Ambulatory Percutaneous Nephrolithotomy in a Free-Standing Surgery Center: An Analysis of 500 Consecutive Cases

Advancements in Performance of Percutaneous Nephrolithotomy in Ambulatory Surgery Centers: Outcomes and Lessons From 1250+ Cases

OBJECTIVE

To evaluate the safety and efficacy of routine ambulatory percutaneous nephrolithotomy (PCNL) in a freestanding ambulatory surgical center.

METHODS

Patients were treated between 2015 and 2022 by one of three experienced endourologists in Maryland. The surgery center is free-standing, with the nearest hospital approximately 10 minutes away. Patient characteristics and surgical datapoints, including need for transfer, were gathered prospectively at the time of surgery. Subset analyses were performed in patients with staghorn calculi or elevated body mass index, as they represent higher-risk populations.

RESULTS

A total of 1267 patients underwent ambulatory PCNL with a median stone diameter of 32 mm. The average recovery time was 87 minutes, with 1.7% of patients requiring transfer to the hospital, generally for postoperative hypotension or inadequate pain control. 166 patients with body mass index >40 were safely treated, with no significant difference in transfer rate (P = .5). 2.8% of patients had a complication, with the majority being Clavien-Dindo grade I or II. 88 patients with staghorn calculi were treated, with a 6% transfer rate. Staghorn calculi were the only factor found on multivariable analysis to be a significant predictor of transfer (OR 3.56 (1.17-10.82) P < .05).

CONCLUSION

Ambulatory PCNL may safely be performed in a surgery center in most patients. These outcomes reflect the real-world experience of high-volume surgeons and demonstrate a multiyear paradigm shift in PCNL from an inpatient procedure to an outpatient procedure in a surgery center.

Percutaneous nephrolithotomy in supine position with less than 24-hour hospital stay; a single-center experience

Objectives

To report our initial experience of day care percutaneous nephrolithotomy (PCNL) with early hospital discharge within less than 24 hours of the procedure.

Patients and Methods

The files of patients treated with PCNL between 1st January 2020 till 31st December 2022 were retrospectively reviewed. Day care PCNL was defined as the discharge of patients either on the same day or within 24 hours after surgery. Patient age, ASA score, body mass index, stone diameter, laterality, stone burden, Hounsfield unit, and Guy's score were analyzed. Operative time, size of the access tract, method of lithotripsy, estimated blood loss, and length of hospital stay were also recorded. Postoperative complications were stratified according to the Dindo-Clavien classification. The primary outcome was to evaluate the feasibility and safety of early discharge within 24 hours after PCNL compared to the in-patients who were kept in hospital for at least 2 days after surgery.

Results

A total of 85 patients underwent PCNL at our center of whom 36 patients were discharged within 24 hours (day care PCNL) of the procedure and 49 patients were kept for at least 2 days (in-patient PCNL). In the day care group, median stone burden was 465 mm2 (360-980) and 18 patients (50%) had Guy's stone score ≥ III. The median tract size was 24 (13-30) and endoscopic combined intrarenal surgery (ECIRS) was performed in 7 cases in the day care group. Tubeless PCNL was carried out in 88.8% of the day care surgery group compared to 37.5% in the in-patient group (p < 0.0001). The postoperative complication rate was comparable between both groups (13.8% vs 22.4% for day care vs in-patient group, respectively, p = 0.08).

Conclusions

Day care PCNL is feasible and safe for selected patients including those having large stone burden without increasing the risk of complications or readmission rate.

Initial results of endourological treatment of renoureteral lithiasis by means of flexible ureteroscopy and percutaneous surgery in an outpatient procedure in a tertiary care center

OBJECTIVE

Urinary lithiasis is a prevalent disease with a high socioeconomic impact, where endourological surgery has shown excellent results with minimal complications. For its part, outpatient surgery is an efficient, safe and quality care model. We present our experience in the outpatient endourological treatment of lithiasis and a review of the main series.

MATERIAL AND METHODS

Prospective analysis of 85 flexible or percutaneous procedures for the treatment of lithiasis, carried out in our center between January 2021 and April 2022. The main objective was to analyze the rate of unplanned admission and the success and incidence of complications as secondary objectives. The patients were selected following the inclusion criteria of the care process.

RESULTS

The mean age was 56 ± 14 years. Urine culture was positive in 13.9% of the patients, 38% had a pre-surgical double-J catheter. Median stone surface was 55 mm 2 (961 ± 323 Hounsfield Units). 73 flexible and 12 percutaneous procedures were performed. 8 patients required immediate unplanned admission and another 2 during the first month. 94% were stone-free at the third month. No intraoperative complications were detected, although 16.5% of the patients presented some type of postoperative complication.

CONCLUSION

In our experience, with a strict selection of patients and following a care process with multidisciplinary participation, endourological procedures are feasible and safe in the outpatient setting. Periodic monitoring of the results is essential for the sake of a constant improvement of the process.

The Safety and Efficacy of Endoscopic Combined Intrarenal Surgery (ECIRS) versus Percutaneous Nephrolithotomy (PCNL): A Systematic Review and Meta-Analysis

Purpose

Our aim is to evaluate the safety and efficacy of endoscopic combined intrarenal surgery compared to percutaneous nephrolithotomy to guide practitioners and inform guidelines.

Materials and Methods

A detailed database search was performed in PubMed, OVID, Scopus, and Web of Science in October 2021 to identify articles pertaining to ECIRS published between 2001 and 2021.

Results

Four nonrandomized comparative studies and one RCT were identified, yielding five studies with a total of 546 patients (ECIRS/mini-ECIRS, n = 277; PCNL/mini-PCNL, n = 269). Subjects in these five studies met the predefined inclusion criteria established by two reviewers (J.E.A. and R.L.S.) and were therefore eligible for analysis. The results demonstrated that ECIRS was associated with a higher SFR (OR: 4.20; 95% CI: 2.79, 6.33; p < 0.00001), fewer complications (OR: 0.63; 95% CI: 0.41, 0.97; p=0.04), and a shorter hospital stay (WMD: −1.27; 95% CI: −1.55, −0.98; p < 0.00001) when compared to PCNL. There were no statistically significant differences in blood transfusions (OR: 0.45; 95% CI: 0.12, 1.68; p=0.24), operative time (SMD: −1.05; 95% CI: −2.42, 0.31; p=0.13), or blood loss (SMD: −1.10; 95% CI: −2.46, 0.26; p=0.11) between ECIRS and PCNL.

Conclusions

ECIRS may be a more suitable approach for the surgical management of large and complex kidney stones currently indicating PCNL due to its superior efficacy with comparable surgical time and complication rate, though it is thought that a lack of resources and properly trained personnel may preclude ECIRS from becoming the standard. It is our impression that ECIRS may become the preferred technique in the endourologic community corresponding to the evolutionary sequence of percutaneous stone surgery.

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

We aimed to perform a systematic review of randomized trials to summarize the evidence on the safety and stone-free rate after Tubeless percutaneous nephrolithotomy (PCNL) (ureteral stent/catheter, no nephrostomy) compared to Standard PCNL (nephrostomy, with/without ureteral stent/catheter) to evaluate if the tubeless approach is better. The inverse variance of the mean difference with a random effect, 95% Confidence Interval (CI), and p values was used for continuous variables. Categorical variables were assessed using Cochran-Mantel-Haenszel method with the random effect model, and reported as Risk Ratio (RR), 95% CI, and p values. Statistical significance was set at p < 0.05 and a 95% CI. 26 studies were included. Mean operative time was significantly shorter in the Tubeless group (MD-5.18 min, 95% CI - 6.56, - 3.80, p < 0.00001). Mean postoperative length of stay was also significantly shorter in the Tubeless group (MD-1.10 day, 95% CI - 1.48, - 0.71, p < 0.00001). Incidence of blood transfusion, angioembolization for bleeding control, pain score at the first postoperative day, the number of patients requiring postoperative pain medication, fever, urinary infections, sepsis, perirenal fluid collection, pleural breach, hospital readmission, and SFR did not differ between the two groups. Incidence of postoperative urinary fistula was significantly lower in the Tubeless group (RR 0.18, 95% CI 0.07, 0.47, p = 0.0005). This systematic review shows that tubeless PCNL can be safely performed and the standout benefits are shorter operative time and hospital stay, and a lower rate of postoperative urinary fistula.