Is Totally Tubeless Percutaneous Nephrolithotomy a Safe and Efficacious Option for Caliceal Diverticular Calculi?

Introduction and Objectives: Percutaneous nephrolithotomy (PCNL) is a common treatment for caliceal diverticular calculi and provides excellent stone-free outcomes. Because of a concern for urinary stasis in the setting of a dilated nephrostomy tract, an indwelling ureteral stent and/or nephrostomy tube (NT) was traditionally left in the collecting system. The rationale for investigating totally tubeless PCNL (tt-PCNL) for the treatment of caliceal diverticula was to determine whether the advantages attributed to tt-PCNL for normal collecting system stones, such as shorter hospital stay and reduced morbidity, would extend to PCNL of caliceal diverticula. We describe our experience with tt-PCNL for caliceal diverticula, where patients typically go home the same day without any tube. Methods: We identified 42 patients (21 tt-PCNL, 21 PCNL with a NT and/or stent [t-PCNL]) with caliceal diverticular calculi undergoing PCNL from 2013 to 2024 in our prospectively maintained PCNL database. Demographics, stone characteristics, and intraoperative data were compared. Outcomes included final stone-free rate (SFR) using the absolute (0 mm) and relative (≤2 mm, 2.1-4 mm) fragment cutoffs, diverticular cavity resolution, 30-day complications, emergency department (ED) visits, readmissions, and phone calls. Categorical variables were compared using Chi-square or Fisher's exact tests and continuous variables with Mann-Whitney U tests. Results: Demographics and stone characteristics were similar between groups. SFRs were 94% for tt-PCNL and 90% for t-PCNL (p = 0.910) using CT-based criteria, with effective diverticular resolution in 90% and 100% of cases, respectively (p = 0.480). Complications, all Clavien-Dindo grade 1, occurred in four tt-PCNL patients and in one t-PCNL patient (p = 0.343). There were no statistically significant differences in readmission rates, 30-day complication and ED visit rates, or in the incidence of phone calls within 7 days. tt-PCNL patients were discharged same day, whereas t-PCNL required overnight observation. Conclusions: tt-PCNL is a safe effective option for caliceal diverticular stones, offering similar SFRs and safety outcomes compared with t-PCNL, but with shorter hospital stays.