[Prevention of bleeding during tubeless percutaneous nephrolithotomy]

Nephrostomy tube placed after percutaneous removal of kidney stones can cause pain and discomfort in the early postoperative period [1, 2]. A tubeless percutaneous nephrolithotomy (PCNL) is considered as alternative approach. However, the most serious complication after tubeless procedure is a development of active uncontrolled bleeding from percutaneous tract in the early postoperative period.

To improve the results of surgical treatment of kidney stones by evaluation of efficiency of using hemostatic matrix during tubeless PCNL.

A total of 113 patients with large kidney stones undergone to the tubeless PCNL for the past 9 years in our clinic. The external or internal stent was put for the drainage of upper urinary tract for 2 and 14 days, respectively. All patients were divided into 2 groups, depending on severity of bleeding (group 1 - no bleeding vs. group 2 - mild bleeding). Each group was further divided into two subgroups based on the technique and type of drainage of upper urinary tract at the end of the surgery. In the main group (n=74) the hemostatic matrix based on lyophilized thrombin 2000 IU was injected in percutaneous tract at the end of the surgery. The control group included 39 patients who underwent mini-PCNL without using hemostatic matrix. The blood loss, intensity of urine leakage from percutaneous tract (duration, visual analog scale) and degree of fluid extravasation in pararenal fat estimated by US were evaluated.

The mean operative time was 47.5+/-3.6 min (52, 58, 38 and 49 min in subgroup I, II, III and control group, respectively). Hemoglobin drop was 9.3+/-4.1, 12.1+/-7.5, 14.6+/-11.2 and 10.6+/-5.9 in subgroups I, II, III and in the control group, respectively, while duration of hematuria was 16.1, 20.3, 28.5 and 22.9 hours, respectively. Fluid extravasation in pararenal space was found in 1 out 7 patients in subgroup III and control group, respectively (p<0.05). The dilatation of collection system (after double-J) persisted in 18.1%, 20% 22.2% and 13.3% cases in subgroup I, II, III and control group, respectively. There were no significant differences in other evaluated parameters. In 1 case in the control group there was severe bleeding which required selective embolization of the renal artery.

The use of hemostatic matrix is an additional important measure which allows to prevent active bleeding from the percutaneous tract in early postoperative period. Moreover, the hemostatic matrix contributes to the sealing of tract and reduces the risk of fluid extravasation in pararenal space after mini-PCNL.