Almost totally tubeless percutaneous nephrolithotomy: further evolution of the technique

There is renewed interest in the concept of foregoing placement of the postoperative nephrostomy tube (PNT) after percutaneous nephrolithotomy (PCNL) with the intent of reducing postoperative discomfort and hospital stay. We have omitted the PNT and placed an internal ureteral stent or externalized ureteral catheter after PCNL in selected patients. We reviewed our experience in order to assess the efficacy and safety of this practice.

Primary PCNL was performed in 26 renal units in 21 patients (5 bilateral PCNL, 4 of which were simultaneous) by one surgeon at the University of Michigan and the Ann Arbor Veterans Affairs Medical Center. A postoperative nephrostomy tube was placed if the stone burden was >3 cm, more than one access site was used, the renal anatomy was obstructive, significant bleeding or perforation was noted, or a second look was required.

No PNT was placed in 10 renal units in 8 patients (no-PNT group). In six no-PNT kidneys, internal ureteral stents were used, and in four, externalized ureteral stents were placed for 1 to 2 days. The mean stone size in the PNT and no-PNT patients was 3.0 and 1.8 cm, respectively. Of the 16 kidneys in the PNT group, 4 were initially eligible for omission of PNT, but a PNT was placed because of bleeding or other access-related problem. All patients were rendered stone free except for three (one PNT and two no-PNT) patients, who each had a fragment < or =4 mm. Omission of PNT placement resulted in decreased mean length of stay (2.3 days in the no-PNT group v 3.6 days in the PNT group). There were four complications, all managed with delayed stenting (one in a no-PNT patient and the remaining three in the PNT group).

Omission of PNT placement in selected patients may reduce morbidity without compromising efficacy and safety, but further study is needed.