JOURNAL OF ENDOUROLOGY Volume 27, Number 3, March 2013 ª Mary Ann Liebert, Inc. Pp. 294–297 DOI: 10.1089/end.2012.0218
Ureteroscopy and Percutaneous Procedures
Supracostal Tubeless Percutaneous Nephrolithotomy: A Retrospective Cohort Study Brian Duty, MD,1 Michael Conlin, MD,2 Matthew Wagner, MD,2 Aaron Bayne, MD,2 Gregory Adams, MD,2 and Eugene Fuchs, MD 2
Abstract
Purpose: To evaluate the safety of tubeless percutaneous nephrolithotomy in patients undergoing supracostal percutaneous renal access. Patients and Methods: Between October 1999 and October 2010, 302 patients underwent percutaneous nephrolithotomy via a supracostal access tract. Two hundred forty-eight (82.1%) patients had a nephrostomy tube placed at the end of the case and 54 (17.9%) did not. The medical records of both cohorts were compared regarding patient demographics (age, sex, body mass index, preoperative creatinine level), operative characteristics (estimated blood loss, length of stay, treatment efficacy), and complication rates (overall, thoracic, hemorrhage necessitating transfusion). Results: Patient demographics did not differ between the tubeless and nephrostomy tube groups. Estimated blood loss was significantly less in the tubeless patients (67 mL vs 123 mL; P = 0.019). The tubeless group had a shorter mean length of stay than the nephrostomy tube group (2.5 vs 3.4 days, P < 0.01). Treatment success was comparable between the two groups (tubeless 81.5% vs nephrostomy tube 77.8%; P = 0.553). Overall complication (P = 0.765) and blood transfusion (P = 0.064) rates were equivalent. Chest complications were higher in the tubeless group (22.2%) compared with the nephrostomy tube patients (10.9%) (P = 0.024). Nevertheless, chest complications necessitating intervention were not different (P = 0.152). Conclusions: Tubeless supracostal percutaneous nephrolithotomy was associated with less intraoperative blood loss and a shorter hospital stay. Although the tubeless group experienced more chest complications overall, the need for intervention was no different among the two cohorts. Tubeless supracostal percutaneous nephrolithotomy appears safe. Introduction
A
percutaneous nephrostomy tube is traditionally placed at the end of the percutaneous nephrolithotomy (PCNL) procedure to tamponade bleeding from the access tract, maximize perioperative collecting system drainage, and maintain access for possible secondary procedures. Despite these potential advantages, multiple prospective comparative series have demonstrated that nephrostomy tubes are a significant source of postoperative pain leading to longer hospital stays and increased opioid requirements.1–5 In 1984, Wickham and associates6 argued that nephrostomy tube placement could be omitted after selected PCNL cases. Initial indications for tubeless PCNL (ureteral stent without nephrostomy tube) included cases with a single access tract, minimal blood loss, no collecting system perforation, and no intention of second-look nephroscopy. Over time,
tubeless PCNL gained use, with multiple studies establishing its safety in uncomplicated cases.7–10 The purpose of this study was to evaluate the safety of tubeless PCNL after cases necessitating supracostal renal access, given that supracostal access has been associated with an increased risk of thoracic complications.11 Patients and Methods This is a retrospective review of our patients undergoing supracostal PCNL, comparing the results of two cohorts: Patients who had a nephrostomy tube placed and those who did not. Between October 1999 and October 2010, we performed PCNLs through a supracostal access tract on 302 patients. Two hundred and forty-eight (82.1%) patients had a nephrostomy tube placed at the end of the case and 54 (17.9%) did not. One of two urologists (EF or MC)
1 Department of Urology, Smith Institute for Urology, Hofstra University, North Shore–Long Island Jewish Health System, New Hyde Park, New York. 2 Division of Urology, Oregon Health Science University, Portland, Oregon.
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SUPRACOSTAL TUBELESS PERCUTANEOUS NEPHROLITHOTOMY acquired percutaneous access and performed the PCNL in every case as previously reported.12 The decision to place a nephrostomy tube at the end of the procedure was at the surgeon’s discretion. Patients in whom a nephrostomy tube was placed had either a Councill-tip catheter (range 18–22F) or a locking loop nephrostomy tube (12F). General indications for tubeless PCNL were a single access tract, minimal bleeding during the case, no evidence of collecting system perforation, and low index of suspicion for residual stone fragments. A portable chest radiograph was obtained, regardless of nephrostomy tube status, in the recovery unit to rule out pneumothorax and hydrothorax. In the nephrostomy tube group, the tube was removed the day after surgery if there was no significant bleeding or retained stone fragments. Patients were discharged home later that day if their pain was controlled. The urethral catheter was removed on the second postoperative day (in the hospital or at home) if the puncture site was dry. In the tubeless group, the urethral catheter was removed the morning after surgery if there was no urine extravasation from the access site. Patients were then discharged home once their pain was controlled with oral agents. The primary end point of the study was the incidence of perioperative complications. Secondary end points included estimated blood loss (EBL), length of stay, and treatment success. Treatment success was defined as no residual stone fragments greater than 3 mm on postoperative CT or plain abdominal radiography. Statistical analyses (t test for continuous data, chi-square test, and Fisher exact test for binomial data) were performed to compare the two cohorts using Stata 11.2 (StataCorp LP, College Station, TX). Results Patient demographics, access characteristics, and perioperative outcomes are summarized in Table 1. There were no differences in sex, age, body mass index, and preoperative creatinine levels between the groups. Two access tracts were used in 21 (8.5%) nephrostomy patients and 3 (5.6%) tubeless patients. The remainder of the patients underwent only one tract dilation. More patients in the tubeless group (38.9%) had undergone a previous PCNL than in the nephrostomy tube cohort (25.4%) (P = 0.045). The mean EBL was 123.1 mL and 67.4 mL in the nephrostomy tube and tubeless groups, respectively (P = 0.019).
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The tubeless group had a shorter mean length of stay than did the nephrostomy tube group (2.5 vs 3.4 days, P < 0.01). There was no difference (P = 0.553) in the treatment success rate between the nephrostomy tube group (77.8%) and the tubeless cohort (81.5%). Perioperative complications are summarized in Table 2. The overall complication rate was 25.8% and 27.8% for the nephrostomy tube and tubeless groups respectively (P = 0.765). Fifteen (6.1%) patients with nephrostomy tubes needed a blood transfusion, while none in the tubeless group were transfused (P = 0.064). Hydrothorax or pneumothorax on postoperative chest radiograph was noted in 27 nephrostomy tube patients (10.9%) and 12 tubeless patients (22.2%) (P = 0.024). Of these, 11 nephrostomy tube (4.4%) and 5 tubeless patients (9.3%) needed intervention (chest tube placement) (P = 0.152). Ancillary procedures were needed in 15.3% of patients with nephrostomy tubes and 13.0% without nephrostomy drainage (P = 0.695). Discussion A nephrostomy tube is traditionally placed at the end of the PCNL procedure in an attempt to minimize complications. Potential benefits of nephrostomy tube drainage are decreased bleeding from the access tract, maximal collecting system drainage, and continued renal access should a secondary procedure be needed. Nephrostomy tubes, however, especially when placed adjacent to a rib, are a significant source of pain. In a prospective randomized study, Desai and associates1 showed that large bore (20F) compared with small bore (9F) nephrostomy drainage is associated with increased postoperative analgesia requirements and prolonged leakage of urine from the access tract after tube removal.1 In a similar study, Pietrow and colleagues5 randomized 30 patients to either a 10F pigtail or 22-F Councill-tip catheter.5 The authors found no difference in blood loss between the groups, but the pigtail cohort reported significantly less pain 6 hours after surgery. In 1984, Wickham and coworkers6 reported 250 cases of PCNL and concluded that in selected cases, leaving a nephrostomy tube could be avoided. Two years later, however, Winfield and associates13 reported two cases of ‘‘marked patient discomfort’’ and prolonged hospitalization from not
Table 1. Patient Demographics, Preoperative and Operative Characteristics
Gender Age (years) Body mass index Preoperative creatinine (mg/dL) Previous nephrolithotomy Stone size (greatest diameter in cm) Number of access tracts One tract Two tracts Estimated blood loss (mL) Length of stay (days) Treatment success rate
Nephrostomy tube group (248 patients)
Tubeless group (54 patients)
134 men 114 women 49.6 30.0 1.11 25.4% 2.9
28 men 26 women 48.7 31.6 1.02 38.9% 2.7
227 patients 21 patients 123.1 3.4 77.8%
51 patients 3 patient 67.4 2.5 81.5%
P value 0.771 0.711 0.233 0.395 0.045 0.442
0.019 < 0.01 0.553
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DUTY ET AL. Table 2. Perioperative Complications and Ancillary Procedures Nephrostomy tube group (248 patients)
Tubeless group (54 patients)
P value
25.8% 6.1% 10.9% 4.4% 15.3%
27.8% 0.0% 22.2% 9.3% 13.0%
0.765 0.064 0.024 0.152 0.659
Overall complication rate Transfusion rate Chest complication rate Chest complications necessitating intervention Ancillary procedures
leaving a nephrostomy tube after single-stage PCNL. Nephrostomy tube drainage after PCNL became standard practice and was not challenged until Bellman and colleagues14 reported 50 patients who underwent tubeless percutaneous renal procedures. They showed a significantly decreased analgesia need and length of stay, quicker return to normal activity, and more than $2000 in cost savings without an increase in the complication rate compared with matched patients with postoperative nephrostomy tube drainage. Subsequent studies established tubeless PCNL as a good option in selected patients.15–17 Tubeless PCNL was initially considered in patients needing only one access tract, with no significant bleeding during the case, no evidence of collecting system perforation, and those who were not suspected of having residual stone fragments needing continued access. Over time, the indications have been expanded to allow tubeless PCNL in the morbidly obese15 and for bilateral stone extraction.16 Totally tubeless PCNL (no nephrostomy tube or ureteral stent) also has been reported.17 Few PCNL studies have evaluated the feasibility of extending tubeless PCNL to include patients undergoing supracostal renal access.18,19 A supracostal approach is needed in most patients to gain upper pole access.20 Upper pole access is often advantageous because entering the collecting system in line with the long axis of the kidney provides excellent visualization of the lower pole, renal pelvis, and proximal ureter. Consequently, patients with upper pole stones, staghorn calculi, and proximal ureteral stones may need supracostal punctures to facilitate optimal treatment results.20 We prefer supracostal access for most of our PCNL cases. Unfortunately, supracostal access has been associated with an increased risk of complications. Munver and coworkers11 compared 202 cases of infracostal PCNL with 98 patients undergoing supracostal access (26 supra-11, 72 supra-12). The overall complication rate for the infracostal group was 4.5% vs 16.3% for the supracostal patients (9.7% supra-12, 34.6% supra-11). The incidence of thoracic complications in the supracostal cohort was 7.1% (1.4% supra-12, 23% supra-11). Shah and colleagues18 published a retrospective study of 72 patients undergoing supracostal tubeless PCNL. The study group was compared with a historical cohort of 72 patients managed with a 28F nephrostomy tube after supracostal PCNL. A 6F double pigtail ureteral stent was used in each of the ‘‘tubeless’’ patients. The authors found no significant difference in the transfusion (three study patients, four control patients) or overall complication rate between the two groups. Thoracic complications were encountered in two tubeless (2.8%) patients and three nephrostomy tube (4.2%) patients. On average, patients without nephrostomy tubes needed less parenteral analgesia (111 mg of tramadol vs 357 mg) and were discharged 19 hours sooner.
In a similar study, Jun-Ou and Lojanapiwat19 compared 43 supracostal tubeless PCNL patients with 52 patients with postoperative nephrostomy tube drainage. They also found no difference in thoracic complications between the tubeless (9.3%) and nephrostomy tube (9.6%) groups. The operative time (tubeless 47.4 minutes; nephrostomy 58.9 minutes), hospital stay (tubeless 3.5 days; nephrostomy 4.8 days), and meperdine requirements (tubeless 37.0 mg; nephrostomy 70.0 mg) were significantly less in the tubeless group. In contrast to these two previous studies, we found the overall incidence of chest complications to be higher in the tubeless (22.2%) group than the nephrostomy tube (10.9%) group. There was no difference in symptomatic chest complications necessitating intervention between the tubeless (9.3%) and nephrostomy tube (4.4%) group, however. The percentages of symptomatic chest complications in our series are comparable with those of the two previously cited studies. Like the two previously published series, our study is limited by being retrospective in nature. Ours is a retrospective cohort study, however, comparing our supracostal tubeless patients with the entire cohort of supracostal PCNL patients with a nephrostomy tube. Given the discrepancy in findings between our review and the two previous studies, a prospective, comparative study with strict inclusion criteria should be considered to conclusively demonstrate the safety and efficacy of supracostal tubeless PCNL. Conclusions Tubeless supracostal PCNL was associated with less intraoperative blood loss and shorter hospital stay. Although the tubeless group experienced more chest complications overall, the need for intervention was no different among the two cohorts. Tubeless supracostal percutaneous nephrolithotomy appears safe. Disclosure Statement No competing financial interests exist. References 1. Desai MR, Kukreja RA, Desai MM, et al. A prospective randomized comparison of type of nephrostomy drainage following percutaneous nephrostolithotomy: Large bore versus small bore versus tubeless. J Urol 2004;172:565–567. 2. Maheshwari PN, Andankar MG, Bansal M. Nephrostomy tube after percutaneous nephrolithotomy: Large-bore or pigtail catheter? J Endourol 2000; 14:735–738. 3. Marcovich R, Jacobson AI, Singh J, et al. No panacea for drainage after percutaneous nephrolithotomy. J Endourol 2004;18:743–747.
SUPRACOSTAL TUBELESS PERCUTANEOUS NEPHROLITHOTOMY 4. Liatsikos EN, Hom D, Dinlenc CZ, et al. Tail stent versus reentry tube: A randomized comparison after percutaneous stone extraction. Urology 2002;59:15–19. 5. Pietrow PK, Auge BK, Lallas CD, et al. Pain after percutaneous nephrolithotomy: Impact of nephrostomy tube size. J Endourol 2003;17:411–414. 6. Wickham JE, Miller RA, Kellett MJ, Payne SR. Percutaneous nephrolithotomy: One stage or two? Br J Urol 1984;56:582– 585. 7. Lojanapiwat B, Soonthornphan S, Wudhikarn S. Tubeless percutaneous nephrolithotomy in selected patients. J Endourol 2001;15:711–713. 8. Limb J, Bellman GC. Tubeless percutaneous renal surgery: Review of first 112 patients. Urology 2002;59:527–531. 9. Shah HN, Kausik VB, Hegde SS, et al. Tubeless percutaneous nephrolithotomy: A prospective feasibility study and review of previous reports. Br J Urol 2005;96:879–883. 10. Abou-Elela A, Emran A, Mohsen MA, et al. Safety and efficacy of tubeless percutaneous renal surgery. J Endourol 2007;21:977–984. 11. Munver R, Delvecchio FC, Newman GE, Preminger GM. Critical analysis of supracostal access for percutaneous renal surgery. J Urol 2001;166:1242–1246. 12. Lashley DB, Fuchs EF. Urologist-acquired renal access for percutaneous renal surgery. Urology 1998;51:927–931. 13. Winfield HN, Weyman P, Clayman RV. Percutaneous nephrostolithotomy: Complications of premature nephrostomy tube removal. J Urol 1986;136:77–79. 14. Bellman GC, Davidoff R, Candela J, et al. Tubeless percutaneous renal surgery. J Urol 1997;157:1578–1582. 15. Yang RM, Bellman GC. Tubeless percutaneous renal surgery in obese patients. Urology 2004;63:1036–1041.
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16. Shah HN, Kausik VB, Hedge SS, et al. Safety and efficacy of bilateral simultaneous tubeless percutaneous nephrolithotomy. Urology 2005;66:500–504. 17. Aghamir SM, Hosseini SR, Gooran S. Totally tubeless percutaneous nephrolithotomy. J Endourol 2004;18:647–648. 18. Shah HN, Hedge SS, Shah JN, Bansal MB. Safety and efficacy of supracostal access in tubeless percutaneous nephrolithotomy. J Endourol 2006;20:1016–1021. 19. Jun-Ou J, Lojanapiwat B. Supracostal access: Does it affect tubeless percutaneous nephrolithotomy efficacy and safety? Int Braz J Urol 2010;36:171–176. 20. Gupta R, Kumar A, Kapoor KR, et al. Prospective evaluation of safety and efficacy of the supracostal approach for percutaneous nephrolithotomy. BJU Int 2002;90:809–813.
Address correspondence to: Brian Duty, MD The Arthur Smith Institute for Urology Hofstra University North Shore–Long Island Jewish Health System 450 Lakeville Road New Hyde Park, NY 11042 E-mail:
[email protected]
Abbreviations Used CT ¼ computed tomography EBL ¼ estimated blood loss PCNL ¼ percutaneous nephrolithotomy
