- Email: [email protected]
Percutaneous Nephrolithotomy: Nephrostomy or Tubeless or Totally Tubeless?
Endourology and Stones Percutaneous Nephrolithotomy: Nephrostomy or Tubeless or Totally Tubeless? Mustafa Okan Istanbulluoglu, Tufan Cicek, Bulent Ozturk, Murat Gonen, and Hakan Ozkardes OBJECTIVES
METHODS
RESULTS
CONCLUSIONS
To compare the feasibility and morbidity of tubeless, totally tubeless, and standard percutaneous nephrolithotomy (PNL) with nephrostomy tube in a single center with selected patient population. Between July 2006 and February 2008, PNL was performed in 176 patients in this retrospective study. Patients with no serious bleeding or perforation in the collecting system during the operation, stone-free status, or clinically insignificant residual fragments (⬍4 mm) at the end of the procedure and patients with no more than one access were enrolled in the study. Patients were categorized into 3 groups. In group 1 (n ⫽ 43), no nephrostomy or ureter catheters were placed after PNL (totally tubeless group); in group 2 (n ⫽ 41), no nephrostomy catheter was placed but antegrade J-stent was used (tubeless group), and in group 3 (n ⫽ 92), standard nephrostomy catheters were placed (standard group). Three groups were compared with respect to age, stone volume, postoperative hemoglobin change, transfusion rate, operation time, analgesic requirement, hospitalization time, and complication rates. No significant differences were found in mean stone volume, operation time, transfusion rates, and hemoglobin level change between the groups. However, hospitalization time and the amount of narcotic analgesic required were significantly higher in group 3 compared with the other groups (P ⬍.05). Complications were observed in 2 (4.6%), 3 (7.3%), and 7 (7.6%) patients in groups 1, 2, and 3, respectively (P ⫽ .738). In patients with no major intraoperative bleeding and calyceal perforation, tubeless approach is safe with decreased analgesia requirement and hospital stay. UROLOGY 75: 1043–1048, 2010. © 2010 Elsevier Inc.
P
ercutaneous nephrolithotomy (PNL) is a well-established technique for the treatment of urinary stone disease. Placement of a nephrostomy catheter after PNL is considered the standard procedure. The purpose is to tamponade bleeding, aid in renal drainage, prevent urinary extravasation, and offer access for the future endoscopic procedures. However, in recent years, with a growing realization of significant postoperative pain and morbidity after PNL because of nephrostomy tubes, attempts have been made to modify standard PNL. For that reason new modifications were described in PNL operations such as using external ureter catheter or Jstent instead of nephrostomy catheters to reduce complaints caused by the catheter, which was later called as tubeless PNL.1-5 Also, in a limited number of studies in the published data, no ureter stents and nephrostomy catheter have been implemented and this is called totally tubeless PNL.6-10 From the Department of Urology, Baskent University School of Medicine, Konya, Turkey Reprint requests: Mustafa Okan Istanbulluoglu, M.D., Department of Urology, Baskent University School of Medicine, Konya, Turkey. E-mail: [email protected] Submitted: January 10, 2009, accepted (with revisions): June 10, 2009
© 2010 Elsevier Inc. All Rights Reserved
In this study we evaluated the safety and efficacy of tubeless and totally tubeless PNL, and compared it with the standard PNL. To our knowledge, this is the first study to compare these 3 approaches.
MATERIAL AND METHODS Of 264 patients who underwent PNL at our center between July 2006 and February 2008, a total of 176 patients were enrolled in this retrospective study according to the inclusion criteria. The inclusion criteria were patients with no serious bleeding or perforation in the collecting system during the operation, stonefree status, or clinically insignificant residual fragments (⬍4 mm) at the end of the procedure and no more than one access. Patients with staghorn stone, solitary kidney, or kidneys with congenital anomalies and those who had undergone bilateral simultaneous PNL were excluded from the study. Before the surgery, complete blood count, creatinine levels, and urine culture were performed. Radiological evaluation was performed with ultrasonography and intravenous pyelography, and in a limited number of patients with noncontrast computerized tomography. Under general anesthesia with the aid of cystoscope, a 7F ureter catheter was placed into the ipsilateral ureter and then the catheter was attached to the urethral Foley catheter. After that, patient was positioned to prone position. 0090-4295/10/$34.00 doi:10.1016/j.urology.2009.06.104
1043
Table 1. Patient characteristics Totally Tubeless PCNL Group 1 (n ⫽ 43)
Tubeless PCNL Group 2 (n ⫽ 41)
Standard PCNL Group 3 (n ⫽ 92)
P
44.87 ⫾ 14.95 461.53 ⫾ 271.03 *2.09 ⫾ 1.25 53.02 ⫾ 24.66 1.57 ⫾ 0.91 4 (9.3%) 31.0 ⫾ 10.07
47.29 ⫾ 16.60 517.56 ⫾ 276.56 *,†1.74 ⫾ 2.22 51.29 ⫾ 25.22 1.40 ⫾ 0.89 3 (7.3%) 35.29 ⫾ 8.61
46.94 ⫾ 14.32 491.94 ⫾ 204.10 2.96 ⫾ 1.60 60.07 ⫾ 19.03 1.62 ⫾ 0.94 7 (7.6%) 29.76 ⫾ 10.05
.982 .438 ⬍.001 .130 .297 .400 .406
*17.76 ⫾ 32.98 2 (4.6%) 4 (9.3%) 3 (6.9%)
*12.19 ⫾ 24.44 3 (7.3%) 2 (4.8%) 4 (9.7%)
27.17 ⫾ 33.49 7 (7.6%) 9 (9.7%) 10 (10.8%)
⬍.05 .738 .952 .128
Age (y) Stone size (mm2) Hospitalization time (d) Operation time (min) Postoperative hemoglobin drop (g/dL) Blood transfusion Nonsteroidal anti-inflammatory analgesic requirement (tenoxicam) Narcotic analgesic requirement (meperidine) Complications (no.) Supracostal access (11-12 rib) (no.) Secondary procedure (no.) Data presented as Mean ⫾ Standard deviation. * Compared with standard PNL group, P ⬍.05. † Compared with totally tubeless PNL group, P ⬍.05.
All percutaneous accesses were performed in prone position. Access to the selected calyx was performed with the aid of C-armed and 18 gauge needle. After entering the collecting system with a guide wire, dilatation was performed with Amplatz dilators and a 30 F Amplatz sheath was placed, through which a 26F rigid nephroscope was inserted and the stone fragmentation was carried out with pneumatic lithotripter. At the end of the operation, floroscopy and pyelography were performed for the evaluation of collecting system to assess the stone-free patients and the patients with CIRF (⬍4 mm). Patients were categorized into 3 groups. In 43 patients, previously inserted 7F ureter catheters were removed after the operation and no nephrostomy catheter was placed (totally tubeless group; group 1). In 41 patients in group 2, no nephrostomy catheter was placed but antegrade J-stent was used (tubeless group; group 2). In group 3, standard 14 F nephrostomy catheters (malecot catheter) were placed in 92 patients in group 3 (standard group; group 3), which were then controlled with antegrade pyelography. Hemoglobin levels were checked in all patients 16 hours after the operation and if there was any doubt about perinephric collection, ultrasonography was performed. Ureter catheters were removed immediately after the operation and the urethral Foley catheters were removed the following day in all patients. The decision of removal of the nephrostomy catheters in group 3 was made according to the urine color. Double-J stents in group 2 were removed 2 weeks after the operation under local anesthesia with cystoscopy. Age, stone diameters, operation time, postoperative hemoglobin change, complication rates, blood transfusion rates, analgesic need, supracostal access, number of secondary procedure, and hospitalization time were compared among 3 groups. Differences in percentages (qualitative variables) were analyzed by the 2 test. Kruskal-Wallis and Mann–Whitney U test with a Bonferroni correction were used for comparison of treatment groups. Statistical analyses were performed using the SPSS 15.0. The P value ⬍.05 was considered statistically significant. Bonferroni correction lowered the basic P ⬍.05 level of significance to P ⬍.017.
RESULTS Patient characteristics in each group are summarized in Table 1. No significant differences were found among the groups with regard to age and stone size (P ⬎.05). The 1044
Table 2. Locations of the stones
Lower calyx Renal pelvis Multiple calyces Upper calyx Upper ureter
Totally Tubeless PCNL Group 1 (n ⫽ 43)
Tubeless PCNL Group 2 (n ⫽ 41)
Standard PCNL Group 3 (n ⫽ 92)
22 (51.2%) 12 (27.9%) 6 (13.9%) 2 (4.6%) 1 (2.3%)
16 (39.1%) 17 (41.4%) 7 (17.1%) 0 1 (2.4%)
36 (39.1%) 24 (26.1%) 19 (20.7%) 10 (10.8%) 3 (3.3%)
stone locations are provided in detail in Table 2. A total of 17 patients had undergone PNL or open nephrolithotomy previously (3 [6.9%], 4 [9.7%], and 10 [10.8%] patients in groups 1, 2, and 3, respectively). Supracostal access (between 11th and 12th rib) was performed in 4 (9.3%) patients in group 1, 2 (4.8%) in group 2, and 9 (9.7%) in group 3. No significant differences were found in mean stone volume, mean operation time, transfusion rates, and hemoglobin level change between the groups (Table 1). However, mean hospitalization time was significantly higher in group 3 compared with other groups (Table 1) (P ⬍.001). Nonsteroid analgesics were given to the patients, with a dose of maximum 40 mg of tenoxicam intramuscularly. If this was not effective, intramuscularly meperidine was administered. Four patients (9.3%) in group 1, 7 patients (17.03%) in group 2, and 5 (5.4%) in group 3 did not require any analgesics in the first 24 hours postoperatively. Amount of nonsteroidal analgesic required did not differ between the groups (P ⬎.05). By contrast, the amount of narcotic analgesic (meperidine) required was found significantly higher in group 3 as compared with the other groups (Table 1) (P ⬍.05). Complications occurred in 2 (4.6%), 3 (7.3%), and 7 (7.6%) patients in groups 1, 2, and 3, respectively (P ⬎ .05) (Table 1). Complication rates are listed in Table 3. Double-J stent was inserted in 5 patients with prolonged drainage. In 2 patients in the totally tubeless group, UROLOGY 75 (5), 2010
Table 3. Complication rates (n) Group 1 Totally Tubeless Prolonged drainage Pseudoaneurysm High fever (⬎38°C) Perirenal collection
Group 2 Tubeless
Group 3 Standard
1 2
3 1 2 1
2
prolonged drainage was found to be due to ureteral stone, which was removed with ureteroscopy. Two patients with hematuria were diagnosed as pseudoaneurysm on renal angiography. Angioembolization was performed to control bleeding. Four patients suffered from high fever and (⬎38.5°C) were treated with intravenous antibiotics. One patient with perirenal collection was treated with the insertion of double-J stent and drainage tube under ultrasonography guidance.
COMMENT Several modifications of PNL have been tried to decrease pain, hospitalization time, and morbidity. It has been shown that using small caliber nephrostomy tube, miniperc, external ureteral stent, double-J stent, or avoiding nephrostomy or ureteral drainage (totally tubeless) decreases postoperative pain and hospitalization time.1-11 Limb and Bellmann12 performed tubeless percutaneous renal procedures in 112 patients using double-J stent. Of these, 86 patients underwent percutaneous nephrolithotomy and 26 patients underwent percutaneous antegrade endopyelotomy. They concluded that tubeless percutaneous renal surgery is a safe and effective procedure, although a subset of young men cannot tolerate the double-J stent. In another study, Agrawal et al13 compared tubeless and standard PNL and showed that tubeless procedure reduces postoperative urinary leakage and local pain related to the drainage tube. In their series, most patients who underwent tubeless procedure were discharged from the hospital in less than 24 hours. We believe that insertion of double-J stent has certain disadvantages such as urinary tract symptoms, requirement of cystoscopy for its removal, which results in an additional cost. In our study, some of the patients in the tubeless group complained of symptoms like dysuria and frequency. As an alternative method in tubeless PNL, a ureteral catheter can be used as an externalized tube instead of a double-J stent. As shown by previous studies, by substituting an external ureteral catheter for the double-J stent, the problem of stent morbidity and requirement of cystoscopy can be avoided.12 Al-Ba’adani et al14 pointed out that tubeless PNL is a new gold standard technique. They have reported that tubeless PNL was effective in 121 patients and an insertion of a ureteral catheter was sufficient for the drainage reaching a complication rate of 9.9%. In a prospective study, Mandhani et al15 compared the outcome of tubeless PNL with or UROLOGY 75 (5), 2010
without a double-J stent and concluded that avoiding double-J stent may not compromise the safety of tubeless percutaneous nephrolithotomy. We think that if tubeless procedure is being planned, placement of double-J stent is a safe method as it provides continuous urinary drainage. In the published data, totally tubeless PNL studies are few in number. Wickham et al8 first described totally tubeless PNL in 1984. Karami and Gholamrezaie9 compared 30 totally tubeless patients with 30 standard PNL and stated that avoiding percutaneous nephrostomy tube and removing ureteral catheter at the end of the procedure in selected patients were safe, along with significantly decreased hospitalization time and analgesic requirements. Crook et al6 also showed that totally tubeless PNL is a safe and well-tolerated procedure that may be considered standard of care in selected patients. The possibility of uncontrolled hemorrhage and ureteral obstruction were the main concerns about tubeless PNL. Nevertheless, they claimed that lack of a tube aids in tamponade of the tract, which was attributed to the thrombolytic effect of urokinase present in the urine. In another study by Crook et al, patients were randomized prospectively to have nephrostomy tube after PNL or totally tubeless PNL (n ⫽ 50 patients). Patient selection criteria were no significant bleeding or residual stone, an intact pelvicaliceal system, and no evidence of residual ureteral stone. No differences were found between the groups with regard to hemorrhage, infection, transfusion rate, and serum parameters. Length of hospitalization was significantly longer in patients who received a nephrostomy tube after PNL.10 According to our experience, the 2 important criteria in selection of patients for tubeless PNL are absence of major intraoperative bleeding and perforation of pelvicalyceal system. Moreover, patients with no residual stones are appropriate for totally tubeless procedure. We believe that the complications encountered in our study in the totally tubeless group are due to unidentified residual stones that are left in the ureters. The inability to perform a second look procedure for residual stones is a major drawback of tubeless PNL. For that reason we do not recommend performing totally tubeless procedure when there is any likelihood of residual stone. We included those with history of renal surgery and supracostal procedures to show that tubeless PNL can also be performed in such challenging cases with increased risk of bleeding. Shah et al16 also showed that tubeless PNL in patients with history of previous open renal surgery is associated with decreased morbidity without any severe complications.
CONCLUSIONS To our knowledge this is the first study to compare standard, tubeless, and totally tubeless PNL. In patients with no major intraoperative bleeding and calyceal perforation, tubeless approach is safe with decreased analge1045
sia requirement and hospital stay. However, totally tubeless procedure should be reserved for those without any residual stones, so the “totally tubeless” approach is not dangerous in highly selected patients. References 1. Shah HN, Kausık VB, Hegde SS, et al. Tubeless percutaneous nephrolithotomy: a prospective feasibility study and review of previous reports. BJU Int. 2005;96:879-883. 2. Rana AM, Mithani S. Tubeless percutaneous nephrolithotomy: call of the day. J Endourol. 2007;21:169-172. 3. Singh I, Singh A, Mittal G. Tubeless percutaneous nephrolithotomy: is it really less morbid? J Endourol. 2008;22:427-434. 4. Tefekli A, Altunrende F, Tepeler K, et al. Tubeless percutaneous nephrolithotomy in selected patients: a prospective randomized comparison. Int Urol Nephrol. 2006;39:57-63. 5. Mouracade P, Spie R, Lang H, et al. Tubeless percutaneous nephrolithotomy: what about replacing the Double-J stent with a ureteral catheter? J Endourol. 2008;22:273-275. 6. Crook TJ, Lockyer CR, Keoghane SR, et al. Totally tubeless percutaneous nephrolithotomy. J Endourol. 2008;22:267-272. 7. Istanbulluoglu OM, Ozturk B, Cicek T, et al. Case report: bilateral simultaneous tubeless and stentless percutaneous nephrolithotomy. J Endourol. 2008;22:25-28. 8. Wickham JE, Miller RA, Kellett MJ, et al. Percutaneous nephrolithotomy: one stage or two? Br J Urol. 1984;56:582-585. 9. Karami H, Gholamrezaie HR. Totally tubeless percutaneous nephrolithotomy in selected cases. J Endourol. 2004;18:475-476. 10. Crook TJ, Lockyer CR, Keoghane SR, et al. A randomized controlled trial of nephrostomy placement versus tubeless percutaneous nephrolithotomy. J Urol. 2008;180:612-614. 11. Desai MR, Kukreja RA, Desai MM, et al. A prospective randomized comparison of type of nephrostomy drainage following percutaneous nephrostolithotomy: large bore versus small bore versus tubeless. J Urol. 2004;172:565-567. 12. Limb J, Bellman GC. Tubeless percutaneous renal surgery: review of first 112 patients. Urology. 2002;59:527-531. 13. Agrawal MS, Agrawal M, Gupta A, et al. A randomized comparison of tubeless and standard percutaneous nephrolithotomy. J Endourol. 2008;22:439-442. 14. Al-Ba’adani HT, Al-Kohlany KM, Al-Adimi A, et al. Tubeless percutaneous neprolithotomy: the new gold standard. Int Urol Nephrol. 2008;40:603-608. 15. Mandhani A, Goyal R, Vijjan V, et al. Tubeless percutaneous nephrolithotomy-should a stent be an integral part? J Urol. 2007; 178:921-924. 16. Shah HN, Mahajan AP, Hegde SS, et al. Tubeless percutaneous nephrolithotomy in patients with previous ipsilateral open renal surgery: a feasibility study with review of literature. J Endourol. 2008;22:19-24.
EDITORIAL COMMENT As with many other surgical disciplines, there is an impetus within the endourologic community to decrease the morbidity of surgical procedures when feasible. With regard to percutaneous renal surgery, such efforts have focused on different modalities for postoperative drainage, including smaller nephrostomy tubes, indwelling ureteral stents, or no drainage tubes or catheters altogether. The preceding article highlights in a retrospective manner that all these modalities are feasible and suggests improved morbidity in patients who are left tubeless (albeit with a ureteral stent) or totally tubeless (no adjunctive drainage measures). Such observations are similar to that described in several other series referenced within the manuscript. Although 1046
this retrospective analysis provides a valuable starting point to query such issues, the ultimate goal is to evaluate this question in a prospective manner that is less susceptible to confounding variables and biases. In that regard, there are several important points that merit consideration. Pain, convalescence, and morbidity are often challenging variables to quantify. Surrogate measures such as hospital duration and narcotic analgesic use can be problematic. For example, in many tertiary care practices in the United States, patients are routinely discharged on postoperative day 1 after PCNL unless a complication occurs or imaging necessitates an immediate second-look flexible nephroscopy. Hence, hospital duration may be a function of individual or regional practice patterns as opposed to the particular drainage modality. Narcotic analgesic use, similarly, can vary substantially according to baseline underlying conditions, perioperative administration of non-narcotic analgesics, and intraoperative use of local anesthetic infusions. As such, it is essential to use validated instruments such as visual analog scale scores or quality of life questionnaires to better define objective differences in morbidity.1,2 An additional key point is the fate of residual fragments after PCNL. As recognized by the authors, a limitation of a tubeless or totally tubeless approach is the inability to perform a secondlook procedure for retrieval of residual stone fragments. Contemporary published data suggest that despite meticulous intraoperative evaluation with fluoroscopic imaging, residual fragments are often inevitable.3,4 Thus, it is difficult to assign a true “stone-free status” (the ideal candidate for a totally tubeless procedure) at the time of initial PCNL. Furthermore, many clinically insignificant residual fragments (CIRF) may not be as insignificant as we would like to believe. Specifically, recent work has indicated that residual fragments as small as 2 mm can result in stone-related events including growth, emergency room visits, and ancillary surgical procedures.5 Thus, while much attention will be placed on the effect of tube status on immediate recovery, it is important for us to follow-up patients longitudinally to identify associated long-term implications and sequelae. Jay D. Raman, M.D., Division of Urology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
References 1. Penniston KL, Nakada SY. Health related quality of life differs between male and female stone formers. J Urol. 2007;178:2435-2440; discussion:2440. 2. Bensalah K, Tuncel A, Gupta A, et al. Determinants of quality of life for patients with kidney stones. J Urol. 2008;179:2238-2243; discussion:2243. 3. Portis AJ, Laliberte MA, Drake S, et al. Intraoperative fragment detection during percutaneous nephrolithotomy: evaluation of high magnification rotational fluoroscopy combined with aggressive nephroscopy. J Urol. 2006;175:162-165; discussion:165-166. 4. Osman Y, El-Tabey N, Refai H, et al. Detection of residual stones after percutaneous nephrolithotomy: role of nonenhanced spiral computerized tomography. J Urol. 2008;179:198-200; discussion:200. 5. Raman JD, Bagrodia A, Gupta A, et al. Natural history of residual fragments following percutaneous nephrostolithotomy. J Urol. 2009; 181:1163-1168.
doi:10.1016/j.urology.2009.07.1283 UROLOGY 75: 1046, 2010. © 2010 Elsevier Inc.
UROLOGY 75 (5), 2010
METHODS
RESULTS
CONCLUSIONS
To compare the feasibility and morbidity of tubeless, totally tubeless, and standard percutaneous nephrolithotomy (PNL) with nephrostomy tube in a single center with selected patient population. Between July 2006 and February 2008, PNL was performed in 176 patients in this retrospective study. Patients with no serious bleeding or perforation in the collecting system during the operation, stone-free status, or clinically insignificant residual fragments (⬍4 mm) at the end of the procedure and patients with no more than one access were enrolled in the study. Patients were categorized into 3 groups. In group 1 (n ⫽ 43), no nephrostomy or ureter catheters were placed after PNL (totally tubeless group); in group 2 (n ⫽ 41), no nephrostomy catheter was placed but antegrade J-stent was used (tubeless group), and in group 3 (n ⫽ 92), standard nephrostomy catheters were placed (standard group). Three groups were compared with respect to age, stone volume, postoperative hemoglobin change, transfusion rate, operation time, analgesic requirement, hospitalization time, and complication rates. No significant differences were found in mean stone volume, operation time, transfusion rates, and hemoglobin level change between the groups. However, hospitalization time and the amount of narcotic analgesic required were significantly higher in group 3 compared with the other groups (P ⬍.05). Complications were observed in 2 (4.6%), 3 (7.3%), and 7 (7.6%) patients in groups 1, 2, and 3, respectively (P ⫽ .738). In patients with no major intraoperative bleeding and calyceal perforation, tubeless approach is safe with decreased analgesia requirement and hospital stay. UROLOGY 75: 1043–1048, 2010. © 2010 Elsevier Inc.
P
ercutaneous nephrolithotomy (PNL) is a well-established technique for the treatment of urinary stone disease. Placement of a nephrostomy catheter after PNL is considered the standard procedure. The purpose is to tamponade bleeding, aid in renal drainage, prevent urinary extravasation, and offer access for the future endoscopic procedures. However, in recent years, with a growing realization of significant postoperative pain and morbidity after PNL because of nephrostomy tubes, attempts have been made to modify standard PNL. For that reason new modifications were described in PNL operations such as using external ureter catheter or Jstent instead of nephrostomy catheters to reduce complaints caused by the catheter, which was later called as tubeless PNL.1-5 Also, in a limited number of studies in the published data, no ureter stents and nephrostomy catheter have been implemented and this is called totally tubeless PNL.6-10 From the Department of Urology, Baskent University School of Medicine, Konya, Turkey Reprint requests: Mustafa Okan Istanbulluoglu, M.D., Department of Urology, Baskent University School of Medicine, Konya, Turkey. E-mail: [email protected] Submitted: January 10, 2009, accepted (with revisions): June 10, 2009
© 2010 Elsevier Inc. All Rights Reserved
In this study we evaluated the safety and efficacy of tubeless and totally tubeless PNL, and compared it with the standard PNL. To our knowledge, this is the first study to compare these 3 approaches.
MATERIAL AND METHODS Of 264 patients who underwent PNL at our center between July 2006 and February 2008, a total of 176 patients were enrolled in this retrospective study according to the inclusion criteria. The inclusion criteria were patients with no serious bleeding or perforation in the collecting system during the operation, stonefree status, or clinically insignificant residual fragments (⬍4 mm) at the end of the procedure and no more than one access. Patients with staghorn stone, solitary kidney, or kidneys with congenital anomalies and those who had undergone bilateral simultaneous PNL were excluded from the study. Before the surgery, complete blood count, creatinine levels, and urine culture were performed. Radiological evaluation was performed with ultrasonography and intravenous pyelography, and in a limited number of patients with noncontrast computerized tomography. Under general anesthesia with the aid of cystoscope, a 7F ureter catheter was placed into the ipsilateral ureter and then the catheter was attached to the urethral Foley catheter. After that, patient was positioned to prone position. 0090-4295/10/$34.00 doi:10.1016/j.urology.2009.06.104
1043
Table 1. Patient characteristics Totally Tubeless PCNL Group 1 (n ⫽ 43)
Tubeless PCNL Group 2 (n ⫽ 41)
Standard PCNL Group 3 (n ⫽ 92)
P
44.87 ⫾ 14.95 461.53 ⫾ 271.03 *2.09 ⫾ 1.25 53.02 ⫾ 24.66 1.57 ⫾ 0.91 4 (9.3%) 31.0 ⫾ 10.07
47.29 ⫾ 16.60 517.56 ⫾ 276.56 *,†1.74 ⫾ 2.22 51.29 ⫾ 25.22 1.40 ⫾ 0.89 3 (7.3%) 35.29 ⫾ 8.61
46.94 ⫾ 14.32 491.94 ⫾ 204.10 2.96 ⫾ 1.60 60.07 ⫾ 19.03 1.62 ⫾ 0.94 7 (7.6%) 29.76 ⫾ 10.05
.982 .438 ⬍.001 .130 .297 .400 .406
*17.76 ⫾ 32.98 2 (4.6%) 4 (9.3%) 3 (6.9%)
*12.19 ⫾ 24.44 3 (7.3%) 2 (4.8%) 4 (9.7%)
27.17 ⫾ 33.49 7 (7.6%) 9 (9.7%) 10 (10.8%)
⬍.05 .738 .952 .128
Age (y) Stone size (mm2) Hospitalization time (d) Operation time (min) Postoperative hemoglobin drop (g/dL) Blood transfusion Nonsteroidal anti-inflammatory analgesic requirement (tenoxicam) Narcotic analgesic requirement (meperidine) Complications (no.) Supracostal access (11-12 rib) (no.) Secondary procedure (no.) Data presented as Mean ⫾ Standard deviation. * Compared with standard PNL group, P ⬍.05. † Compared with totally tubeless PNL group, P ⬍.05.
All percutaneous accesses were performed in prone position. Access to the selected calyx was performed with the aid of C-armed and 18 gauge needle. After entering the collecting system with a guide wire, dilatation was performed with Amplatz dilators and a 30 F Amplatz sheath was placed, through which a 26F rigid nephroscope was inserted and the stone fragmentation was carried out with pneumatic lithotripter. At the end of the operation, floroscopy and pyelography were performed for the evaluation of collecting system to assess the stone-free patients and the patients with CIRF (⬍4 mm). Patients were categorized into 3 groups. In 43 patients, previously inserted 7F ureter catheters were removed after the operation and no nephrostomy catheter was placed (totally tubeless group; group 1). In 41 patients in group 2, no nephrostomy catheter was placed but antegrade J-stent was used (tubeless group; group 2). In group 3, standard 14 F nephrostomy catheters (malecot catheter) were placed in 92 patients in group 3 (standard group; group 3), which were then controlled with antegrade pyelography. Hemoglobin levels were checked in all patients 16 hours after the operation and if there was any doubt about perinephric collection, ultrasonography was performed. Ureter catheters were removed immediately after the operation and the urethral Foley catheters were removed the following day in all patients. The decision of removal of the nephrostomy catheters in group 3 was made according to the urine color. Double-J stents in group 2 were removed 2 weeks after the operation under local anesthesia with cystoscopy. Age, stone diameters, operation time, postoperative hemoglobin change, complication rates, blood transfusion rates, analgesic need, supracostal access, number of secondary procedure, and hospitalization time were compared among 3 groups. Differences in percentages (qualitative variables) were analyzed by the 2 test. Kruskal-Wallis and Mann–Whitney U test with a Bonferroni correction were used for comparison of treatment groups. Statistical analyses were performed using the SPSS 15.0. The P value ⬍.05 was considered statistically significant. Bonferroni correction lowered the basic P ⬍.05 level of significance to P ⬍.017.
RESULTS Patient characteristics in each group are summarized in Table 1. No significant differences were found among the groups with regard to age and stone size (P ⬎.05). The 1044
Table 2. Locations of the stones
Lower calyx Renal pelvis Multiple calyces Upper calyx Upper ureter
Totally Tubeless PCNL Group 1 (n ⫽ 43)
Tubeless PCNL Group 2 (n ⫽ 41)
Standard PCNL Group 3 (n ⫽ 92)
22 (51.2%) 12 (27.9%) 6 (13.9%) 2 (4.6%) 1 (2.3%)
16 (39.1%) 17 (41.4%) 7 (17.1%) 0 1 (2.4%)
36 (39.1%) 24 (26.1%) 19 (20.7%) 10 (10.8%) 3 (3.3%)
stone locations are provided in detail in Table 2. A total of 17 patients had undergone PNL or open nephrolithotomy previously (3 [6.9%], 4 [9.7%], and 10 [10.8%] patients in groups 1, 2, and 3, respectively). Supracostal access (between 11th and 12th rib) was performed in 4 (9.3%) patients in group 1, 2 (4.8%) in group 2, and 9 (9.7%) in group 3. No significant differences were found in mean stone volume, mean operation time, transfusion rates, and hemoglobin level change between the groups (Table 1). However, mean hospitalization time was significantly higher in group 3 compared with other groups (Table 1) (P ⬍.001). Nonsteroid analgesics were given to the patients, with a dose of maximum 40 mg of tenoxicam intramuscularly. If this was not effective, intramuscularly meperidine was administered. Four patients (9.3%) in group 1, 7 patients (17.03%) in group 2, and 5 (5.4%) in group 3 did not require any analgesics in the first 24 hours postoperatively. Amount of nonsteroidal analgesic required did not differ between the groups (P ⬎.05). By contrast, the amount of narcotic analgesic (meperidine) required was found significantly higher in group 3 as compared with the other groups (Table 1) (P ⬍.05). Complications occurred in 2 (4.6%), 3 (7.3%), and 7 (7.6%) patients in groups 1, 2, and 3, respectively (P ⬎ .05) (Table 1). Complication rates are listed in Table 3. Double-J stent was inserted in 5 patients with prolonged drainage. In 2 patients in the totally tubeless group, UROLOGY 75 (5), 2010
Table 3. Complication rates (n) Group 1 Totally Tubeless Prolonged drainage Pseudoaneurysm High fever (⬎38°C) Perirenal collection
Group 2 Tubeless
Group 3 Standard
1 2
3 1 2 1
2
prolonged drainage was found to be due to ureteral stone, which was removed with ureteroscopy. Two patients with hematuria were diagnosed as pseudoaneurysm on renal angiography. Angioembolization was performed to control bleeding. Four patients suffered from high fever and (⬎38.5°C) were treated with intravenous antibiotics. One patient with perirenal collection was treated with the insertion of double-J stent and drainage tube under ultrasonography guidance.
COMMENT Several modifications of PNL have been tried to decrease pain, hospitalization time, and morbidity. It has been shown that using small caliber nephrostomy tube, miniperc, external ureteral stent, double-J stent, or avoiding nephrostomy or ureteral drainage (totally tubeless) decreases postoperative pain and hospitalization time.1-11 Limb and Bellmann12 performed tubeless percutaneous renal procedures in 112 patients using double-J stent. Of these, 86 patients underwent percutaneous nephrolithotomy and 26 patients underwent percutaneous antegrade endopyelotomy. They concluded that tubeless percutaneous renal surgery is a safe and effective procedure, although a subset of young men cannot tolerate the double-J stent. In another study, Agrawal et al13 compared tubeless and standard PNL and showed that tubeless procedure reduces postoperative urinary leakage and local pain related to the drainage tube. In their series, most patients who underwent tubeless procedure were discharged from the hospital in less than 24 hours. We believe that insertion of double-J stent has certain disadvantages such as urinary tract symptoms, requirement of cystoscopy for its removal, which results in an additional cost. In our study, some of the patients in the tubeless group complained of symptoms like dysuria and frequency. As an alternative method in tubeless PNL, a ureteral catheter can be used as an externalized tube instead of a double-J stent. As shown by previous studies, by substituting an external ureteral catheter for the double-J stent, the problem of stent morbidity and requirement of cystoscopy can be avoided.12 Al-Ba’adani et al14 pointed out that tubeless PNL is a new gold standard technique. They have reported that tubeless PNL was effective in 121 patients and an insertion of a ureteral catheter was sufficient for the drainage reaching a complication rate of 9.9%. In a prospective study, Mandhani et al15 compared the outcome of tubeless PNL with or UROLOGY 75 (5), 2010
without a double-J stent and concluded that avoiding double-J stent may not compromise the safety of tubeless percutaneous nephrolithotomy. We think that if tubeless procedure is being planned, placement of double-J stent is a safe method as it provides continuous urinary drainage. In the published data, totally tubeless PNL studies are few in number. Wickham et al8 first described totally tubeless PNL in 1984. Karami and Gholamrezaie9 compared 30 totally tubeless patients with 30 standard PNL and stated that avoiding percutaneous nephrostomy tube and removing ureteral catheter at the end of the procedure in selected patients were safe, along with significantly decreased hospitalization time and analgesic requirements. Crook et al6 also showed that totally tubeless PNL is a safe and well-tolerated procedure that may be considered standard of care in selected patients. The possibility of uncontrolled hemorrhage and ureteral obstruction were the main concerns about tubeless PNL. Nevertheless, they claimed that lack of a tube aids in tamponade of the tract, which was attributed to the thrombolytic effect of urokinase present in the urine. In another study by Crook et al, patients were randomized prospectively to have nephrostomy tube after PNL or totally tubeless PNL (n ⫽ 50 patients). Patient selection criteria were no significant bleeding or residual stone, an intact pelvicaliceal system, and no evidence of residual ureteral stone. No differences were found between the groups with regard to hemorrhage, infection, transfusion rate, and serum parameters. Length of hospitalization was significantly longer in patients who received a nephrostomy tube after PNL.10 According to our experience, the 2 important criteria in selection of patients for tubeless PNL are absence of major intraoperative bleeding and perforation of pelvicalyceal system. Moreover, patients with no residual stones are appropriate for totally tubeless procedure. We believe that the complications encountered in our study in the totally tubeless group are due to unidentified residual stones that are left in the ureters. The inability to perform a second look procedure for residual stones is a major drawback of tubeless PNL. For that reason we do not recommend performing totally tubeless procedure when there is any likelihood of residual stone. We included those with history of renal surgery and supracostal procedures to show that tubeless PNL can also be performed in such challenging cases with increased risk of bleeding. Shah et al16 also showed that tubeless PNL in patients with history of previous open renal surgery is associated with decreased morbidity without any severe complications.
CONCLUSIONS To our knowledge this is the first study to compare standard, tubeless, and totally tubeless PNL. In patients with no major intraoperative bleeding and calyceal perforation, tubeless approach is safe with decreased analge1045
sia requirement and hospital stay. However, totally tubeless procedure should be reserved for those without any residual stones, so the “totally tubeless” approach is not dangerous in highly selected patients. References 1. Shah HN, Kausık VB, Hegde SS, et al. Tubeless percutaneous nephrolithotomy: a prospective feasibility study and review of previous reports. BJU Int. 2005;96:879-883. 2. Rana AM, Mithani S. Tubeless percutaneous nephrolithotomy: call of the day. J Endourol. 2007;21:169-172. 3. Singh I, Singh A, Mittal G. Tubeless percutaneous nephrolithotomy: is it really less morbid? J Endourol. 2008;22:427-434. 4. Tefekli A, Altunrende F, Tepeler K, et al. Tubeless percutaneous nephrolithotomy in selected patients: a prospective randomized comparison. Int Urol Nephrol. 2006;39:57-63. 5. Mouracade P, Spie R, Lang H, et al. Tubeless percutaneous nephrolithotomy: what about replacing the Double-J stent with a ureteral catheter? J Endourol. 2008;22:273-275. 6. Crook TJ, Lockyer CR, Keoghane SR, et al. Totally tubeless percutaneous nephrolithotomy. J Endourol. 2008;22:267-272. 7. Istanbulluoglu OM, Ozturk B, Cicek T, et al. Case report: bilateral simultaneous tubeless and stentless percutaneous nephrolithotomy. J Endourol. 2008;22:25-28. 8. Wickham JE, Miller RA, Kellett MJ, et al. Percutaneous nephrolithotomy: one stage or two? Br J Urol. 1984;56:582-585. 9. Karami H, Gholamrezaie HR. Totally tubeless percutaneous nephrolithotomy in selected cases. J Endourol. 2004;18:475-476. 10. Crook TJ, Lockyer CR, Keoghane SR, et al. A randomized controlled trial of nephrostomy placement versus tubeless percutaneous nephrolithotomy. J Urol. 2008;180:612-614. 11. Desai MR, Kukreja RA, Desai MM, et al. A prospective randomized comparison of type of nephrostomy drainage following percutaneous nephrostolithotomy: large bore versus small bore versus tubeless. J Urol. 2004;172:565-567. 12. Limb J, Bellman GC. Tubeless percutaneous renal surgery: review of first 112 patients. Urology. 2002;59:527-531. 13. Agrawal MS, Agrawal M, Gupta A, et al. A randomized comparison of tubeless and standard percutaneous nephrolithotomy. J Endourol. 2008;22:439-442. 14. Al-Ba’adani HT, Al-Kohlany KM, Al-Adimi A, et al. Tubeless percutaneous neprolithotomy: the new gold standard. Int Urol Nephrol. 2008;40:603-608. 15. Mandhani A, Goyal R, Vijjan V, et al. Tubeless percutaneous nephrolithotomy-should a stent be an integral part? J Urol. 2007; 178:921-924. 16. Shah HN, Mahajan AP, Hegde SS, et al. Tubeless percutaneous nephrolithotomy in patients with previous ipsilateral open renal surgery: a feasibility study with review of literature. J Endourol. 2008;22:19-24.
EDITORIAL COMMENT As with many other surgical disciplines, there is an impetus within the endourologic community to decrease the morbidity of surgical procedures when feasible. With regard to percutaneous renal surgery, such efforts have focused on different modalities for postoperative drainage, including smaller nephrostomy tubes, indwelling ureteral stents, or no drainage tubes or catheters altogether. The preceding article highlights in a retrospective manner that all these modalities are feasible and suggests improved morbidity in patients who are left tubeless (albeit with a ureteral stent) or totally tubeless (no adjunctive drainage measures). Such observations are similar to that described in several other series referenced within the manuscript. Although 1046
this retrospective analysis provides a valuable starting point to query such issues, the ultimate goal is to evaluate this question in a prospective manner that is less susceptible to confounding variables and biases. In that regard, there are several important points that merit consideration. Pain, convalescence, and morbidity are often challenging variables to quantify. Surrogate measures such as hospital duration and narcotic analgesic use can be problematic. For example, in many tertiary care practices in the United States, patients are routinely discharged on postoperative day 1 after PCNL unless a complication occurs or imaging necessitates an immediate second-look flexible nephroscopy. Hence, hospital duration may be a function of individual or regional practice patterns as opposed to the particular drainage modality. Narcotic analgesic use, similarly, can vary substantially according to baseline underlying conditions, perioperative administration of non-narcotic analgesics, and intraoperative use of local anesthetic infusions. As such, it is essential to use validated instruments such as visual analog scale scores or quality of life questionnaires to better define objective differences in morbidity.1,2 An additional key point is the fate of residual fragments after PCNL. As recognized by the authors, a limitation of a tubeless or totally tubeless approach is the inability to perform a secondlook procedure for retrieval of residual stone fragments. Contemporary published data suggest that despite meticulous intraoperative evaluation with fluoroscopic imaging, residual fragments are often inevitable.3,4 Thus, it is difficult to assign a true “stone-free status” (the ideal candidate for a totally tubeless procedure) at the time of initial PCNL. Furthermore, many clinically insignificant residual fragments (CIRF) may not be as insignificant as we would like to believe. Specifically, recent work has indicated that residual fragments as small as 2 mm can result in stone-related events including growth, emergency room visits, and ancillary surgical procedures.5 Thus, while much attention will be placed on the effect of tube status on immediate recovery, it is important for us to follow-up patients longitudinally to identify associated long-term implications and sequelae. Jay D. Raman, M.D., Division of Urology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
References 1. Penniston KL, Nakada SY. Health related quality of life differs between male and female stone formers. J Urol. 2007;178:2435-2440; discussion:2440. 2. Bensalah K, Tuncel A, Gupta A, et al. Determinants of quality of life for patients with kidney stones. J Urol. 2008;179:2238-2243; discussion:2243. 3. Portis AJ, Laliberte MA, Drake S, et al. Intraoperative fragment detection during percutaneous nephrolithotomy: evaluation of high magnification rotational fluoroscopy combined with aggressive nephroscopy. J Urol. 2006;175:162-165; discussion:165-166. 4. Osman Y, El-Tabey N, Refai H, et al. Detection of residual stones after percutaneous nephrolithotomy: role of nonenhanced spiral computerized tomography. J Urol. 2008;179:198-200; discussion:200. 5. Raman JD, Bagrodia A, Gupta A, et al. Natural history of residual fragments following percutaneous nephrostolithotomy. J Urol. 2009; 181:1163-1168.
doi:10.1016/j.urology.2009.07.1283 UROLOGY 75: 1046, 2010. © 2010 Elsevier Inc.
UROLOGY 75 (5), 2010