Abstract
F
For large stones, PCNL currently is the recommended surgical approach with high stone-free rates at least in expert hands. PCNL, however, is associated with well-recognized shortcomings and complications and the standard procedure has been to leave a percutaneous nephrostomy catheter in place at the end of the procedure. During recent years, PCNL has been modified with use of smaller and smaller instruments (mini-PCNL, ultramini PCNL, and micro-PCNL) and so has the principles for draining the collecting system after stone removal.
In the present article, the authors have carried out a review and meta-analysis of the literature on standard PCNL and modified tubeless PCNL with internal or external ureteral stenting. 1
The role of drainage after PCNL is to observe and take care of bleedings, avoid ureteral obstruction by debris, stones, and stone fragments, and to cope with an edematous ureteropelvic junction (UPJ). Moreover, the standard nephrostomy catheter might be important for reducing bleeding by compressing vessels in the renal parenchyma by tamponade.
Although totally tubeless PCNL was described many years ago, it is obvious that this approach, for various reasons, has not been commonly accepted or only slowly implemented. Accordingly, tubeless PCNL has been combined with either internal or external stenting (modified tubeless PCNL). The conclusion from the present report is that an external stent should be preferred because stent-related symptoms thereby were avoided, resulting in better quality of life for patients. It should be observed, however, that whereas the external stents were removed within approximately 2 days, internal stents were left in place for roughly 2–4 weeks. The other advantage with the externalized stent is that there is easy percutaneous access if re-entry will become necessary.
Needless to say, tubeless PCNL should be considered only after uncomplicated PCNL with no or marginal bleeding and when the kidney is essentially stone free. Accordingly, the key to effective outcome with tubeless PCNL is appropriate patient selection. In view of the short postoperative time that obviously was required for external stenting, the question that can be raised is, in these selected patients, is it at all necessary with internal or external stenting or would it be equally effective to apply a totally tubeless procedure instead of the modified tubeless procedure? So far it seems obvious that there are patients who need some form of drainage. But with a simplified approach, patient suffering, length of hospital stay, and treatment costs can be significantly reduced. Inasmuch as hospital stay still is considered necessary, another alternative would be to leave a standard ureteral catheter fixed to a bladder catheter that can be easily removed on the first or second postoperative day. 2,3
Sealing has been discussed to control bleeding from the percutaneous tract in the absence of a nephrostomy catheter, and despite contradictory results with this technique, it is possible that improved sealing methods can add value to the tubeless approach.
When reading the literature of draining procedures, it is my personal opinion that a less confusing terminology would be of value, for instance, standard percutaneous nephrostomy, tubeless/stented PCNL, and tubeless PCNL, the latter designation replacing “totally tubeless PCNL.”
Knoll and coworkers 3 recently summarized instructions on how to carry out PCNL and concluded that “PCNL is here to stay.” That is absolutely true at least until any dramatic improvement can be discerned in noninvasive stone disintegration. To make PCNL increasingly attractive to patients by less suffering, short hospital stay, reduced cost, and maintained safety, gentle but efficient methods for drainage are indeed desirable.