (n = 35, 58%), an impression of active bleeding (n = 16, 27%), significant extravasation (n = 5, 8%), and suspected hydrothorax (n = 4, 7%). The overall transfusion rate was 3%. The average analgesia requirement (pethidine HCL) was 0.4 and 1.2 mg/kg (P <0.01), the median hospital stay was 1 and 4 days (P <0.0001), and the median back-to-work time was 7 and 15 days (P <0.001) for the tubeless and regular PCNL groups, respectively.

Conclusions

The results of our study have shown that tubeless PCNL can be safely and effectively performed based on intraoperative factors, without preoperative contraindications. Compared with the standard procedure, tubeless PCNL was associated with reduced postoperative pain, hospital stay, and recovery time.

Section snippets

Material and Methods

The study consisted of a consecutive and prospective series of 126 patients presenting for PCNL during a 2-year period, starting January 2004. After providing written informed consent, all patients were considered for tubeless PCNL without any preoperative selection. The institutional review board representative had ruled that no institutional review board approval was needed because the study was not randomized, all the performed procedures represented well-established and commonly practiced

Results

Using the study protocol, we performed 66 (52%) tubeless and 60 (48%) regular PCNLs. The groups were similar in terms of demographic and clinical data, as well as access position and method of tract dilation (Table 1).

The median operative time was 115 and 120 minutes and the immediate stone-free rate was 92% and 90% for the tubeless and standard PCNL groups, respectively (P >0.05). Residual stones were identified in 5 patients after the tubeless procedure: 2 were referred for shock wave

Comment

In recent years, interest has been evolving in the search for refinements of percutaneous procedures. The research has focused on decreasing the trauma to the kidney and the percutaneous tract, as well as reducing postoperative morbidity, analgesia requirements, hospital stay, and cost. One of the clinically tested modifications is the minipercutaneous approach.12, 13, 14 First reported by Jackman et al.¹² in pediatric patients, minipercutaneous PCNL, using 13F to 20F working sheaths, was soon

Conclusions

Our results have attested that tubeless PCNL can be safely and effectively performed without preoperative contraindications. The intraoperative assessment is accurate enough to achieve results as good as those with the standard technique. By confirming the advantages of the tubeless technique in terms of postoperative patient discomfort, hospitalization, and recovery, we believe that this study represents another contribution to the further popularization of the tubeless technique.

Acknowledgment

To Esther Eshkol for editorial assistance.

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Cited by (37)

Use of hemostatic sealant in tubeless percutaneous nephrolithotomy: Experience of a single institution from Taiwan
2017, Urological Science
Tubeless percutaneous nephrolithotomy (PCNL) offers several advantages over standard PCNL, including a shorter hospital stay, less analgesic requirement, and less postoperative pain. Using a fibrin sealant to seal the nephrostomy tract had become a widely accepted technique at the conclusion of tubeless PCNL. Our objective is to evaluate the efficacy and safety of tubeless PCNL using hemostatic matrix.
This is a retrospective review of PCNL database at our hospital between June 2014 and March 2016. During this period, a total of 139 PCNLs were performed, including 41 with tubeless technique with adjunct of hemostatic matrix (Floseal; Baxter, Deerfield, IL, USA) at the conclusion of the PCNL procedure. The standard PCNL group and the tubeless PCNL group were compared in terms of demographic characteristics, perioperative data, stone characteristics, and complication rate.
Of all 123 patients included in this study, 41 underwent tubeless PCNL. Demographic data of the two groups were comparable except for a higher proportion of male patients in the tubeless PCNL group (73.2% vs. 53.7%). Stone characteristics were also comparable in the two groups. Perioperative variables, including operative time, drop of serum hemoglobin level, and perioperative complication rate, revealed no statistical difference between the two groups. Tubeless PCNL was associated with less postoperative pain, less analgesic requirement, and a shorter hospital stay (p < 0.01).
Tubeless PCNL with adjunct use of a hemostatic sealant can be considered as a safe treatment option for renal calculi with favorable outcome, without an increase in complications. Compared with standard PCNL, tubeless PCNL with hemostatic sealant use is associated with less pain, use of fewer narcotic agents, and a shorter hospital stay.
Upper Calyx Approachability through a Lower Calyx Access for Prone Versus Supine Percutaneous Nephrolithotomy
2016, Journal of Urology
Citation Excerpt :
Our basic approach consisted of insertion of a No. 5 open-ended ureteral catheter, retrograde pyelography and puncture of the lower posterior calyx under multiplanar fluoroscopy guidance for the prone position, and combined ultrasonographic and anteroposterior fluoroscopic guidance for the supine position. Further details of our prone8 and supine9 techniques have been reported previously. The operations were performed without postoperative nephrostomy tubes (tubeless).
We assessed the approachability of the upper calyx through lower calyx access for prone and supine percutaneous nephrolithotomy and used computerized tomography to analyze anatomical factors that may influence it.
A prospective series of 45 patients treated with percutaneous nephrolithotomy were operated on in the prone (20) and supine (25) positions. Computerized tomography simulated access to the lower and upper calyx longitudinal axes were used to measure skin-to-lower calyx distance, thickness of the body wall, muscle and fat, the muscle-to-fat thickness ratio and the angle between the lower calyx tract and the upper calyx axis. Intraoperative approachability to the upper calyx was also evaluated.
The upper calyx was successfully approached in 20% of prone and 80% of supine percutaneous nephrolithotomies (p <0.0001). The average skin-to-lower calyx distance was 98.4 mm (range 65.3 to 128.6) in the prone position and 98.7 mm (range 60.8 to 150) in the supine position (p = 0.99). Body wall and muscular thickness, and the muscle-to-fat thickness ratio were significantly lower in supine than prone nephrolithotomy (p <0.001, <0.0005 and <0.05, respectively). The average angle between the lower and upper calyces axes was wide in the supine position (141 degrees, range 90 to 170) and acute in the prone position (84 degrees, range 65 to 110, p <0.05^E-10).
Upper calyx endoscopic approachability through the lower calyx is significantly higher in supine than in prone percutaneous nephrolithotomies, possibly due to a thinner body wall, a thinner muscular layer, a lower muscle-to-fat thickness ratio and a wider angle between the lower and upper calyx axes.
Tubeless versus standard PCNL in geriatric population
2015, Actas Urologicas Espanolas
La nefrolitotomía percutánea (NLPC) es un procedimiento estándar, seguro y eficaz para los cálculos renales de gran tamaño en todos los grupos de edad. La sonda de nefrostomía constituye una parte muy valiosa de la nefrolitotomía. Sin embargo, recientemente se ha modificado la sonda de nefrostomía al ser reemplazada por el catéter ureteral o la sonda doble J, gracias a los avances en urotecnología y en las herramientas quirúrgicas. El objetivo del presente artículo es evaluar la seguridad y la fiabilidad de la nefrolitotomía percutánea sin catéter en la población geriátrica.
Entre enero de 2009 y septiembre de 2013 un total 52 pacientes de 65 o más años con cálculos renales mayores de 2 cm fueron sometidos a NLPC. El primer grupo de 25 pacientes (48%), con una edad media de 70,0 años (des: +3,8) fueron sometidos a NLPC sin catéter, mientras que el segundo grupo formado por 27 (52%) pacientes con una edad media de 71,3 años (des: +4,0) fueron sometidos a NLPC estándar. Se compararon aleatoriamente y de forma retrospectiva los pacientes en términos de carga litiásica, necesidad de antibióticos, valores de creatinina, espesor del parénquima renal, índice de masa corporal (IMC), grado de Clavien, tiempo de hospitalización y estado libre de litiasis.
Se apreció que los grupos eran similares en cuanto a edad, IMC y sexo (p > 0,05). La carga litiásica, la duración del procedimiento quirúrgico y la tasa de empleo de analgésicos narcóticos fueron significativamente mayores desde el punto de vista estadístico en el grupo de NLPC estándar que en el grupo de NLPC sin catéter (p < 0,05). El tiempo de hospitalización fue de 1,7 días en el grupo de NLPC sin catéter y de 2,6 en el de NLPC estándar (p < 0,05). No se halló ninguna diferencia significativa entre los grupos en cuanto a una disminución en los niveles de hemoglobina, creatinina, los niveles de espesor del parénquima y el grado de Clavien, transfusiones preoperatorias de sangre, LEC previa, localización del cálculo, número de accesos y la tasa de éxito (p > 0,05). La carga litiásica fue de 900 mm² (304-4.232) en el grupo de NLPC estándar y de 600 mm² (220-2.660) en el grupo de NLPC sin catéter, siendo esta diferencia estadísticamente significativa (p = 0,014). Se alcanzó éxito global en el 96,0 y 96,3% de los pacientes sometidos a NLPC sin catéter y NLPC estándar, respectivamente, tras una sesión de NLPC.
Se determinó que la nefrolitotomía percutánea sin catéter es tan segura y eficaz como la NLPC estándar en la población geriátrica. Está especialmente recomendada en este grupo de pacientes dadas sus ventajas, como son un período de hospitalización más corto, una menor necesidad de analgésicos y una recuperación de la movilidad más rápida.
Percutaneous nephrolithotomy (PCNL) is a standard, safe, and efficient method for large-volume renal calculi for all age groups. Nephrostomy tube constitutes an invaluable part of the nephrolithotomy operation. However, the nephrostomy tube has been recently replaced with ureteral catheter or double J-stent thanks to advances in urotechnology and operation equipment. The aim of the current article was to evaluate the safety and reliability of tubeless percutaneous nephrolithotomy in the geriatric population.
Between January 2009 and September 2013, a total of 52 patients aged 65 years or elder with renal calculi bigger than 2 cm underwent PCNL operation. The first group of 25 patients (48%) with a mean age of 70.0 years (std: ±3,8) underwent tubeless PCNL whereas the second group consisting of 27 (52%) patients with a mean age of 71.3 years (std: ±4,0) underwent standard PCNL. The patients were randomly compared retrospectively in terms of burden of calculus, analgesic requirement, creatinine value, renal parenchymal thickness, Body-mass index (BMI), clavien score, length of hospitalization, and being calculus-free.
The groups were found to be similar in age, BMI, and gender (P > .05). Burden of calculus, duration of operation, and rate of narcotic analgesic use were found to be statistically significantly higher in the group of Standard PCNL group than in the Tubeless PCNL group (P < .05). Length of hospital stay was 1.7 days in the group of tubeless PCNL and 2.6 days in the standard PCNL group (P < .05). No significant difference was found between the groups in terms of fall in hemoglobin, creatinine, values of parenchymal thickness, and clavien score, preoperative blood transfusion, previous SWL, location of calculi, number of access, and rate of success (P > .05). Burden of calculus was 900 mm2 (304-4232) in the standard PCNL group and 600 mm² (220-2660) in the tubeless PCNL group with the difference being statistically significant (P = .014). Overall success was achieved in 96.0 and 96.3% of tubeless PCNL and standard PCNL patients after one session of PCNL, respectively.
Tubeless percutaneous nephrolithotomy was found to be as safe and effective as standard PCNL in the geriatric population. It is recommended especially in this group of patients because of its advantages such as shorter length of hospitalization, less analgesic requirement, and earlier mobilization.
Percutaneous extraction of a ureteral stent after tubeless percutaneous nephrolithotomy
2015, Revista Mexicana de Urologia
Evaluar la seguridad del retiro percutáneo del stent ureteral tras nefrolitotomía percutánea (NLPC).
Se incluyeron 7 pacientes a los cuales se les realizó NLPC tubeless, dejando un sujetador con nailon 3-0 en el extremo proximal del stent ureteral, que salía al exterior por el tracto de acceso. Se retiró el stent ureteral por vía percutánea una semana después de la cirugía. El seguimiento se realizó con placa simple de abdomen posquirúrgica, ecografía renal y urocultivo.
Los pacientes tuvieron adecuada tolerancia al dolor con una media de 2 en escala visual analógica del dolor. Dos pacientes presentaron urocultivo positivo al mes de seguimiento. Uno reingresó al servicio de urgencias por fiebre. Ninguno evidenció urinoma en la ecografía de control.
La técnica tubeless en la NLPC ha disminuido la morbilidad de la técnica, con reducción de dolor postoperatorio y menor estancia hospitalaria. El retiro del stent en forma percutánea evita la necesidad de realizar cistoscopia posquirúrgica.
El retiro percutáneo del stent ureteral posterior a una NLPC tubeless es factible, sencillo y reproducible, con adecuada tolerancia al procedimiento en el consultorio.
To evaluate the percutaneous removal of a ureteral stent after percutaneous nephrolithotomy (PNL).
The study included 7 patients that underwent tubeless PNL, leaving a tether at the proximal end of the ureteral stent with nylon 3-0 suture, exteriorizing it through the access tract. The ureteral stent was percutaneously removed one week after surgery. Follow-up was conducted with a postoperative plain abdominal x-ray, kidney ultrasound, and urine culture.
The patients presented with adequate pain tolerance with a mean of 2 points on the visual analog scale for pain. Two patients had a positive urine culture at the follow-up at un month. One patient was readmitted to the emergency department due to fever. None of the patients presented with urinoma in the control ultrasound.
The tubeless technique in PNL has reduced the procedure's morbidity, with a decrease in postoperative pain and a shorter hospital stay. Percutaneous removal of the stent eliminates the need for postoperative cystoscopy.
The percutaneous removal of a ureteral stent after tubeless PNL is simple, feasible, and reproducible and is adequately tolerated as an office procedure.
Experience in percutaneous nephrolithotomy with ambulatory management vs hospitalization in a urology center, Pereira, 2009-2012
2014, Urologia Colombiana
Reportar la experiencia en nefrolitotomía percutánea (NLPC), revisando variables sociodemográficas y quirúrgicas en pacientes ambulatorios y hospitalizados.
Estudio de cohorte retrospectivo que analiza datos de 95 pacientes que fueron sometidos a NLPC de junio/2009 a mayo/2012. Las variables analizadas incluyen tipo de litiasis, anestesia, punción del cáliz, litiasis residual y complicaciones intra y postoperatorias.
Paso de catéter ureteral y contraste, acceso al colector con guía 0,38-F, dilatación con Alken y colocación de Amplatz 28-F. Se empleó nefroscopio rígido 26-F y nefrostomía en todos los pacientes. Las variables clínicas de desenlace se evaluaron en los grupos ambulatorios vs hospitalizados a la semana siguiente al procedimiento. Análisis estadístico con STATA11, p < 0,05.
La edad media de los pacientes fue 47,09 años, 55,79% fueron mujeres. 58,95% de los cálculos fueron de ubicación izquierda. Dos cirujanos realizaron los procedimientos, 80% en posición prona usando anestesia general en el 77,89%. El acceso más común fue el cáliz inferior (58,95%) y el sangrado intraoperatorio estimado fue < 200 mL en el 93,68%. Luego del procedimiento, 37 pacientes fueron hospitalizados y 58 se manejaron de forma ambulatoria. Hubo un caso de perforación de colon que resolvió con manejo conservador. El dolor postoperatorio a la semana siguiente del procedimiento fue en promedio 2 para los ambulatorios y 3,70 para los hospitalizados. La mayoría de variables no estuvieron asociadas a ninguno de los manejos iniciales. Conclusiones: La NLPC es una técnica segura para el manejo de grandes litiasis, incluso en pacientes tratados en base ambulatoria y con nefrostomía.
© 2013 Sociedad Colombiana de Urología. Publicado por Elsevier España, S.L. Todos los derechos reservados.
To report the experience in percutaneous nephrolithotomy (PCNL), reviewing demographic and surgical variables in ambulatory and hospitalized patients.
Retrospective cohort study was performed by analyzing data from 95 patients who underwent PCNL from June/2009 to May/2012. The variables included, type of stones, anesthesia, calyx puncture, residual stones, and intra -and postoperative complications. Technique: ureteral catheter and contrast medium, access to collector with 0.38-F guide, dilation with Alken, and placement of 28-F Amplatz. A 26-F rigid nephroscope and nephrostomy was used in all patients. Clinical outcome variables were evaluated in the outpatient vs hospitalization groups in the week following the procedure. Statistical analysis was performed using STATA11, P<.05.
Mean age was 47.09 years, and 55.79% of patients were women. A total of 58.95% of stones were at left location. Two surgeons performed the procedures, with 80% of patients in prone position, and under general anesthesia in 77.89%. The most common access was lower calyx (58.95%), and the estimated intraoperative bleeding was < 200mL in 93.68%. After the procedure, 37 patients were hospitalized and 58 were managed as outpatients. There was one case of bowel perforation, which resolved with conservative management. Postoperative pain during the week following the procedure was an average of 2 for outpatients, and 3.70 for hospitalized. Most variables were not associated with any of the initial treatment.
PCNL is a safe technique for the management of large stones, even in patients treated on an outpatient basis with nephrostomy.
© 2013 Sociedad Colombiana de Urología. Published by Elsevier España, S.L. All rights reserved.
Non-contrast computed tomography after percutaneous nephrolithotomy: Findings and clinical significance
2012, Urology
Citation Excerpt :
Achievement of a stone-free status is the main goal of PNL, and its assessment relies on imaging studies. Contemporary series reveal post-PNL stone-free rates that exceed 90%.9,12 Missed RFs may have significant consequences.
To describe the post-percutaneous nephrolithotomy (PNL) non–contrast-enhanced computed tomography (NCCT) findings and assessed their clinical significance. NCCT evaluates stone clearance after PNL and also reveals procedure-related changes.
One hundred consecutive patients who underwent PNL were evaluated by NCCT one day post-procedure. Two radiologists analyzed the type and severity of the NCCT findings, which were then statistically analyzed in relation to the patient's clinical course.
The patients' mean age was 54 years (range 18–82) and the mean maximal stone diameter was 37 mm (range 15–70). The median operative time was 110 minutes for an immediate stone-free rate of 83%, changing to 94% (P = .073) after a second-look PNL in 11 patients. The post-PNL NCCT findings were hydronephrosis (70%), atelectasis (54%), ipsilateral pleural effusion (52%), paracolic gutter fluid (44%), perinephric hematoma (40%), perinephric fluid (32%), ureteronephrosis (31%), renal swelling (23%), contralateral pleural effusion (22%), residual fragments (RFs) (17%), subcapsular hematoma (10%), and flank hematoma (6%). Univariate analysis revealed a significant association with clinical variables for all NCCT findings except for atelectasis, ureteronephrosis, contralateral pleural effusion, RFs, and flank hematoma. In multivariate analysis, only perinephric fluid (P = .007) and ipsilateral pleural effusion (P = .034) were associated with longer hospitalization, and perinephric fluid with longer recovery (P = .004). The complication rate was 12%, but none were linked with the radiological findings.
This work describes the post-PNL NCCT findings and their clinical significance. Perinephric fluid and ipsilateral pleural effusion were found to independently predict longer hospitalization and recovery time.

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Adult UrologyExtending the Application of Tubeless Percutaneous Nephrolithotomy

Abstract

Objectives

Methods

Results

Conclusions

Section snippets

Material and Methods

Results

Comment

Conclusions

Acknowledgment

Urology

J Urol

Urology

J Urol

Urology

J Urol

Urology

J Urol

J Urol

Urology

Adult Urology
Extending the Application of Tubeless Percutaneous Nephrolithotomy