Almost totally tubeless percutaneous nephrolithotomy: Further evolution ofthe technique

Background and Objectives: There is renewed interest in the concept of fore going placement of the postoperative nephrostomy tube (PNT) after percutane ous nephrolithotomy (PCNL) with the intent of reducing postoperative discom fort and hospital stay. We have omitted the PNT and placed an internal uret eral stent or externalized ureteral catheter after PCNL in selected patient s. We reviewed our experience in order to assess the efficacy and safety of this practice. Patients and Methods: Primary PCNL was performed in 26 renal units in 21 pa tients (5 bilateral PCNL, 4 of which were simultaneous) by one surgeon at t he 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, si gnificant bleeding or perforation was noted, or a second look was required. Results: 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, ext ernalized 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, bu t 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 less than or equal to 4 mm, Omission of PNT placement resulted in decreased mean length of stay (2.3 days in the n o-PNT group v 3.6 days in the PNT group). There were four complications, al l managed with delayed stenting (one in a no-PNT patient and the remaining three in the PNT group). Conclusion: Omission of PNT placement in selected patients may reduce morbi dity without compromising efficacy and safety, but further study is needed.