Tubeless vs standard percutaneous nephrolithotomy: a meta-analysis

Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? This study showed that tubeless PCNL could reduce hospital stay with little need for postoperative analgesia. This study discussed the clinical feasibility of tubeless PCNL, which is the tendency of PCNL. Our results are reliable by using veta‐analysis from individual studies.

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 Rev Man 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.

     

Tubeless percutaneous nephrolithotomy. A comparative study with standard percutaneous nephrolithotomy

INTRODUCTION: To assess the efficacy, safety and morbidity of tubeless percutaneous nephrolithotomy. MATERIALS AND METHODS: One hundred and fifty-two patients with renal and upper ureteric calculi were included in this study. Sixty-nine patients (71 renal units; group 1) in whom no nephrostomy tube was placed at the conclusion of the procedure was compared with a similar control group of 83 patients (group 2) in whom a nephrostomy tube was placed. Operating time, blood loss, analgesia requirement, puncture site urinary leakage, hospital stay and mean convalescence period were compared in both groups. RESULTS: Both groups were similar with respect to age, sex distribution and stone size. Operating time and blood loss were less in group 1 although they did not reach statistical significance. The mean analgesic requirement, puncture site urinary leakage and hospital stay were significantly less in group 1. CONCLUSION: Tubeless percutaneous nephrolithotomy is a safe and effective procedure in this selected group of patients.     

完全无管化与标准经皮肾镜治疗肾结石的Meta分析

目的系统评价完全无管化经皮肾镜碎石取石术(PCNL)与标准PCNL治疗肾结石的有效性和安全性。方法检索PubMed、Embase、Cochrane Library数据库。检索时限为从建库到2018年2月28日关于完全无管化PCNL和标准PCNL治疗肾结石的随机对照试验或回顾性病例对照试验,2名作者独立进行文献筛查和数据提取,运用RevMan 5.3软件进行Meta分析。结果共纳入5篇随机对照研究,2篇病例对照研究,共计781例患者,其中完全无管化PCNL组379例,标准PCNL组402例。Meta分析结果显示:完全无管化PCNL组的手术时间短于标准PCNL组(WMD:-2.72;95%CI:-4.05^-1.39;P<0.001);住院时间短于标准PCNL组(WMD:-1.48;95%CI:-1.84^-1.11;P<0.001);术后镇痛需求低于标准PCNL组(WMD:-6.91;95%CI:-9.00^-4.82;P<0.001);两组在结石清除率、术后血红蛋白丢失量及输血率方面差异均无统计学意义。结论完全无管化PCNL在治疗选择性肾结石患者方面优于标准PCNL,可以明显减少手术时间、住院时间和术后镇痛需求,而且不会增加手术相关的并发症。医师应根据患者的实际情况,个体化选择治疗方案。     

Tubeless percutaneous nephrolithotomy: call of the day

PURPOSE: We challenge the routine placement of nephrostomy tube after percutaneous nephrolithotomy (PCNL) without taking into consideration the size, burden, and multiplicity of the stones; the degree of obstruction of the pelvicaliceal system, or any anatomic variations of the kidney in shape or position. PATIENTS AND METHODS: Between January 2005 to March 2006, 110 patients underwent PCNL, 77% of whom had multiple stones. The mean size of the single stones was 4.3 cm (range 2.8-6.5 cm), and the mean single-stone burden was 7.2 cm2 (range 5.6-14.3 cm2). The mean burden of multiple stones was 11.4 cm2 (range 8-23 cm2). Among the patients, 18 had had previous renal surgery, 12 had renal insufficiency, and 7 had a solitary functioning kidney. One patient each had horseshoe kidney and malrotated kidney. In 106 patients, no nephrostomy drain was placed, only an externalized 5F ureteral catheter for 16 to 20 hours. Two patients had simultaneous bilateral tubeless PCNL. The outcome was evaluated prospectively. The frequency of complications, length of hospital stay, and stone-free status were assessed. RESULTS: A stone-free rate of 80% was achieved using PCNL as monotherapy. The mean postoperative hospital stay was 16 to 20 hours. Three patients required placement of a nephrostomy tube because of significant bleeding and one because of purulent renal discharge. In four patients, a ureteral catheter was replaced by a stent because of significant residual stone burdens. The initial 18 patients underwent ultrasound examination on the first postoperative day, and none demonstrated any extrarenal collection, so routine ultrasound examination was omitted in succeeding patients. One patient required exploration because of a retroperitoneal hematoma. CONCLUSION: Omission of a nephrostomy tube after PCNL while retaining an externalized ureteral catheter for 16 to 20 hours is sufficient and safe irrespective of the stone characteristics. Shape, position, and function of the kidneys are also irrelevant with regard to tubeless PCNL.     

Tubeless percutaneous nephrolithotomy in selected patients.

BACKGROUND: Placement of the nephrostomy tube is the last step after completion of percutaneous nephrolithotomy (PCNL). We were able to demonstrate in selected patients who had undergone PCNL that the use of an externalized ureteral catheter can reduce postoperative discomfort without complications. PATIENTS AND METHODS: A total of 37 patients underwent tubeless PCNL with an externalized 6F ureteral catheter for 48 hours. Inclusion criteria were use of a single access site where the renal unit was not obstructive, no significant perforation and bleeding, and no need for a second look. The stone burden was not taken into account. RESULTS: The procedure was performed successfully without major complications. The average length of hospitalization was 3.63 days: 25 patients stayed for 4 days, with the final day reserved for observation after removal of the catheter. The remaining 12 patients stayed only 3 days and could be discharged on the day the catheter was removed. The average intramuscular analgesic requirement was 38.57 mg of meperidine, and none of the patients needed a blood transfusion or required the emergency placement of a nephrostomy tube. CONCLUSION: In properly selected patients, tubeless PCNL with only an externalized ureteral catheter was found to be safe and just as economical as tubeless PCNL with the same outcome.     

Tubeless percutaneous nephrolithotomy using hemostatic gelatin matrix

We describe using hemostatic gelatin matrix (FloSeal; Baxter Inc., Irvine, CA) to provide hemostasis of the tract after percutaneous nephrolithotomy, thereby obviating a nephrostomy tube. For patients who are rendered stone free, a 7F, 11.5-mm occlusion balloon catheter, passed retrograde, is used to occlude the collecting system at the level of entry of the 30F Amplatz sheath. FloSeal is then injected through the partially retracted Amplatz sheath while withdrawing the applicator and the sheath in tandem. The guidewire is withdrawn per urethra until its tip resides in the renal pelvis. A 36-cm, 7F tail stent is passed retrograde, and the skin is closed with cyanoacrylate adhesive (Ethicon, Somerville, NJ). A Foley catheter is placed, to be removed the next morning; the patient can be discharged on postoperative day 1. The ureteral stent is removed in 5 to 7 days as an outpatient procedure.     

Tubeless percutaneous nephrolithotomy: safe even in supracostal access

PURPOSE: This study was designed to determine the outcome and safety of tubeless percutaneous nephrolithotomy (PCNL) in the treatment of renal calculi. PATIENTS AND METHODS: Between November 2005 and March 2006, 48 patients were randomized to either an 18F Re-entry nephrostomy tube (group 1) or a 6F Double-J stent (group 2). The two groups were well matched for age, sex, stone size, stone laterality, and number of previous renal procedures. All PCNL procedures were performed by the same surgeon. Postoperative visual analog pain scale (VAS) scores at 8 and 24 hours and 14 days after surgery, in-hospital analgesic use, length of hospital stay, success rate, blood transfusion rate, and postoperative complications were compared for the two groups. RESULTS: The mean hospital stays in groups 1 and 2 were 3.1 and 1.6 days, respectively (P = 0.003). The mean VAS scores 8 and 24 hours after surgery were significantly lower in group 2 than in group 1 (P = 0.001). The postoperative analgesic requirement (diclofenac sodium) was significantly higher in group 1 (263 mg) than in group 2 (120 mg; P = 0.02). The rate of blood transfusion in the two groups was similar (P = NS). There was no difference between the groups in VAS scores on postoperative day 14. The number of supracostal accesses was significantly higher in group 2 than in group 1 (P = 0.02). The stone-free rates and the numbers of patients with insignificant residual fragments were similar in the two groups. There was no urine leakage or formation of urinoma in patients with Double-J stents. CONCLUSION: Tubeless PCNL is safe and effective even after supracostal access and is associated with less postoperative pain and a shorter hospital stay.     

Tubeless percutaneous nephrolithotomy with antegrade stent tether: clinical experience

BACKGROUND AND PURPOSE: A limitation of tubeless percutaneous nephrolithotomy (PCNL) is the need for post-operative office cystoscopy to remove the ureteral stent. We developed a novel technique of intraoperative stent placement that allows removal via the flank. Herein, we report on our initial clinical experience. PATIENTS AND METHODS: Thirty consecutive patients (36 renal moieties) undergoing tubeless PCNL had ureteral stents placed at the end of the procedure with a stent tether exiting the flank incision. Patients were discharged home with the tether protected by a clear occlusive bandage. The stents were removed in the office between 3 and 12 days postoperatively by gently pulling on the tether. Patients were assessed for difficulty in removing the stent, leakage of urine from the flank, and any other postoperative complications. RESULTS: All stents could be removed from the flank using the tether. No urine leakage was noted in any patient, nor did any patient develop any complication related to stent placement or removal. Stents from several manufacturers were employed, with no difference noted. Patients reported no additional discomfort from the presence of the flank tether, and no significant pain was noted during stent removal. CONCLUSION: Utilization of the tether to remove the ureteral stent via the flank after tubeless PCNL is a feasible, safe, and cost-effective improvement on the standard tubeless PCNL technique. This modification obviates postoperative office cystoscopy, allowing easy removal of a stent.     

Tubeless percutaneous neprolithotomy: the new gold standard

PURPOSE: We present our experience with tubeless percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: Between July 2004 and December 2006, 121 patients (82 males and 39 females) with 18-70 mm (mean 31.19 mm) renal stones underwent tubeless PCNL leaving only a 6 Fr externalized ureteric catheter. Their ages ranged between 4 and 80 years (mean 37.27). Two patients had bilateral disease, so a total of 123 renal units are included. The procedure was performed under general anesthesia in the prone (110 units) or supine position (13 units). A total of 133 punctures were performed. The punctures were single (114 units), double (8 units), or triple (1 unit). The approach was subcostal through the lower calyx (n = 110) or middle calyx (n = 10), or supracostal through the middle calyx (n = 8) or upper calyx (n = 5). RESULTS: Mean operative time was 46.30 min (range 15-100). Mean reduction in hemoglobin level was 1.57 g (range 0.3-4) with blood transfusion rate 4.13%. Complication rate was 9.9% in the form of perirenal collection (five patients), urinary leakage (two patients), fever (four patients), and hydrothorax (one patient). The ureteric catheter was left for 7-72 h (mean 45.67). Postoperative analgesia was required in 22 patients (18.2%) with mean 22.9 mg diclofenac sodium per patient. Mean hospital stay was 50.69 h (range 12-96) with 106 units (86.18%) rendered stone free, 13 (10.57%) with insignificant residuals, and four units (3.25%) were left with significant residual stones. CONCLUSIONS: Tubeless PCNL is a good option in non-complicated PCNL with the advantages of reduced hospital stay, low postoperative pain, and little need for postoperative analgesia.     

Tubeless percutaneous nephrolithotomy in selected patients: a prospective randomized comparison

Objectives To prospectively compare the outcome of standard and tubeless percutaneous nephrolithotomy (PNL) in a selected group of patients with renal stones. Methods Patients with simple, isolated renal pelvis or lower pole caliceal stones and no significant hydronephrosis were randomly enrolled to undergo either standard PNL, in which routine nephrostomy tube was placed at the end of operation, or tubeless PNL. Occurrence of intraoperative complications, total operative time exceeding 2 h, indication for additional access or second-look PNL due to residual stones were exclusion criteria. Results There were 11 isolated lower pole caliceal stones (mean stone burden: 3.1 cm²) and 6 isolated renal pelvis stones (mean stone burden: 2.8 cm²) in the tubeless PNL group (n: 17), and 9 isolated lower pole caliceal stones (mean stone burden: 3.4 cm²) and 9 isolated renal pelvis stones (mean stone burden: 3.1 cm²) in the standard PNL group (n: 18). Mean operation time was 59.6 ± 9.1 (range: 50–90) min in the tubeless group, and 67.3 ± 10.1 (range: 60–115) min in the standard PNL group (P > 0.05). Successful stone removal was achieved in all patients, and no significant complication was observed in any case. The mean postoperative analgesic requirement was significantly less in the tubeless group (P < 0.05). Mean hospital stay was 1.6 ± 0.4 (range: 1–3) days in the tubeless group, and 2.8 ± 0.9 (range: 2–4) days in the former group (P < 0.05). Conclusion Our results indicate that tubeless PNL is safe in the management of selected patients and that mean analgesic requirement as well as hospitalization time is diminished with this modification. Presented at the 23rd World Congress on Endourology and SWL, August 23–26, 2005, Amsterdam, The Netherlands     

Tubeless percutaneous nephrolithotomy: 5 years of experience in 201 patients

BACKGROUND AND PURPOSE: Our aim was to evaluate the safety, effectiveness, and feasibility of tubeless percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: From June 2000 to September 2005, 201 patients with renal stones >2 cm underwent tubeless PCNL by a single surgeon. We report details of the outcomes. RESULTS: The complete stone clearance rate was 91.04% (183 patients). After surgery, 18 patients (8.96%) had stones (mean size = 7 mm) detected on a plain abdominal radiograph or ultrasonographic examination and were referred for shockwave lithotripsy. The mean stone size was 30 mm (range 20-40 mm). The mean operative time was 35 minutes (range 30-60 min), and the mean hospital stay was 3.5 days (range 2-5 days). Postoperative ultrasonography did not reveal considerable fluid collection. There were no visceral injuries. Twenty-two (10.9%) patients received a transfusion, and 16 (7.9%) patients had urinary tract infection. CONCLUSION: In our experience, tubeless PCNL is safe, effective, and feasible without any discomfort for patients.     

微创经皮肾镜与传统经皮肾镜治疗肾结石的效果评价

目的评价微创经皮肾镜（PCNL）与传统经皮肾镜治疗肾结石的临床效果及安全性。方法检索Medlilie、Coehrane Library以及中国期刊全文数据库、中文科技期刊数据库等全文数据库,收集并按照纳入和排除标准筛选关于微创经皮肾镜与传统经皮肾镜治疗肾结石疗效比较的对照研究,提取纳入研究中关于手术时间、住院时间、结石清除率、手术成功率、术中术后出血及输血率的数据进行Meta分析。结果共获得5个符合标准的研究,Meta分析显示微创PCNL在结石清除率、手术成功率方面与传统PCNL无统计学差异[P=0．11,OR=1．11,95％CI：（0．98,1．27）;P=0．77,OR=1．02,95％CI：（0．89,1．17）1,两种术式治疗肾结石方面所用的手术时间无差异怍O．06,OR=14．36,95％CI：（-0．7,29．42）1。但在术中及术后出血输血方面,微创PCNL明显优于传统PCNL炉=0．002,OR=0．11,95％CI：10．03,0．44）1。结论在结石清除率、手术成功率、手术时间方面,微刨经皮肾镜与传统经皮肾镜无差别,而术中及术后出血输血方面,微创PCNL明显优于传统PCNL。     

Tubeless percutaneous nephrolithotomy: Experience of 1000 cases at a single institute

ObjectiveTo access the safety and efficacy of tubeless percutaneous nephrolithotomy (PCNL).Materials and methodsSince January 2001, 1000 consecutive tubeless PCNLs performed at our hospital were enrolled into this retrospective chart review. The average age of the patients (659 males and 341 females) was 54.4 ± 12.6 years, and 55 patients were 75 years old or older. The stone characteristics were 490 non-complete staghorn kidney stones, 218 ureteral stones, 119 kidney + ureteral stones and 173 complete staghorn stones. The mean stone size was 3.5 ± 2.0 cm, and 200 patients had stone size ≥5.0 cm. The average operative time was 78.0 ± 29.4 minutes. The stone free rates were 78.8%, 100%, 84.9% and 45.0% for kidney, ureter, kidney + ureter and complete staghorn stones, respectively, with an overall stone free rate of 78.3%. The average postoperative hospital stay was 3.6 ± 2.1 days, and the blood transfusion rate was 2.4%. Postoperative fever was noted in 104 patients, and urosepsis was noted in 13 patients. Pulmonary complication included hydrothorax in 5 patients, hemothorax in 2 patients, pneumothorax in 2 patients and acute pulmonary edema in 1 patient. Cadiovascular complications included congestive heart failure in 1 patient and pneumomediastinum in 1 patient.ConclusionOur study demonstrated that sith adequate hemotasis, tubeless modification is a safe modality for PCNL.