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Re: A Randomized Comparison of Totally Tubeless and Standard Percutaneous Nephrolithotomy in Elderly Patients
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EUROPEAN UROLOGY 59 (2011) 1065–1070
Re: A Randomized Comparison of Totally Tubeless and Standard Percutaneous Nephrolithotomy in Elderly Patients Kara C, Resorlu B, Bayindir M, Unsal A Urology 2010;76:289–93 Expert’s summary: The authors have performed a study with strong methodology regarding a topic on which there is much controversy: totally tubeless percutaneous nephrolithotomy (PCNL) in the elderly. Over a 2.5-yr period, 410 PCNLs were performed by a single surgeon. Only after the stone removal portion of each case were the patients assessed for inclusion in the study. Only 60 highly selected cases (15%) were identified and randomized to receive either no tube (ie, no nephrostomy tube or internal stent) or an 18-Fr nephrostomy tube. A decision was made a priori that no patient would be considered for second-look nephroscopy. Preoperatively, the groups were similar. Postoperatively, a large proportion of patients in each group were stone free (86% on kidney– ureter–bladder [KUB] radiography and 83% on ultrasound). Totally tubeless patients had significantly lower analgesic requirements and hospital stays. Interestingly, the totally tubeless group did not have a higher complication rate or require higher rates of secondary shock wave lithotripsy or ureteroscopy procedures.
required a secondary procedure even though he was left with no urinary drainage following PCNL. We have shown that approximately 20% of postureteroscopy patients with residual fragments 4 mm will experience a stone event within 1.5 yr [3]. My patients tend to have large complex staghorn stones and want to be stone free with one admission and discharged with no tubes. Furthermore, if they experience pain or fever postoperatively, I like to know that they are well drained with a decompressed urinary system. The nephrostomy access allows for easy, flexible nephroscopy, and intravenous sedation alone can often be used for most second-look cases. What this study has shown is that totally tubeless PCNL may be feasible in highly selected patients with a small stone burden who undergo uncomplicated surgeries. Because most PCNL patients do not satisfy these criteria, I believe that all potential PCNL patients should be counseled for a nephrostomy tube and that all surgeons should be prepared to use them. Conflicts of interest: The author has nothing to disclose.
References [1] Bellman GC, Davidoff R, Candela J, et al. Tubeless percutaneous renal surgery. J Urol 1997;157:1578–82. [2] Jackman SV, Potter SR, Regan F, et al. Plain abdominal x-ray versus computerized tomography screening: sensitivity for stone localiza-
Expert’s comments: Ralph Clayman taught me early on in my training to ‘‘never burn a bridge.’’ Tubeless and totally tubeless PCNLs have been all the talk since first described by Bellman et al in 1997 [1]. The fundamental flaw in the concept is that the patient, even the most highly selected patient, may not be stone free. In this study by Kara et al, 14% and 17% of patients in the tubeless and nephrostomy tube groups, respectively, had residual stone fragments on ultrasound or KUB. These rates would be higher had computed tomography scans been used to assess residual stone burden [2]. In this study, only one patient (3.3%)
tion after nonenhanced spiral computerized tomography. J Urol 2000;164:308–10. [3] Rebuck DA, Macejko A, Bhalani V, et al. The natural history of renal stone fragments following ureteroscopy. Urology 2011;77:564–8. Robert B. Nadler Northwestern University Feinberg School of Medicine, Urology, 675 North St. Clair Street, Galter 20-150, Chicago, IL 60611, USA E-mail address: [email protected] DOI: 10.1016/j.eururo.2011.03.045
EUROPEAN UROLOGY 59 (2011) 1065–1070
Re: A Randomized Comparison of Totally Tubeless and Standard Percutaneous Nephrolithotomy in Elderly Patients Kara C, Resorlu B, Bayindir M, Unsal A Urology 2010;76:289–93 Expert’s summary: The authors have performed a study with strong methodology regarding a topic on which there is much controversy: totally tubeless percutaneous nephrolithotomy (PCNL) in the elderly. Over a 2.5-yr period, 410 PCNLs were performed by a single surgeon. Only after the stone removal portion of each case were the patients assessed for inclusion in the study. Only 60 highly selected cases (15%) were identified and randomized to receive either no tube (ie, no nephrostomy tube or internal stent) or an 18-Fr nephrostomy tube. A decision was made a priori that no patient would be considered for second-look nephroscopy. Preoperatively, the groups were similar. Postoperatively, a large proportion of patients in each group were stone free (86% on kidney– ureter–bladder [KUB] radiography and 83% on ultrasound). Totally tubeless patients had significantly lower analgesic requirements and hospital stays. Interestingly, the totally tubeless group did not have a higher complication rate or require higher rates of secondary shock wave lithotripsy or ureteroscopy procedures.
required a secondary procedure even though he was left with no urinary drainage following PCNL. We have shown that approximately 20% of postureteroscopy patients with residual fragments 4 mm will experience a stone event within 1.5 yr [3]. My patients tend to have large complex staghorn stones and want to be stone free with one admission and discharged with no tubes. Furthermore, if they experience pain or fever postoperatively, I like to know that they are well drained with a decompressed urinary system. The nephrostomy access allows for easy, flexible nephroscopy, and intravenous sedation alone can often be used for most second-look cases. What this study has shown is that totally tubeless PCNL may be feasible in highly selected patients with a small stone burden who undergo uncomplicated surgeries. Because most PCNL patients do not satisfy these criteria, I believe that all potential PCNL patients should be counseled for a nephrostomy tube and that all surgeons should be prepared to use them. Conflicts of interest: The author has nothing to disclose.
References [1] Bellman GC, Davidoff R, Candela J, et al. Tubeless percutaneous renal surgery. J Urol 1997;157:1578–82. [2] Jackman SV, Potter SR, Regan F, et al. Plain abdominal x-ray versus computerized tomography screening: sensitivity for stone localiza-
Expert’s comments: Ralph Clayman taught me early on in my training to ‘‘never burn a bridge.’’ Tubeless and totally tubeless PCNLs have been all the talk since first described by Bellman et al in 1997 [1]. The fundamental flaw in the concept is that the patient, even the most highly selected patient, may not be stone free. In this study by Kara et al, 14% and 17% of patients in the tubeless and nephrostomy tube groups, respectively, had residual stone fragments on ultrasound or KUB. These rates would be higher had computed tomography scans been used to assess residual stone burden [2]. In this study, only one patient (3.3%)
tion after nonenhanced spiral computerized tomography. J Urol 2000;164:308–10. [3] Rebuck DA, Macejko A, Bhalani V, et al. The natural history of renal stone fragments following ureteroscopy. Urology 2011;77:564–8. Robert B. Nadler Northwestern University Feinberg School of Medicine, Urology, 675 North St. Clair Street, Galter 20-150, Chicago, IL 60611, USA E-mail address: [email protected] DOI: 10.1016/j.eururo.2011.03.045