The comparison of standard and tubeless percutaneous nephrolithotomy procedures

ARTICLE INFO _______________________________________________________________________________ IBJU | THE COMPARISON OF STANDARD AND TUBELESS PERCUTANEOUS NEPHROLITHOTOMY PROCEDURES 796 they got rid of the nephrostomy tube and tubeless PCNL emerged. We, in this study, aimed to compare the results of the traditional PCNL with the less invasive method, tubeless PCNL, retrospectively. MATERIALS AND METHODS Data of 195 patients submitted to PCNL in our clinic between June 2009 and May 2012 were evaluated retrospectively. Two groups were formed: Group 1 included patients submitted to totally tubeless and Group 2 to standard PCNL (with any nephrostomy tube). All procedures were performed by a single surgeon. The groups had no differences between operation techniqueincluding dilatation size and type. Pre and post operative hematocrit values, blood transfusion rates, fl uoroscopy durations, post operative complications, length of hospital stay, post operative 1st and 6th hours pain scores and analgesic requirements were compared in tubeless and standard patients. Patients having staghorn calculi, requiring multiple accesses were excluded from the study. Pain scores were performed using the Visual Analog Scale. In group 2, patients were checked for residual fragments by X-ray and in addition to this, renal ultrasound was performed to patients in Group 1 for urinoma, hematoma or clinically signifi cant residual fragments. Inclusion criteria for the totally tubeless PCNL during the operation were intact collecting system (no perforations), no serious bleeding, having one access, no previous operations or drainage and no serious extravasations determined by retrograde pyelogram at the end of the operation. Achieving stone free patients or patients having clinically insignifi cant residual fragments (CIRF) (smaller than 4 millimeters,-mm-), no bleeding for 5 minutes after fi nalization of operation, were also considered as inclusion criteria. All patients had been evaluated with complete blood count, plasma electrolytes, kidney and liver function tests, coagulation parameters and urine analysis and urine cultures. Patients with urinary tract infections (UTI) were treated with antibiotics and operation was performed after sterile urine cultures. Measuring the largest edge and the edge perpendicular and multiplying them calculated the stone load. With multiple stones, the measurement was done to all stones and added. Statistical analysis was done using SPSS for Windows 15.0 and Mann Withney U test. P values < 0.05 were considered statistically signifi cant.


INTRODUCTION
Kidney stones have been a frequent, signifi cantly morbid problem.Patients need to undergo invasive surgery and to go through a hard time with long recovery.Until the last 2 decades, open surgery for kidney stones was a must.Because of the morbidity of those operations, new modalities were researched and Percutaneous Nephrolitotomy (PCNL) was described as a treatment method.
Inıtially, Rupel and Brown's removal of the obstructing kidney stone (1), Fenstrom and Johansson published their report on the new stone surgery, which they called Percutaneous Pyelolithotomy (2).The method quickly gained popularity and all patients assigned for open surgery were told to be candidates for percutaneous surgery.After gaining experience with the standard method, surgeons tended to perform this operation with even more decreased morbidity.To achieve that goal, they got rid of the nephrostomy tube and tubeless PCNL emerged.
We, in this study, aimed to compare the results of the traditional PCNL with the less invasive method, tubeless PCNL, retrospectively.

MATERIALS AND METHODS
Data of 195 patients submitted to PCNL in our clinic between June 2009 and May 2012 were evaluated retrospectively.Two groups were formed: Group 1 included patients submitted to totally tubeless and Group 2 to standard PCNL (with any nephrostomy tube).All procedures were performed by a single surgeon.The groups had no differences between operation technique-including dilatation size and type.Pre and post operative hematocrit values, blood transfusion rates, fl uoroscopy durations, post operative complications, length of hospital stay, post operative 1 st and 6 th hours pain scores and analgesic requirements were compared in tubeless and standard patients.Patients having staghorn calculi, requiring multiple accesses were excluded from the study.Pain scores were performed using the Visual Analog Scale.In group 2, patients were checked for residual fragments by X-ray and in addition to this, renal ultrasound was performed to patients in Group 1 for urinoma, hematoma or clinically signifi cant residual fragments.
Inclusion criteria for the totally tubeless PCNL during the operation were intact collecting system (no perforations), no serious bleeding, having one access, no previous operations or drai-nage and no serious extravasations determined by retrograde pyelogram at the end of the operation.Achieving stone free patients or patients having clinically insignifi cant residual fragments (CIRF) (smaller than 4 millimeters,-mm-), no bleeding for 5 minutes after fi nalization of operation, were also considered as inclusion criteria.
All patients had been evaluated with complete blood count, plasma electrolytes, kidney and liver function tests, coagulation parameters and urine analysis and urine cultures.Patients with urinary tract infections (UTI) were treated with antibiotics and operation was performed after sterile urine cultures.
Measuring the largest edge and the edge perpendicular and multiplying them calculated the stone load.With multiple stones, the measurement was done to all stones and added.
Statistical analysis was done using SPSS for Windows 15.0 and Mann Withney U test.P values < 0.05 were considered statistically signifi cant.

RESULTS
We evaluated the data of 195 cases undergoing PCNL in our clinic.There were 85 patients in Group 1 and 110 in group 2. The groups had similar demographics according to co-morbidities.They are summarized in Table-1.Mean stone burden was 321.25 ± 102.4 mm² in Group 1 and, 324.10 ± 169.5 mm² in Group 2.Even though mean stone load, fl uoroscopy duration and operative time was higher in Group 2, the difference was not statistically signifi cant.Need for analgesics and VAS scores at 1 st and 6 th hours were statistically lower for patients in Group 1. Parameters concerning the operation are summarized in Table-2.
In Group 1, for 78 (91.6%) patients and in Group 2, for 96 (87.7%) patients complete stone removal was achieved.7 (8.2%)cases in Group 1 had prolonged (at least 24 hours) leakage.Six patients were treated by placing a double j stent, the other patient undergone ureteroscopy for distal ureter stone.In group 2, 11 (10%) cases had prolonged leakage.3 of these cases (2.7%) had to undergo ureterorenoscopy and 7 were treated by retrograde double j stenting.There were no complications postoperatively.
Postoperative outcomes are summarized in Table-3.
All patients were evaluated with urinary X-ray post operatively.In addition, all patients in

COMMENTS
The European Association of Urology (EAU) recommends PCNL for kidney stones larger than 2 cm in its guideline on Urolithiasis (3).
In our practice, placing a nephrostomy tube after PCNL is the standard method.In the last years, tubeless PCNL, the procedure without placing a nephrostomy tube, neither internally nor externally was described.By placing a nephrostomy tube, the surgeon obtains adequate urinary discharge, hemostasis, tract recovery and a guide for a second operation, if needed.However, because it can cause pain in early hours, it can deteriorate the patient comfort.In the series published by Bdesha, patients with tubeless PCNL were hospitalized for about 2 days, and there was no need for urgent placing of a tube.Hemedra reported a 1.2 gr/dL decrease in hemoglobin and suggested the tubeless procedure in patients with solitary kidney.Goh and Wolf reported decreased morbidity with tubeless operations (4).
After the rapid advancement in PCNL, some surgeons have a tendency on not placing the nephrostomy tube (5).Zilberman et al. reviewed the papers about tubeless PCNL.They reported similar results with tubeless PCNL compared to standard PCNL (6).With this approach, the target is to achieve less hospital days, less pain scores, less analgesics, faster return to normal activities and lower costs.
In addition, there are some indications for tubeless PCNL, such as cases with single tracts, no distal obstruction, no intraoperative complications (such as calyx perforation) and not planning the second look (7,8).
In the study designed by Karami et al. ( 9), 210 patients had undergone tubeless PCNL.All patients had over 2 cm kidney stones (avg 3 cm) and 21 had staghorn stones.91.04% of the cases were stone free, and 8.95 % (18 patients) had residual fragments around 7 mm and they all were treated by SWL.40 patients had minor bleeding, 22 patients (10.9%) needed blood transfusion and 16 patients (7.9%) suffered UTI.For pain management, diclofenac or indomethacin was used; 50 mg of petidine was used for 10 patients.Mean hospitalization time was 3.5 days.The researchers underlined that tubeless PCNL is a safe and economic approach with high patient comfort (9).
In a similar study, Shah et al. (10) randomized patients to tubeless and a small diameter (8F) nephrostomy tube and compared their pain, need for analgesics and days of hospitalization.Tubeless group were placed a 6 F Double J tube.That group had less pain, need for analgesics and days of hospitalization.But 39.4% of the same group suffered pain from Double J.
Tubeless PCNL indications expanded in recent literature.Jung and Bellman used the technique successfully on obese patients (5).Shuh et al. performed on bilateral kidney stones.Jou et al. underlined the fact that over 3 cm or staghorn stones were also candidates for tubeless PCNL (11).
PCNL is a challenging operation; even in the most experienced hands around 1.1-83% complications may emerge.Hemorrhage, cured by intervention (0.6-17%) is the most important complication (12,13).Bleeding may occur during In our study, our data tend to be parallel to current literature.Even though it was not statistically signifi cant, duration of operation and fl uoroscopy were both longer in Group 2. It was considered to be because of the extra time spent to place the nephrostomy tube.Performing a tubeless PCNL is decided at the end of the operation.By that means, the higher number of patients with decrease in hematocrit in Group 2 was considered on this matter.Mean hospitalization days were higher in Group 1 (p < 0.05).Also, pain scores and need for analgesics were higher in Group 2 (p < 0.05).All those parameters are about patient comfort and being able to return to everyday activities.We suggest choosing tubeless PCNL when possible.

CONCLUSIONS
Because of the superiority of PCNL over open surgery about safety, easily usability, being able to gain more stone-free rates and patient comfort, it is commonly used on stone disease.Parallel to that fact, post operative patient comfort, shorter hospitalization, less need for analgesics might make tubeless PCNL the new standard.In suitable cases, it can be used safely as standard PCNL.
Despite our study's low patient population and retrospective nature, for cases without collecting system perforation or intraoperative hemor-rhage, we suggest the use of tubeless PCNL safely.Prospective randomized studies including larger populations are needed to back up these results.