Editor's Commentary - Systematic review and meta-analysis of nephrostomy placement versus tubeless percutaneous nephrolithotomy

BERKELEY, CA (UroToday.com) - Like car tires, therapeutic nephrostomy tracts are going “tubeless” – in both cases the change is more efficient and less costly. In this thoroughgoing meta-analysis, the authors identified 10 randomized control trials of tube vs. tubeless percutaneous nephrostolithotomy. Of note, only two of the studies entered more than 25 patients in each group (one with 45 patients and one with 101 patients). Nonetheless, it was clear that in each study, the tubeless approach resulted in less use of analgesics (up to a 10 fold difference) and shorter hospital stay (mean decrease of 1.35 days). Of note, there was no difference in stone free rates, operative time, blood transfusion, decrease in hemoglobin, or postoperative fever. Nearly 30 years after Mr. John Wickham of the Institute of Urology in London, espoused a tubeless approach, it would now appear that he was quite correct and this is the way to go in the absence of significant tract bleeding or suspected residual stone.1

The questions that remain are twofold:

  1. Is it necessary to place an indwelling ureteral stent at the end of the procedure? Two of the ten studies did not and their results did not appear to be adversely affected; of note these two studies randomized only 50 and 90 patients and thus were underpowered to detect potentially clinically significant differences in the 10-20% range. Still, the elimination of an indwelling stent would decrease the cost of the procedure and would likely decrease postoperative discomfort

  2. How best to leave the nephrostomy tract? In this regard there are innumerable methods using a variety of sealants or hemostatic agents, electrocautery, suturing, or nothing. Recently, at the University of California Irvine we did conduct a randomized study of Floseal vs. nephrostomy tube vs. suturing. The last provided results equal to the other two modalities and was the most cost effective.2


  1. Wickham, JEA, Miller, RA, Kellett, MJ. Percutaneous nephrolithotomy: one stage or two? Brit. J. Urol, 56: 582, 1984.
  2. Li, R., Louie, M. K., Lee, H. J., et al.: Prospective randomized trial of Floseal tubeless exit vs. fascial stitch vs. Cope loop nephrostomy following percutaneous nephrolithotripsy (J. Urology: submitted 2010)

Borges CF, Fregonesi A, Silva DC, Sasse AD

J Endourol. 2010 Oct 19. (Epub ahead of print)

PubMed Abstract
PMID: 20958141

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