Complications and outcomes of tubeless versus nephrostomy tube in percutaneous nephrolithotomy: a systematic review and meta-analysis of randomized clinical trials

Present Insights and Future Perspectives in Pediatric Percutaneous Nephrolithotomy: A Systematic Review by the EAU-YAU Pediatric Urology Working Group

Background and Objective: The incidence of stone disease in children has risen worldwide, leading to the development of more treatment options. Percutaneous nephrolithotomy (PCNL) is often the preferred approach in many pediatric cases. This systematic review aims to assess the effectiveness and safety of PCNL in children, as well as to identify future directions for improving procedural outcomes. Methods: For this systematic review a comprehensive electronic search was conducted in PubMed and EMBASE in August 2023. The search included patients younger than 18 with renal stones requiring any modality of PCNL, as well as to establish the deficiencies in the reports of outcomes. The search strategy adhered to PRISMA guidelines, and quality assessments were performed using the Cochrane tool and MINORS tool. Key Findings and Limitations: Regardless of age, PCNL is safe and efficient in children, with stone-free rate above 85% and complication rate below 7%. However, neither the definition of stone free nor the way of reporting complications is homogeneous among studies. In addition, aspects such as diagnostic imaging, antibiotic prophylaxis, postoperative drainage, metabolic study, or follow-up are not systematically or uniformly reported in the studies. Conclusions and Clinical Implications: PCNL maintains its efficiency and safety even when the working tract caliber is reduced. However, the lack of standardization when describing pre-, peri-, and postoperative aspects creates a gap that does not allow grouping outcomes and highlights the lack of clear guidelines when implementing this surgical procedure.

Safety and efficacy of standard vs. tubeless percutaneous nephrolithotomy in pediatric populations: an updated systematic review and meta-analysis

OBJECTIVE

This study aims to compare the safety and efficacy of standard versus tubeless percutaneous nephrolithotomy (PCNL) in pediatric populations.

METHODS

A systematic search was conducted in the Web of Science, Cochrane Library, PubMed, and Embase databases to identify studies that met the inclusion criteria. Two authors independently screened the literature and extracted data. A meta-analysis was performed using RevMan 5.4 software. This study has been prospectively registered with PROSPERO (ID: CRD42024622238). Sensitivity analysis was performed using Stata 17.0 to assess the impact of low-quality studies, and publication bias was evaluated using funnel plots.

RESULTS

A total of 3 randomized controlled trials and 10 case-control studies were included, comprising 661 cases. The meta-analysis revealed that, in pediatric populations, the tubeless PCNL group had significantly shorter hospital stays compared to the standard PCNL group (WMD = -1.60, 95% CI: -2.27 to -0.92, P < 0.01), as well as shorter operative times (WMD = -2.06, 95% CI: -4.02 to -0.10, P = 0.04). The stone clearance rate was higher in the tubeless PCNL group than in the standard group (OR = 2.18, 95% CI: 1.09 to 4.34, P = 0.03). Additionally, the tubeless PCNL group had lower rates of postoperative fever (OR = 0.46, 95% CI: 0.27 to 0.78, P < 0.01) and postoperative urine leakage (OR = 0.20, 95% CI: 0.08 to 0.50, P < 0.01) compared to the standard group. The tubeless PCNL group also had shorter pain management times (WMD = -2.00, 95% CI: -2.44 to -1.56, P < 0.01) and lower visual analog scale (VAS) scores (WMD = -2.52, 95% CI: -2.81 to -2.22, P < 0.01). However, no significant differences were observed between the two groups in terms of hemoglobin decline, overall complications (including perinephric fluid collections, urinary tract infections, and blood transfusion requirements), and reoperation rates.

CONCLUSION

In children with kidney stones and low stone burden or an uneventful procedure, tubeless PCNL offers clear clinical advantages, including shorter hospital stays, higher stone clearance rates, and lower postoperative fever. Additionally, it improves surgical efficiency, reduces postoperative complications, and decreases the need for analgesia. These benefits suggest that tubeless PCNL can be safely applied in pediatric patients, yielding outcomes comparable to standard PCNL, provided that indications are properly managed".

CLINICAL TRIAL NUMBER

Not applicable.

Thulium laser-based hemostasis during percutaneous nephrolithotomy: a prospective observational multicentric study

PURPOSE

Percutaneous nephrolithotomy (PNL) is a controlled grade IV renal trauma and intraoperative bleeding is the most crucial complication. Contemporarily, pulsed mode thulium laser has been reported to confer adequate hemostasis. Therefore, the primary outcome of this study was to assess safety and efficacy of thulium laser-based hemostasis during PNL.

METHODS

This was a prospective observational study including all patients, aged  ≥ 18 years old with renal stone(s)  ≥ 20 mm in the maximal dimension, candidate for PNL. Pregnant patients or those with uncorrected coagulopathy were excluded. All procedures were performed in the prone position and in case of a well-defined active blood spurter, and hemostasis was deployed by thulium laser. Hence, the patients were further classified into group (A): required thulium laser-based hemostasis and group (B): did not require hemostasis. A comparison was made between the groups regarding patients' history, PNL outcomes and complications.

RESULTS

Seven hundred and thirty three patients underwent the procedure and abided by the follow-up regimen. Eighty-eight patients required hemostasis (12%) for tract spurters (51 patients, 58% of group A), renal unit spurters (18 patients, 20.5% of group A) and spurters of both (19 patients, 21.5% of group A). Twenty-two patients (3.1%) received blood transfusion during the study and there was no statistically significant difference between both groups regarding the outcomes and complications. Additionally, there was no statistically significant difference between the preoperative and postoperative value of the mean glomerular filtration rate.

CONCLUSION

Thulium laser-based hemostasis is safe and effective for controlling the intraoperative bleeding during PNL.

Pre- and post-operative safety considerations for patients undergoing percutaneous nephrolithotomy

INTRODUCTION

Percutaneous nephrolithotomy (PCNL) is a widely used surgical procedure for treating large and complex kidney stones. Although effective, it carries risks of complications such as bleeding, infection, and injury to adjacent structures. Optimisation of procedural techniques and perioperative care can help minimize these risks.

AREAS COVERED

This review examines key pre- and post-operative safety considerations for PCNL patients. Topics include pre-operative imaging, patient positioning, puncture techniques, tract dilation, postoperative drainage, and complication management. The literature search involved analyzing recent studies and clinical guidelines to identify best practices. The search was conducted in several databases, including PubMed, Embase, the Cochrane Library and clinical guidelines. Training modalities for improving procedural skills are discussed.

EXPERT OPINION

Improving the safety of PCNL requires a combination of meticulous surgical technique, proper patient selection, and adherence to standardized protocols. Continuous skill development and technological advancements will further improve patient outcomes.

Is Outpatient Totally Tubeless Standard Percutaneous Nephrolithotomy Safe and Efficacious?

Introduction and Objectives: Percutaneous nephrolithotomy (PCNL) is the gold standard treatment for large, complex intrarenal stones. Tubeless PCNL (t-PCNL) where no nephrostomy tube is placed and totally tubeless PCNL (tt-PCNL) in selected patients have been well described. There has been no study to our knowledge discharging patients the same day totally tubeless. In this study, we describe our experience with tt-PCNL on a totally outpatient basis-with the patient going home with absolutely no tube, catheter, or stent, evaluating its safety and efficacy vis-à-vis a comparison with outpatient t-PCNL patients discharged with an indwelling stent. Methods: We prospectively collected data from 130 consecutive patients scheduled for outpatient PCNL from August 2023 to January 2024. Demographics, stone characteristics, and intraoperative data were compared. Outcomes included postoperative (post-op) pain, stone-free rate (SFR), 30-day complications, and ED visits or readmissions. Categorical variables were compared using Chi-square or Fisher's exact tests and continuous variables via Mann-Whitney U tests. Results: After exclusions, 53 patients underwent tt-PCNL and 50 had t-PCNL. Demographics and stone burden did not differ between groups. No visceral or pleural injuries occurred in either group. Post-op transfusion rates, SFR, 30-day complications, ED visits, and readmissions were also comparable between the two groups. The mean operative (OR) time and incidence of Clavien-Dindo I complications were higher with t-PCNL with stent (80 minutes vs 58 minutes, p < 0.001,16% vs 3.8%, p = 0.048). Post-op pain scores and postanesthesia care unit stay times were similar. Conclusions: In this first ever comparison of outpatient t-PCNL to tt-PCNL, we found the same-day discharge of tt-PCNL patients to be safe and effective. Stent omission in our patients did not increase the risk of RF, ED visits, complications, or readmissions. A large, multicenter, randomized prospective controlled trial will help to confirm our findings.

Supine or prone position in percutaneous nephrolithotomy: A systematic review and meta-analysis of 11,774 cases

INTRODUCTION

Percutaneous nephrolithotomy is the gold standard for large renal stones, with prone and supine positions offering distinct advantages and disadvantages. This meta-analysis compares the efficacy and safety of these two approaches.

METHODS

This meta-analysis registered in PROSPERO (CRD42024603670) followed PRISMA and AMSTAR guidelines, including RCTs, cohort, and case-control studies comparing SP and PP PCNL for renal stones. It assessed demographic data, stone-free rate, operative time, hospital stay, complications and hemoglobin drop, with bias risk evaluated using Cochrane and ROBINS-I tools and statistical analysis performed in Jamovi.

RESULTS

Forty-three studies with 11,774 patients were included. No significant differences were found in patient characteristics, SFR (RR=0.9945, P=0.7008), hemoglobin drop (P=0.0800), or hospital stay duration (P=0.1942). The SP group showed shorter OT (SMD=-0.3895, P=0.0084), fewer overall (RR=0.8692, P=0.0026) and major complications (RR=0.7461, P=0.0151). SP also had lower rates of visceral injury (RR=0.8485, P=0.1581), transfusion (RR=0.8514, P=0.1497), sepsis (RR=0.7880, P=0.1304), urinary leakage (RR=0.7699, P=0.2681), and pleural effusion (RR=0.5564, P=0.0898), but these were not statistically significant.

CONCLUSION

This meta-analysis found no significant differences between SP and PP in demographics, stone size, SFR, hospital stay, or hemoglobin drop. However, SP was associated with shorter OT, fewer complications and major complications, suggesting it is a viable alternative.

Pain management in percutaneous nephrolithotomy - an approach rooted in pathophysiology

Pain related to percutaneous nephrolithotomy (PCNL) is multifactorial and poorly elucidated. However, understanding the pathophysiology of pain can enable a practical approach to pain management, which can be tailored to each patient. A number of potential mechanisms underlie pain perception in PCNL, and these mechanisms can be leveraged at various points on the perioperative care pathway. These interventions provide opportunities for modulation of pain associated with PCNL but must take into account various technical, pharmacological and patient-related considerations. Technical considerations include the influence of percutaneous access, stone removal and drainage techniques. Pharmacological aspects include the use of various analgesics and anaesthesia approaches. Patient factors include consideration of the biopsychosocial model in pain experience to understand each individual's response to pain. By understanding the contemporary evidence surrounding the physiology of postoperative pain and identifying tangible intervention points, we can seek to mitigate postoperative pain in patients undergoing PCNL.

Comparative Outcomes of Day-case Percutaneous Nephrolithotomy Versus Conventional Inpatient Surgery: A Systematic Review and Meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis to evaluate the effectiveness and safety of PCNL performed as a day-case surgery in comparison to inpatient PCNL.

METHODS

Databases were searched up to January 27, 2024, for randomized and non-randomized studies comparing outcomes between day-case PCNL and inpatient PCNL. Pooled data were analyzed using a random-effects (RE) model when Higgins I2% heterogeneity values were >50%; otherwise, a fixed-effects model was employed. The results were reported as odds ratios (OR), mean difference (MD) or standardized MD (SMD) with 95% confidence intervals (CI). Statistical significance was set at P <.05.

RESULTS

One randomized controlled trial (RCT) and 14 observational studies totaling 1574 patients were included. Pooled results revealed that patients in the day-case PCNL group experienced reduced blood loss (SMD -0.71 95% CI: [-1.31, -0.12] P .02) and transfusion rates (OR 0.10 95% CI: [0.03, 0.39], P .0008), lower overall and minor complications (OR 0.56, 95% CI: [0.42, 0.76], P .0002, and OR 0.52, 95% CI: [0.37, 0-73], P .0002, respectively), shorter operative time (MD -11.46, 95% CI: [-17.41, -5-50], P <.00001), and reduced total costs (MD -1597.18, 95% CI [-2436.42, -757.93], P .0002). Major complications, stone-free rate (SFR), emergency department (ED) visits, and readmission rates were similar between the groups.

CONCLUSION

Day-case PCNL is a feasible and safe alternative to inpatient PCNL surgery in carefully selected patients, without increasing the risk of complications or readmission rates, and is likely to reduce total costs.

Visualizing the landscape of urolithiasis research from 1979-2023: a global bibliometric analysis of randomized clinical trials

Urolithiasis is the most prevalent benign urological condition, imposing a significant burden on morbidity, disability, and healthcare costs globally. Despite its impact, comprehensive bibliometric analyses of randomized clinical trials (RCTs) related to urolithiasis, which are essential for advancing evidence-based medical practices, are lacking. This study aimed to examine the global research landscape and trends in RCTs focused on urolithiasis. This study used bibliometric techniques to analyze a selection of RCTs on urolithiasis published between 1979 and 2023. VOSviewer software version 1.6.20 was used to visualize international collaborations and perform a keyword analysis of the included articles. The main objective was to identify key research areas and focal points within the field of urolithiasis RCTs. Between 1979 and 2023, a comprehensive search identified 16,716 research articles on urolithiasis. A total of 693 relevant RCTs were found in the Scopus database. The number of publications has significantly increased over time, indicating a strong positive correlation (R² = 0.9303; P < 0.001). China was the top contributor, with 166 publications (23.95%), followed by the United States, with 130 publications (18.76%). Turkey and Iran contributed 44 (6.35%) and 62 (8.95%) publications, respectively. Citation analysis revealed an average of 28.13 citations per article, an h-index of 70, and a total of 19,493 citations. The co-occurrence analysis highlighted current research trends and key topics in urolithiasis RCTs, including 'comparative effectiveness of surgical and laser techniques and patient outcomes', 'medical expulsive therapy (MET) for ureteral calculi and clinical outcomes', 'systematic reviews and meta-analyses of RCTs investigating urolithiasis', and 'dietary interventions and correlations between stone composition and the risk of recurrence.' The bibliometric analysis provides an overview of research on urolithiasis RCTs. It examines global research trends and identifies new developments in the field. Our review identified key research themes, including systematic reviews and meta-analyses, dietary interventions, medical therapy for the expulsion of ureteral stones, and comparisons of surgical techniques-areas that will remain focal points in future research. This bibliometric analysis is an invaluable resource for researchers, clinicians, and policymakers, providing a complete overview of past and present research trends. Informed decision making can be promoted and guided in future research, ultimately improving management and understanding.

Evaluating the safety of bipolar nephrostomy tract cauterization "BNTC" towards a safe tubeless percutaneous nephrolithotomy: a randomized controlled trial

To assess the safety and effectiveness of tubed versus tubeless percutaneous nephrolithotomy (PCNL) after tract inspection and bipolar cauterization of the significant bleeders. Patients who were scheduled for PCNL were screened for enrollment in this prospective randomized controlled trial. The patients were randomly assigned to one of two groups; Group 1 received tubeless PCNL with endoscopic inspection of the access tract using bipolar cauterization of the significant bleeders only, while Group 2 had a nephrostomy tube was inserted without tract inspection. We excluded patients with multiple tracts, stone clearance failure, and significant collecting system perforation. We recorded blood loss, hemoglobin drop after 6 h, postoperative analgesia requirements, hospital stay, and the need for angioembolization. A total of 110 patients completed the study. There were no significant differences between the two groups in in terms of demographic characteristics. Likewise, there was no significant difference in the mean decrease in hemoglobin after 6 h and the frequency of blood transfusion. However, the incidence of hematuria within the first 6 h (p = 0.008), postoperative pain scale (p = 0.0001), the rate of analgesia requirement (p = 0.0001) and prolonged hospital stay (p = 0.0001) were significantly higher in Group 2. Only 9 cases of tract screened patients (16% of group 1) required cauterization. Tubeless PCNL with tract inspection and cauterization of bleeders can provide a safer tubeless PCNL with less postoperative pain, analgesia requirement, and same-day discharge.

Management of urinary stones: state of the art and future perspectives by experts in stone disease

AIM

To present state of the art on the management of urinary stones from a panel of globally recognized urolithiasis experts who met during the Experts in Stone Disease Congress in Valencia in January 2024. Options of treatment: The surgical treatment modalities of renal and ureteral stones are well defined by the guidelines of international societies, although for some index cases more alternative options are possible. For 1.5 cm renal stones, both m-PCNL and RIRS have proven to be valid treatment alternatives with comparable stone-free rates. The m-PCNL has proven to be more cost effective and requires a shorter operative time, while the RIRS has demonstrated lower morbidity in terms of blood loss and shorter recovery times. SWL has proven to be less effective at least for lower calyceal stones but has the highest safety profile. For a 6mm obstructing stone of the pelviureteric junction (PUJ) stone, SWL should be the first choice for a stone less than 1 cm, due to less invasiveness and lower risk of complications although it has a lower stone free-rate. RIRS has advantages in certain conditions such as anticoagulant treatment, obesity, or body deformity. Technical issues of the surgical procedures for stone removal: In patients receiving antithrombotic therapy, SWL, PCN and open surgery are at elevated risk of hemorrhage or perinephric hematoma. URS, is associated with less morbidity in these cases. An individualized combined evaluation of risks of bleeding and thromboembolism should determine the perioperative thromboprophylactic strategy. Pre-interventional urine culture and antibiotic therapy are mandatory although UTI treatment is becoming more challenging due to increasing resistance to routinely applied antibiotics. The use of an intrarenal urine culture and stone culture is recommended to adapt antibiotic therapy in case of postoperative infectious complications. Measurements of temperature and pressure during RIRS are vital for ensuring patient safety and optimizing surgical outcomes although techniques of measurements and methods for data analysis are still to be refined. Ureteral stents were improved by the development of new biomaterials, new coatings, and new stent designs. Topics of current research are the development of drug eluting and bioresorbable stents. Complications of endoscopic treatment: PCNL is considered the most invasive surgical option. Fever and sepsis were observed in 11 and 0.5% and need for transfusion and embolization for bleeding in 7 and 0.4%. Major complications, as colonic, splenic, liver, gall bladder and bowel injuries are quite rare but are associated with significant morbidity. Ureteroscopy causes less complications, although some of them can be severe. They depend on high pressure in the urinary tract (sepsis or renal bleeding) or application of excessive force to the urinary tract (ureteral avulsion or stricture). Diagnostic work up:  Genetic testing consents the diagnosis of monogenetic conditions causing stones. It should be carried out in children and in selected adults. In adults, monogenetic diseases can be diagnosed by systematic genetic testing in no more than 4%, when cystinuria, APRT deficiency, and xanthinuria are excluded. A reliable stone analysis by infrared spectroscopy or X-ray diffraction is mandatory and should be associated to examination of the stone under a stereomicroscope. The analysis of digital images of stones by deep convolutional neural networks in dry laboratory or during endoscopic examination could allow the classification of stones based on their color and texture. Scanning electron microscopy (SEM) in association with energy dispersive spectrometry (EDS) is another fundamental research tool for the study of kidney stones. The combination of metagenomic analysis using Next Generation Sequencing (NGS) techniques and the enhanced quantitative urine culture (EQUC) protocol can be used to evaluate the urobiome of renal stone formers. Twenty-four hour urine analysis has a place during patient evaluation together with repeated measurements of urinary pH with a digital pH meter. Urinary supersaturation is the most comprehensive physicochemical risk factor employed in urolithiasis research. Urinary macromolecules can act as both promoters or inhibitors of stone formation depending on the chemical composition of urine in which they are operating. At the moment, there are no clinical applications of macromolecules in stone management or prophylaxis. Patients should be evaluated for the association with systemic pathologies.

PROPHYLAXIS

Personalized medicine and public health interventions are complementary to prevent stone recurrence. Personalized medicine addresses a small part of stone patients with a high risk of recurrence and systemic complications requiring specific dietary and pharmacological treatment to prevent stone recurrence and complications of associated systemic diseases. The more numerous subjects who form one or a few stones during their entire lifespan should be treated by modifications of diet and lifestyle. Primary prevention by public health interventions is advisable to reduce prevalence of stones in the general population. Renal stone formers at "high-risk" for recurrence need early diagnosis to start specific treatment. Stone analysis allows the identification of most "high-risk" patients forming non-calcium stones: infection stones (struvite), uric acid and urates, cystine and other rare stones (dihydroxyadenine, xanthine). Patients at "high-risk" forming calcium stones require a more difficult diagnosis by clinical and laboratory evaluation. Particularly, patients with cystinuria and primary hyperoxaluria should be actively searched.

FUTURE RESEARCH

Application of Artificial Intelligence are promising for automated identification of ureteral stones on CT imaging, prediction of stone composition and 24-hour urinary risk factors by demographics and clinical parameters, assessment of stone composition by evaluation of endoscopic images and prediction of outcomes of stone treatments. The synergy between urologists, nephrologists, and scientists in basic kidney stone research will enhance the depth and breadth of investigations, leading to a more comprehensive understanding of kidney stone formation.

Related factors of perioperative low body temperature and incidence of postoperative shivering in patients undergoing complex percutaneous nephrolithotomy and the effect analysis of composite insulation nursing intervention

This study aimed to analyze the factors associated with intraoperative hypothermia and postoperative shivering rates in patients undergoing complex percutaneous nephrolithotomy (PCNL) and investigate the effects of combined insulation nursing intervention. A total of 168 patients were included, with 103 patients in the control (Ctrl) group receiving routine care and 65 patients in the nursing (Nur) group receiving combined insulation nursing intervention measures. General information, surgical data, temperature, intraoperative hypothermia incidence, postoperative shivering, and complication rates were statistically analyzed between the two groups. Patient temperature, blood pressure, and blood gas indicators including pH value, bicarbonate, and lactate levels were recorded at admission (T0), before anesthesia (T1), 30 min after spinal-epidural combined anesthesia (T2), 60 min (T3), 90 min (T4), 120 min (T5), and postoperatively (T6). The results demonstrated that the average intraoperative temperature of patients in the Nur group was significantly higher than that of the Ctrl group (P < 0.001), and their incidence of hypothermia was significantly lower than that of the Ctrl group (P < 0.01). Additionally, the Nur group exhibited shorter recovery time (18.36 ± 3.58 min), extubation time (28.01 ± 3.12 min), and length of hospital stay (8.45 ± 2.14 days) compared to the Ctrl group (P < 0.05). The incidence of postoperative shivering was 4.62 %, significantly lower than that of the Ctrl group (P < 0.001). Multifactorial analysis revealed that age ≥60 years, stone diameter ≥3.0 cm, irrigation volume ≥3000 mL, nursing intervention measures, and surgical duration were the main factors influencing the occurrence of intraoperative hypothermia. Age ≥60 years, nursing intervention measures, surgical duration, and intraoperative temperature<36 °C are identified as major risk factors for postoperative shivering. This indicates that specialized nursing care and combined insulation nursing intervention measures in patients undergoing complex percutaneous nephrolithotomy contribute to reducing the incidence of intraoperative hypothermia and postoperative shivering. It is recommended to promptly address the risk factors associated with hypothermia and shivering during and after surgery to mitigate the risk of perioperative complications.

Is Totally Tubeless Percutaneous Nephrolithotomy a Safe and Efficacious Option for Complex Stone Disease?

Background: Percutaneous nephrolithotomy is the gold standard treatment for large, complex intrarenal stones. Historically, this was performed using a nephrostomy tube (PCN) and/or internalized ureteral stent at the end of the procedure. However, totally tubeless nephrolithotomy (tt-PCNL) is a novel technique where no tubes (no stent nor nephrostomy tube) are left post-operatively. We review the literature on this subject regarding peri-operative outcomes, post-operative outcomes, and potential complications of the procedure, discuss our technique, and make recommendations on implementation for centers not currently utilizing the procedure. Materials and methods: We performed a comprehensive search of the literature on totally tubeless nephrolithotomy using MEDLINE database search. Our search included prior review articles, meta-analyses, systematic reviews, primary research articles, case reports, and case studies. Results: In comparison to prior approaches where a stent or nephrostomy tube is placed, tt-PCNL has a similar complication rate and better post-operative outcomes. Totally tubeless PCNL has similar operative times and similar changes in hemoglobin. However, it had shorter length of stays across all studies. The mean difference in length of stay in the studies reviewed was 1.96 days. Additionally, tt-PCNL had decreased post-operative analgesic requirements and pain scores. Conclusions: This review highlights totally tubeless percutaneous nephrolithotomy as a safe and feasible surgical technique with improved outcomes in properly selected patients.

Tubeless PCNL versus standard PCNL for the treatment of upper urinary tract stones: a propensity score matching analysis

PURPOSE

In this study, the feasibility of tubeless percutaneous nephrolithotomy (PCNL) for the treatment of upper urinary tract stones was investigated.

METHODS

From January 2021 to December 2022, the clinical data of 273 patients who received tubeless PCNL (Group A) were studied. The control group includes clinical data from 302 patients (from January 2019 to October 2022) who received standard PCNL (Group B). The baseline characteristics were consistent between the two groups after using the propensity score matching (PSM) method. Compare the preoperative clinical characteristics, postoperative complications, residual stones, catheterization time, and hospital stay between the two groups.

RESULTS

146 pairs of patients were successfully paired through PSM. There was no statistically significant difference in operative time, blood leukocyte counts, haemoglobin decrease, fever, urinary extravasation, sepsis, bleeding, blood transfusion rates, embolism, and residual stones after surgery between the two groups; Postoperative day 1 and discharge day, the VAS pain score in Group A was significantly lower than that in Group B. The catheterization time and hospitalization time of patients in Group A were significantly lower than those in Group B.

CONCLUSION

According to the inclusion and exclusion criteria, selecting suitable patients for tubeless PCNL is safe and effective, while significantly alleviating pain and reducing catheterization time and hospital stay.

Complications of tubeless versus standard percutaneous nephrolithotomy

PURPOSE

The necessity of nephrostomy tube after percutaneous nephrolithotomy (PCNL) has been called into question in modern series. We sought to examine differences in postoperative complications and outcomes of tubeless PCNL versus standard PCNL at our institution.

METHODS

A retrospective review of our institutional stone database was conducted from January 2016 to December 2021 for patients who had undergone either tubeless PCNL, defined by placement of only an internal ureteral stent, or standard PCNL, which involved placement of an externalized nephrostomy tube. Patients were excluded if they underwent totally tubeless PCNL.

RESULTS

A total of 438 patients were included for analysis: 329 patients underwent tubeless PCNL and 109 patients underwent standard PCNL. Between tubeless and standard groups, there was no difference in readmission rates 6.1% vs. 9.2% (p = 0.268), Clavien 2 or > complications 18.5% vs. 19.3% (p = 0.923), and Clavien 3 or > complications 4.0% vs. 7.3% (p = 0.151). The tubeless group experienced shorter operative duration 121.5 vs. 144.8 min (p = 0.012), shorter length of stay 2.5 vs. 3.8 days (p = 0.002), and higher stone-free rates 72.3% vs. 60.2% (p = 0.014), but also increased blood transfusion rates 6.4% vs. 0.9% (p = 0.022).

CONCLUSION

In comparing tubeless with standard PCNL, there was no difference in readmission rates, or significant Clavien complication rates. Patients undergoing tubeless PCNL experienced higher stone-free rates, but more number of patients required postoperative blood transfusion. The decision to leave a nephrostomy tube after PCNL appears unlikely to impact overall complication rates and can be left to surgeon experience and case-based discretion.

Suction in Percutaneous Nephrolithotripsy: Evolution, Development, and Outcomes from Experimental and Clinical studies. Results from a Systematic Review

CONTEXT

Controversy exists regarding the therapeutic benefit of suction use during percutaneous nephrolithotripsy (PCNL).

OBJECTIVE

To review and highlight the options available in the use of suction for PCNL, and to discuss their strengths and limitations.

EVIDENCE ACQUISITION

A systematic literature search was performed using Scopus, EMBASE, and PubMed. Thirty four studies were included. There was one ex vivo study. Among clinical studies, 24 used a vacuum/suctioning sheath and nine a handpiece suction device/direct-in-scope suction. The suction technique was employed in standard, mini-PCNL, supermini-PCNL, and enhanced supermini‑PCNL techniques.

EVIDENCE SYNTHESIS

Handpiece suction devices demonstrated better safety and efficiency in treating large stones than nonsuction PCNL and in a much shorter time. Trilogy and ShockPulse-SE were equally effective, safe, and versatile for standard PCNL and mini-PCNL. The heavier handpiece makes Trilogy less ergonomically friendly. Laser suction handpiece devices can potentiate laser lithotripsy by allowing for better laser control with simultaneous suction of small fragments and dust. Integrated suction-based sheaths are available in reusable and disposable forms for mini-PCNL only. Mini-PCNL with suction reported superior outcomes for operative time and stone-free rate to mini-PCNL. This also helped minimize infectious complications by a combination of intrarenal pressure reduction and faster aspiration of irrigation fluid reducing the risk of sepsis, enhance intraoperative vision, and improve lithotripsy efficiency, which makes it a very attractive evolution for PCNL.

CONCLUSIONS

Suction devices in PCNL are reforming the way PCNL is being done. Adding suction to mini-PCNL reduces infectious complications and improves the stone-free rate. Our review shows that despite the limited evidence, suction techniques appear to improve PCNL outcomes.

PATIENT SUMMARY

In this review, we looked at the intra- and perioperative outcomes of percutaneous nephrolithotripsy (PCNL) with the addition of suction. With better stone fragmentation and fewer postoperative infections, this technology is very useful particularly for mini-PCNL.

Vacuum-assisted access sheath in supine mini-percutaneous nephrolithotomy (mini-PCNL)

INTRODUCTION

The vacuum-assisted access sheath is a new device for the treatment of kidney stones with percutaneous nephrolithotomy (PCNL).

OBJECTIVE

Our aim was to compare the stone-free rate (SFR) and complications between standard mini percutaneous nephrolithotomy (Mini-PCNL) and vacuum-assisted PCNL (Va-PCNL).

METHODS

Retrospective study of patients undergoing Mini-PCNL and Va-PCNL from January 2018 to June 2022. Va-PCNL was performed with a disposable sheath (ClearPetra®) with continuous high-flow irrigation and vacuum fluid dynamics for easier stone fragment removal. Baseline patient characteristics, surgical outcomes, perioperative and postoperative data were collected. We compared SFR and complications.

RESULTS

A total of 136 patients were identified, 57 (41,9%) underwent Va-PCNL and 79 (58,15%) Mini-PCNL. Mean operative time was significantly shorter in the Va-PCNL group (95 min.) than in Mini-PCNL (146 min; P = ,001) group. The tubeless technique was performed more frequently in Va-PCNL group (61,4% vs. 34,2%; P = ,002). We did not observe any differences in postoperative complications. The mean hospital stay was significantly lower in Va-PCNL with 1,7 ± 1,9 days per patient compared with 2,7 ± 1,5 days in the Mini-PCNL group (P = ,001). There were no differences in SFR at 3 months between Va-PCNL (71,9%) and Mini-PCNL (71,8%; P =v ,848).

CONCLUSION

Patients treated with Va-PCNL had comparable results to Mini-PCNL, showing equal SFR with similar infectious complications rates. Potential benefits of Va-PCNL include shorter operative time and postoperative stay.

Efficacy and safety of various endosurgical procedures for management of large renal stone: a systemic review and network meta-analysis of randomised control trials

Urolithiasis is the most common benign urological health condition. It has contributed sizeable burden of morbidity, disability, and medical health expenditure worldwide. There is limited high level of evidence on the efficacy and safety of treatment options of large renal stones. This network meta-analysis has examined the effectiveness and safety of various large renal stone management strategies. Systematic review and network meta-analysis (NMA) study design was employed to summarize comparative randomized controlled trials on humans with a diagnosis of renal stone larger than or equal to 2 cm in size. Our searching strategy was based on the Population, Interventions, Comparison, Outcomes, and Study (PICOS) approach. Medline via PubMed, Embase, Google scholar, SCOPUS, Science Direct, Cochrane library, Web of Science, and ClinicalTrials.gov were searched from inception to March 2023 to find eligible articles. Data extraction, screening, selection and risk of bias assessment were conducted by two independent reviewers. We found ten randomised control trials which consists 2917 patients, nine of them were labeled as low risk and one article was high risk. This network meta-analysis found that SFR was 86% (95% CI 84-88%) for Mini-PCNL, 86% (95% CI 84-88%) for standard PCNL, 79% (95% CI:73-86%) for RIRS, and 67% (95%CI:49-81 for staged URS for management of large renal stone. Overall complication rate was 32% (95% CI 27-38%) for standard PCNL, 16% (95% CI 12-21%) for Mini-PCNL, and 11% (95% CI 7-16%) for RIRS. Mini-PCNL (RR = 1.14 (95% CI 1.01-1.27) and PCNL (RR = 1.13 (95% CI 1.01-1.27)) were statistically associated with a higher SFR compared to RIRS. The pooled mean hospital stays were 1.56 days (95% CI 0.93-2.19) for RIRS, 2.96 days (95% CI 1.78-4.14) for Mini-PCNL, 3.9 days (95% CI 2.9-4.83) for standard PCNL, and 3.66 (95% CI 1.13-6.2) for staged URS. Mini-PCNL and standard PCNL were the most effective treatment options with significant morbidity and length of hospital stay, while RIRS was the safest management option with acceptable SFR, low morbidity, and short hospital stay.

Comparing Tubeless and Tubed Approaches in Percutaneous Nephrolithotomy for Moderate Renal Calculi: Outcomes on Safety, Efficacy, Pain Management, Recovery Time, and Cost-Effectiveness

Introduction This study focuses on investigating the effect of routine nephrostomy tube placement in patients with moderate renal calculi of size 2.5 cm or less who undergo uncomplicated percutaneous nephrolithotomy (PCNL) procedures. Previous studies have not specified whether only uncomplicated cases were included in the analysis, which may affect the results. This study aims to provide a clearer understanding of the effect of routine nephrostomy tube placement on blood loss in a more homogeneous patient population. Materials and methods A prospective randomized controlled trial (RCT) was conducted at our department over 18 months, dividing 60 patients with a single renal or upper ureteric calculus of size ≤2.5 cm into two groups: 30 patients in each group (group 1: tubed PCNL, group 2: tubeless PCNL). The primary outcome was the drop in perioperative hemoglobin level and the number of packed cell transfusions necessary. The secondary outcome included the mean pain score, analgesic requirement, length of hospital stay, time to return to normal activities, and the total cost of the procedure. Results The two groups were comparable in age, gender, comorbidities, and stone size. The postoperative hemoglobin level was significantly lower in the tubeless PCNL group (9.56 ± 2.13 gm/dL) compared to the tube PCNL group (11.32 ± 2.35 gm/dL) (p = 0.0037), and two patients in the tubeless group required blood transfusion. The duration of surgery, pain scores, and analgesic requirement were comparable between the two groups. The total procedure cost was significantly lower in the tubeless group (p = 0.0019), and the duration of hospital stay and time to return to daily activities were significantly shorter in the tubeless group (p < 0.0001). Conclusions Tubeless PCNL is a safe and effective alternative to conventional tube PCNL, with the advantages of shorter hospital stay, faster recovery, and lower procedure costs. Tube PCNL is associated with less blood loss and the need for transfusions. Patient preferences and bleeding risk should be considered when choosing between the two procedures.

A randomized controlled study of ureteral stent extraction string on patient's quality of life and stent-related complications after percutaneous nephrolithotomy in the prone position

To demonstrate the Tianjin Institute of Urology (TJIU) technique to place and remove the ureteral stent with extraction string after percutaneous nephrolithotomy (PCNL). Additionally, we aim to compare the pain experienced during stent removal, quality of life during stent retention, and stent-related complications between patients with and without extraction string. 65 patients were included in the final analysis in the string group constructed by the TJIU technique and 66 patients in the conventional double-J ureteral stent (non-string) group. All patients underwent the surgery in a prone position under general anesthesia. They completed the Ureteral Stent Symptom Questionnaire (USSQ) on postoperative days (POD) 7, as well as before their ureteral stent was removed. The visual analogue scale (VAS) pain score (0-10) was completed immediately after the removal of the ureteral stent. Moreover, a specialized person was responsible for recording stent-related complications. All patients completed the USSQ on POD 7, and we did not find a difference in scores in each field. However, there was a significant difference in the "sex" domain before removing the ureteral stent (4.34 vs 3.23; p = 0.01). Notably, the use of extraction string after PCNL could decrease the pain associated with stent removal significantly (mean VAS scores 1.45 vs 2.76; p < 0.01). Extraction string did not increase the incidence of stent-related complications. We concluded that placing a ureteral stent with an extraction string after PCNL reduces the pain of ureteral stent removal without increasing complications such as accidental removal of the stent, febrile urinary tract infection (UTI).

Risk Factors for Intra-operative Bleeding in Percutaneous Nephrolithotomy in an Academic Center: A Retrospective Study

Background

Percutaneous nephrolithotomy (PNL) is the treatment of choice for renal stones as a safe, effective, and minimally invasive method. However, bleeding remains a major concern in the procedure.

Objectives

This study aimed to investigate the risk factors of bleeding in PNL.

Methods

This retrospective descriptive cross-sectional study was conducted in the Urology department of Razi hospital. The data of patients with urinary calculi staghorn type who underwent PNL in a prone position under general anesthesia were recorded. A checklist including patients' demographics, surgical characteristics, and outcomes was filled out for each patient.

Results

The data from 151 complete files were gathered. The mean age of the cases was 47.89 ± 12.41 years. The mean hemoglobin (Hb) drop was 1.92 ± 1.56 mg/dL. At least 1 mg/dL Hb drop was observed in all cases. The highest Hb drop was 3 mg/dL.). There was no significant relationship between stone bulk, age, BMI, GFR, surgery duration, and the number of tracts, and Hb drop during PNL (P > 0.05). But there was a positive correlation between Urinary Tract Infection (UTI) history (P = 0.01) and transfusion (P = 0.0001) and Hb drop during PNL. Also, the history of open kidney surgery (P = 0.031), nephrostomy insertion (P = 0.003), and extracorporeal shock wave lithotripsy therapy (ESWL) (P = 0.041) were correlated with the increased risk of Hb drop.

Conclusions

Urinary tract infection, history of open surgery, nephrostomy implantation, and ESWL were significantly associated with more bleeding in PNL.