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Abstract
Percutaneous drainage through a nephrostomy tube After completion of PNL is usually advocated. The nephrostomy tube serves several purposes as tamponade bleeding from the tract, allow the renal puncture to heal, allow proper drainage of urine, and as an access to the collecting system if a secondary PNL is required.
Bellman and associates (1997) have suggested that to minimize PNL morbidity, no nephrostomy tube may be placed after PNL in selected patients (Tubeless PNL).
Patients with significant residual stone burden, multiples accesses, perforation of the collecting system, or significant bleeding were not candidates for tubeless PNL.
Topical hemostatic agents including: oxidized regenerated cellulose as (Surgicel), fibrin sealant as (Tissel VH Kit & Hemaseel APR), gelatin matrix as (FloSeal), and polyethylene glycol as (CoSeal) have been found to be effective and safe for controlling surface bleeding during trauma related to urological procedures including pelvic operations as cystectomy and after nephrectomy and can be used to stop bleeding from nephrostomy tract after tubeless PNL.
We performed a prospective randomized clinical trial at the Urology Department, Suez Canal University Hospital, between September 2007 to November 2008 to compare the outcome of tubeless PNL (with and without hemostatic agent) with the conventional PNL. Patients who underwent PNL for their stone kidney were fulfilled the inclusion criteria including adult patient aged 20-60 years old with lower, middle calyceal or pelvic renal stone with normal renal anatomy measuring 3 cm or less in the largest diameter located at one tract access without other renal or ureteric pathology.
Patients was randomized into three equal groups, First group for the Conventional PNL, Second group for the tubeless PNL and the Third group for the tubeless PNL with a piece of absorbable oxidized regenerated cellulose 2ҳ2 inches which was fixed in nephrostomy tract inside the renal parenchyma outside the pelvi-calyceal system.
In our results, the postoperative visual analogue pain scale, demonstrated that the tubeless PNL Mean ± SD (4.08 ± 1.38) was lower than conventional PNL Mean ± SD (7.25 ± 1.06) with a significant statistical difference between them. Post operative analgesic requirement using Declofenac sodium ampoules (in mg per day), demonstrated that the tubeless PNL Mean ± SD (87.5 ± 43.3) was less than conventional PNL Mean ± SD (150 ± 31.98).
Postoperative mean of hemoglobin reduction in conventional group was (1.64 ± 0.92) g/dl compared to tubeless group (1 ± 0.76) g/dl without significant statistical difference between them. Comparing patients with tubeless PNL (group 2) and those underwent tubeless PNL with surgicel (group 3) regarding mean postoperative hemoglobin reduction in our study, revealed no statistical significant difference between the patients included in each group, and thus surgicel made no difference regarding postoperative bleeding from the nephrostomy tract.
Considering postoperative fever in our study, the overall frequency was 16.6% (6 cases out of 36).
Postoperative perinephric collection was detected only in 1 case in group 2 compared to 2 cases in group 3 without significant statistical difference between them. Postoperative urinary leakage from the nephrostomy tract was detected in 4 cases out of 12 patients in our study in conventional group which stopped spontaneously within 48 hours postoperative compared to none in both tubeless PNL and tubeless PNL with surgicel groups. The tubeless PNL is less than conventional PNL regarding postoperative urinary leakage and surgicel made no difference regarding postoperative urinary leakage.
Mean post operative hospital stay (in days) in our study, demonstrated that the conventional PNL was the longest in postoperative hospital stay (4.83 ± 2.12) compared to the tubeless PNL (3.17 ± 2.21) with significant statistical difference between them.
Conclusions
1- Tubeless PNL is a safe procedure in patients with stone burden 3 cm or less located at one tract access with normal renal anatomy without intraoperative significant bleeding, perforation of the pelvicalyceal system, or significant residual stone needing second look PNL.
2- Tubeless PNL has less postoperative pain scale, analgesic requirement, and shorter hospital stay than conventional PNL without significant reduction of postoperative hemoglobin or significant postoperative urinary leakage from the nephrostomy tract and perinephric collection.
3- Surgicel piece after tubeless PNL make no difference regarding postoperative bleeding and urinary leakage from the nephrostomy tract.