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EDITORIAL COMMENT
Year : 2010  |  Volume : 26  |  Issue : 1  |  Page : 24-25
 

Editorial comment


Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India

Date of Web Publication23-Mar-2010

Correspondence Address:
Mahesh Desai
Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Desai M. Editorial comment. Indian J Urol 2010;26:24-5

How to cite this URL:
Desai M. Editorial comment. Indian J Urol [serial online] 2010 [cited 2020 Aug 11];26:24-5. Available from: http://www.indianjurol.com/text.asp?2010/26/1/24/60439


Placement of a nephrostomy tube after percutaneous nephrolithotomy (PCNL) is considered as a standard practice. The advantages of nephrostomy tube drainage include adequate renal drainage, temponade of tract bleeding, reduced urinary extravasation and allowance of nephrostomy tract to mature for a second look procedure. PCNL without a nephrostomy and without ureteral catheters, double J stents and nephrostomy is termed tubeless PCNL and totally tubeless PCNL, respectively. [1],[2] Advances in the technique, better patient selection, use of smaller caliber nephroscopes, cauterization of the tracts and use of hemostatic agents have contributed to establishing tubeless PCNL as minimally morbid, safe and day care procedure. There are many prospective randomized controlled studies [3],[4],[5] which conclude that patients with nephrostomy have more post operative discomfort, analgesic requirement and prolonged hospital stay as compared to tubeless PCNL. According to the recent European Association of Urology, tubeless PCNL is an acceptable procedure for the treatment of large renal calculi in selected patients. [6] Level 1 and 2 evidence indicates that tubeless PCNL may become standard of care for selected patient groups like stone size less than 3 cm, single tract access, no serious bleeding or perforation of the pelvicalyceal system (PCS) and complete clearance at the end of the procedure as judged by the intraoperative use of fluoroscopy. [7] Many authors have extended the indications of doing tubeless PCNL. There are single center Level 4 evidences to suggest that it may be done in patients with solitary kidneys, pediatric patients, larger stone burden, deranged renal function, multiple tracts, supra costal access and bilateral simultaneous procedure.

The criticism for tubeless procedure includes concerns regarding compromised clearance, perioperative complications such as early hematuria, urinary extravasation, clot colic and delayed complications such as need for ancillary procedure for removal of double J stents and stent dysuria. The stone clearance with the tubeless PCNL has been reported between 73-100%. [7] It is now proved that clinically insignificant residual fragments (CIRF) may lead to symptomatic episodes in future and hasten stone recurrence. Raman et al. [8] showed that residual fragment post PCNL of size as small as 2 mm may produce stone related event in 43% patients. We were critical of the residual fragment incidence in cases apt for tubeless PCNL. Therefore, in 22 consecutive cases, we performed non-contrast CT scan on first postoperative day and found the incidence to be 23% 9 (accepted BJU, Ahead of print). Routine use of postoperative non-contrast CT may lead to over detection of CIRF, which is clinically relevant. Routine tubeless PCNL are followed by double J stenting, the purpose of which is to facilitate expulsion of these CIRF.

Standard PCNL have been followed by nephrostomy tube drainage. The advantages of nephrostomy tube drainage include acute compression of the tract bleeding and utilizing the same tract for check nephroscopy if required. There is also an undoubted level 1 evidence to suggest the safety of tubeless procedure. If the tubeless procedure is carried out, the flank is compressed for a brief period to temponade the bleeding. We feel that with the increasing use of smaller tracts, the tract bleeding is significantly less, so the need for temponade is lesser. Also, various types of tissue sealants have been described like fibrin glue, gel matrix, diathermy cauterization of tract and occlusion balloon. The reports of early hematuria and urinary extravasation with these additional procedures are only anecdotal. Antegrade drainage via double j stents or Ureteric catheter also contributes to lower the early postoperative complications.

Shah et al. [9] reported symptoms in 30% patients of whom 60% required medications. Crook analyzed totally tubeless PCNL in uncomplicated procedures in patients with an intact pelvicalyceal system and suggested that the best available drainage of the kidney is the normal peristalting ureter. [2] They conceptualized a totally tubeless procedure to be an equivalent procedure with lower long-term adverse effects of double j stent.

 
   References Top

1.Bellman GC, Davidoff R, Candela J, Gerspach J, Kurtz S, Stout L. Tubeless percutaneous renal surgery. J Urol 1997;157:1578-82.  Back to cited text no. 1  [PUBMED]    
2.Crook TJ, Lockyer CR, Keoghane SR, Walmsley BH. Totally tubeless percutaneous nephrolithotomy. J Endourol 2008;22:267-71.  Back to cited text no. 2  [PUBMED]    
3.Singh I, Singh A, Mittal G. Tubeless percutaneous nephrolithotomy: is it really less morbid? J Endourol 2008;22:427-34.  Back to cited text no. 3  [PUBMED]    
4.Desai MR, Kukreja RA, Desai MM, Mhaskar SS, Wani KA, Patel SH, et al. A prospective randomized comparison of type of nephrostomy drainage following percutaneousnephrostolithotomy: large bore ersus small bore versus tubeless. J Urol 2004;172:565-7.  Back to cited text no. 4  [PUBMED]    
5.Feng MI, Tamaddon K, Mikhail A, Kaptein JS, Bellman GC. Prospective randomized study of various techniques of percutaneous nephrolithotomy. Urology 2001;58:345-50.  Back to cited text no. 5  [PUBMED]    
6.European Association of Urology (EAU) Guideline on Urolithiasis Stone (2008). 7.2.1: 36.  Back to cited text no. 6      
7.Singh I, Singh A, Mittal G. Tubeless percutaneous nephrolithotomy: is it really less morbid? J Endourol 2008;22:427-34.  Back to cited text no. 7  [PUBMED]    
8.Raman JD, Bagrodia A, Gupta A, Bensalah K, Cadeddu JA, Lotan Y, et al. Natural history of residual fragments following percutaneous nephrostolithotomy. J Urol 2009;181:1163-8.   Back to cited text no. 8  [PUBMED]    
9.Shah HN, Kausik VB, Hegde SS, Shah JN, Bansal MB. Tubeless percutaneous nephrolithotomy: a prospective feasibility study and review of previous reports. BJU Int 2005;96:879-83.  Back to cited text no. 9  [PUBMED]    




 

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