Tubeless percutaneous nephrolithotomy: Safe, effective in select patients

Shanghai, China-An innovative technique for tubeless percutaneous nephrolithotomy appears to be a viable alternative to the traditional practice of mandating stenting the ureter and placing a nephrostomy tube following minimally invasive removal of large renal calculi, according to researchers from Duke University, Durham, NC. Which patients benefit most from the procedure remains undetermined, the researchers noted.

Between July 2007 and July 2008, 35 patients with a mean stone burden of 531.8 mm² (range, 99.1 mm² to 2,037.3 mm²) underwent a tubeless-stentless PNL. Only a ureteric catheter remained in situ following these procedures and this was routinely removed on postoperative day 1 in all cases. Twenty-four patients (68.6%) received treatment as outpatients; among those admitted for treatment, mean length of hospital stay was 1.9 days. Seven patients (20%) had multiple accesses performed and seven had a supracostal puncture. Patient body mass index ranged from 14.2 to 61.4, which attested to the safety of this approach even in the morbidly obese. However, in this population, the complication rate is 20% if multiple access tracts are used, reported Michael Ferrandino, MD, clinical associate in laparoscopy and endourology, working with Glenn Preminger, MD, and colleagues. Complications reported among these patients included one pleural effusion, one pulmonary embolus, and one hemothorax/pneumothorax.

"Our group needs to characterize who would benefit most greatly from this procedure and therefore reduce morbidity and potential mortality," Dr. Ferrandino said. He noted that in cases presenting a high risk for perforation or significant bleeding, "we would not advocate the tubeless procedure."

A third abstract on this topic originated at the Naval Medical Center in San Diego. Researchers under the direction of Brian K. Auge, MD, analyzed the outcomes of 107 patients undergoing a tubeless procedure for renal nephrolithiasis.

Among these patients, the immediate targeted stone-free rate was 72%, as defined by postoperative computed tomography scan. The low complication rate consisted of seven asymptomatic subcapsular hematomas (.06%), one pseudoaneurysm that required selective embolization (.009%), one urine leak and five emergency room visits for pain (.046%). Because fibrin sealant was applied to the tract in these patients, Dr. Auge's team speculated that doing so decreased postoperative drainage from the wound.

Overall, tubeless PNL may be a feasible option in selected cases, and is safe as long as the collecting system remains intact and hemostasis is perfect at the conclusion of the procedure.