Editorial Comment for Abbott et al.

Although not all have fully embraced the use of tubeless percutaneous nephrolithotomy (PCNL), there is ample data suggesting advantages. Specifically, two meta-analyses demonstrate benefits to both decreased length of stay and decreased analgesic requirements. ^1,2 The latter outcome is still a subject of debate, because the current “tubeless” PCNL often implies the use of a ureteral stent. It is arguable that the narcotic requirement is an inaccurate surrogate for stent morbidity. Moreover, the use of the ureteral stent necessitates a cystoscopy stent removal procedure in the office (unless string is left emanating from the flank). Nevertheless, these meta-analyses fortunately demonstrate tubeless PCNL has no increased risk of perioperative bleeding, which is the very reason that nephrostomy tubes are often placed.

So how should the renal tract be handled after completion of the case? Abbott and associates detail a very simple and potentially economic method using gel foam and thrombin. I like the idea of using gel foam over passive gelatin granules (Surgifoam or FloSeal), because the former maintains its integrity and expands 200% to 400% and up to 40 times its weight, according to the authors. Fibrin sealants (Tisseel, Evicel, or Vitagel) seem even less ideal given that they are products that form a cap and potentially are at risk for dislodgment or persistence.

The caveat to this technique is to carefully select patients and defer to a more conservative approach (nephrostomy tube) if necessary. The authors provide their inclusion criteria, which serves as a potential guide for selecting our patients in practice: Smaller stones, minimal intraoperative bleeding, no prolonged operations, and no indication for ancillary procedures.