Tubeless percutaneous nephrolithotomy using antegrade tether: a randomized study

Abstract

Background and purpose: Tubeless percutaneous nephrolithotoomy (PCNL), although an accepted technique by now, continues to suffer from two major limitations: The need for postoperative cystoscopy for ureteral stent removal and inability to perform a "second-look" procedure for any residual fragments. We share our experience with a modification of the standard tubeless PCNL technique that allows us to overcome these shortcomings.

Patients and methods: A total of 166 patients selected to have PCNL were randomized into two groups of 83 each. In group A (control group), the patients underwent standard PCNL with the insertion of a nephrostomy tube at completion; in group B (intervention group), modified tubeless PCNL was performed with a Double-J (DJ) stent inserted with a tether attached to its proximal end, taken out through the percutaneous tract. The nephrostomy tube in group A was removed postoperatively on the second or third day, whereas those in group B had the stent removed directly by pulling the attached tether within the office setting 10 to 14 days postoperatively.

Results: The need for postoperative analgesia was significantly higher in group A compared with group B (mean dose of tramadol needed, 128 mg vs 81.3 mg) (P<0.001). Four patients in group A had postoperative urinary leakage from the nephrostomy site, whereas there were no leaks in patients in group B. Group B patients spent significantly shorter average time in hospital (21.6 hours) compared with group A (54 hours) (P<0.001). Two of the patients in group B needed a second-look procedure, performed by the insertion of a guidewire down the stent, which was pulled out partially by its tether. Presence of the tether in the flank or the process of subsequent removal did not cause any discomfort to any patient.

Conclusion: The present study demonstrates that tubeless PCNL with a tethered DJ stent overcomes its main drawback, namely, the need for cystoscopy for stent removal, and also allows access to the pelvicaliceal system for second-look nephroscopy.