Abstract
We read with interest the article by Gupta et al., titled “Is Outpatient Totally Tubeless Standard Percutaneous Nephrolithotomy Safe and Efficacious?,” 1 and we would like to sincerely congratulate for presenting such an innovative and clinically relevant study. The concept of same-day discharge totally tubeless percutaneous nephrolithotomy (tt-PCNL) represents a remarkable step forward in the evolution of minimally invasive stone procedure.
These results suggest that same-day tt-PCNL can be a safe and effective approach in appropriately selected patients, with comparable complication rates and stone-free outcomes. This contributes significantly to the current literature and opens the door to broader discussions on how to enhance perioperative efficiency and patient satisfaction. A safe discharge the same day of the procedure would also be beneficial, particularly in the post-COVID era, 2 where many hospitals in some countries, following necessary departmental reorganizations, 3 have accumulated significant stones surgical waiting lists that remain largely unresolved and difficult to recover.
However, we would like to express a note of caution regarding the generalizability of their findings. As pointed out by the authors, the sample size was relatively limited, with only 53 patients in the tt-PCNL group. It becomes statistically challenging to draw definitive conclusions about the absence of rare but clinically important adverse events such as transfusions, sepsis, or significant delayed complications. In fact, these major events and complications, while infrequent, are critical in the context of PCNL and often occur in fewer than 1%–2% of cases. 4 A larger cohort would be necessary to reliably assess the safety of same-day discharge.
Moreover, while authors’ results are promising, the feasibility of the same-day discharge tt-PCNL may vary greatly depending on the health care setting and patients/population expectations. For instance, in countries with public health systems, such as Italy or Mediterranean countries, patients may be less inclined to accept early discharge after a major urological procedure. Concerns about legal complaints, especially in environments where litigation, including criminal proceedings, is relatively frequent, may also limit the willingness of surgeons to adopt this strategy. These cultural and systemic variables are crucial and to be taken into account when considering this strategy.
To improve both the safety and acceptability of same-day discharge protocols, we believe the establishment of structured postdischarge monitoring systems could be mandatory. Home-based follow-up programs, with nurse visits, telemedicine, dedicated phone triage, or through a dedicated urology app, 5 may provide reassurance to patients and allow for early detection of potential complications.