The Era of Tubeless Percutaneous Nephrolithotomy


Objective: To prescribe our experience in performing tubeless percutaneous nephrolithotomy and how we diagnose its indication, safety, and effectiveness.

Methods: Two hundred and fifty-three patients with renal stones were enrolled for a tubeless percutaneous nephrolithotomy with an externalized ureteric catheter. Their ages ranged between 4 to 80 years old, and of the sample, 168 were male and 85 were female. The stones ranged from 15 to 80 mm in size and were located in different areas of the pelvicalceal system. The majority of the procedures were conducted in the prone position while 24 cases were supine. The majority of the patients were treated with a single puncture, 20 patients were treated with double punctures, and 2 patients required 3 punctures. Haemostatic substances were used in only 50 of the patients, with no significant differences when compared to 50 who were treated without. In addition, 40 patients had a history of previous ipsilateral renal surgery, 20 had renal impairments, and 15 had a solitary kidney.

Results: The mean operative time was 44.34 minutes, the mean stent time was 1.1 days, and the mean hospital stay was 1.6 days. The mean drop in Hb levels was 1.67gm/dl, with 3.95% of the patients needing blood transfusions and 12.65% needing postoperative analgesia. The stone-free rate was 91.76% while the overall success rate was 97.25%. Complications were encountered in 7.9% of the patients, most of which were minor and were managed conservatively. One patient suffered from a colonic injury and 2 patients suffered from hydrothorax.

Conclusion: In the era of tubeless percutaneous nephrolithotomy, nephrostomy tube insertion should only be used for large residuals that need a second look. Tubeless percutaneous nephrolithotomy should be extended to include large stones, multiple numbers, multiple punctures, prone or supine positions, sub- or supracostal approaches, recurrent cases, solitary kidneys, renal impairment, extended time, and bilateral simultaneous cases. It’s safe and effective, and it decreases postoperative pain, discomfort, the need for analgesia, and the length of hospital stay.

Tawfik H Al-Ba’adani, Khaled Telha, Shihab Al-Gormozi, Khalid Al-Badwey, Gamil Al-Alimi, Mohammed Alwan, Nabil Al-Gonaid, Ibraheim H El-Nono

Submitted April 2, 2012 - Accepted for Publication May 1, 2012

KEYWORDS: Percutaneous, nephrolithotomy, tubeless, ureteric, catheter

CORRESPONDENCE: Tawfik H Al-Ba’adani, MD, Urology Department, Urology and Nephrology Center, Al-Thawra Modern General/Teaching Hospital, Medical College-Sana’a University, Sana’a, Yemen ().

CITATION: UroToday Int J. 2012 June;5(3):art 17.



Goodwin’s description of percutaneous nephrostomy (PCN) in 1955 and Fernstrom and Johansson’s first publication of percutaneous nephrolithotomy (PNL) in 1976 are considered some of the most important milestones in the history of percutaneous renal surgery [1,2]. Wikchamen conducted trials omitting the placement of a nephrostomy tube in 100 patients as early as 1984 [3]. However, premature nephrostomy tube removal by Winfield, which led to more complications such as serious hemorrhaging, marked urinary extravasation necessitating transfusion, internal stenting, and prolonged hospitalization made urologists adherent to the policy of nephrostomy drainage [4]. Bellman and associates challenged the requirement for the routine placement of a nephrostomy tube after PNL and were the first to use the term tubeless PNL [5]. Since then there have been increased reports of tubeless PNL utilization [6,7,8,9,10,11].

In this study we present our experience with tubeless PNL, with very limited exclusion criteria as part of the new era of percutaneous renal surgery.


Two hundred and fifty-three patients (255 renal units) with renal stones of different sizes, at different locations, were enrolled and underwent tubeless percutaneous nephrolithotomy (TPNL) in the Urology and Nephrology Center in the period between July 2004 and September 2010. Stone size was determined by measuring the greatest dimension of the stone in plain film. The demographic data of the patients and stone characteristics are shown in Table 1. In the majority of the cases, the procedure was done under general anesthesia as 1 stage TPNL in the prone position; in some cases the supine position was used. Operative time was measured from the moment of puncturing the calyx up until the suturing of the puncture site. The time limit was not considered exclusive criteria. Cases of multiple punctures, unilateral or bilateral, solitary kidney, renal impairment, bleeding to any degree, or pelvicalyceal system injury were not excluded from the study as the bleeding was stopped by deeply suturing the wound (Figure 1, Figure 2, Figure 3) or using a hemostat, in addition to the normal hemostatic function of the body.

Simultaneous bilateral TPNL was performed in 2 patients with 2 punctures in one side and 1 in another side (Figure 4). The procedure was done via the insertion of a 6 Fr ureteric catheter in which opacification of the pelvicalyceal system was performed, as well as puncturing the kidney by the urologist under fluoroscopy guidance. Classic dilatation of the tract using Alkenes serial metallic dilators was performed in the first 100 cases. In the remaining cases, acute dilatation using a facial scalpel then an Amplatz 30 Fr dilator over a central rod was used, followed by the insertion of a 34 Fr Amplatz sheath. A 24 Fr working nephroscope was used, followed by stone disintegration using a pneumatic lithoclast (Swiss LithoClast EMS). Finally, the fragments were removed with 3-jaw, grasping forceps.

After removing all the stone fragments, careful endoscopic and fluoroscopic inspection of the system to check for any significant residual fragments was performed. The nephroscope was then removed, and the sheath was withdrawn to the periphery of the calyx. A retrograde pelvicalycography was performed to ascertain the integrity of the collecting system, and the sheath was withdrawn after applying SURGICEL, Spongstan, or GELFOAM, which was inserted in a sample of 50 patients. In the rest of the study group, only the deep stitch technique was completed, which stopped the bleeding at once. The patients were left with an inserted ureteric catheter only. Hemoglobin level was measured after 12 hours, and on the next day, all patients were evaluated by plain X-ray and an abdominal ultrasound. If they were found to be stone free, with no perinephric collection or hematoma, and their urine was clear, the externalized ureteric and Foley catheters were removed and the patients were discharged. Details of the treatment procedures are provided in Table 2.


The mean operative time was 44.34 minutes, the stent time was about 1.1 days, and the mean hospital stay was 1.6 days. The mean drop in hemoglobin levels was 1.67 gm/dl (range 0.3 to 5 gm/dl) with a blood transfusion rate of 3.95%. The majority of the patients needed a single puncture, but some needed double or triple punctures. Only 12.65% of the sample needed analgesia. A stone-free rate of 91.76% and overall success of 97.25% were achieved (Table 2).

Previous ipsilateral renal surgery was noted in 40 patients, solitary kidney in 15 patients, and renal impairment (creatinine 1.5 to 2.5 mg/dl) in 20 patients. Hemostatic substances were used in 50 patients (first group), and when compared to another 50 patients (second group) where it was not used we found that the Hb drop in both groups was 0.3 to 4 gm (mean 1.2 gm) and 0.3 to 5 gm (mean 1.7 gm), respectively, with no significant difference, as the p value was 0.455.

No intraoperative complications were observed. Postoperative complications were recorded in 20 patients (7.9%) (Table 3). The majority of them were minor, in the form of a perirenal collection of different amounts, urine leakage, high-grade fever, and postoperative bleeding, which was managed conservatively or by insertion of a double-J stent. Major complications came in the form of 1 colonic injury in the supine position, managed conservatively, and hydrothorax in 2 patients, 1 managed conservatively and the other by insertion of a chest tube.


Naturally, the greatest work begins small with insignificant progress but is then enlarged by the hard work of scientists. This is truly what happened in Bellman’s case in 1997 when he began to omit the insertion of the nephrostomy tube at the end of PNL and left only a ureteric stent in the form of the double-J stent [5]. Initially the condition was limited and restricted to a small stone burden no greater than a 25 mm, single puncture, intact pelvicalyceal system with non-considerable bleeding and stone-free results without the need for a second look [11,12,13,14,15]. After continuous work and observation, researchers noted no serious complications with this idea. On the contrary, they observed the advantages of decreased postoperative pain and discomfort, the need for analgesia, and a decrease in hospital stay [6,7,8,10] and cost [16]. However, the drawback was the need for re-cystoscopy, which is more invasive and may need general anesthesia. There are also irritative symptoms and bleeding caused by the double-J stent [5,17]. An externalized ureteric catheter that can replace the double-J stent and stay for 12 to 24 hours solved the previous problem [7,10,18], which made the situation more acceptable. Then the era of TPNL won more support and became widely known, and the inclusion criteria became more and more unlimited with the introduction of patients with previous ipsilateral renal surgery [19], solitary kidney [20], renal impairment, multiple accesses, controllable bleeding, supracostal approaches, and the option of supine or prone position. Time is also no longer a limiting factor [6,20,21,22]. Trials using hemostatic substances like a gelatin matrix, SURGICEL, a sponge stain, or the use of coagulant on bleeding site were conducted to control bleeding, but most of the studies proved insignificant and lack benefit if the tract is without these auxiliary procedures [23,24]. Finally, limited studies with a limited number of patients started what is known as tubeless and stentless PNL, with extended restricted criteria such as being stone free or a 2 cm stone or less without any residual stones, which could not be guaranteed with more or less acceptable manipulation [25,26,27]. Fear of postoperative pain, obstruction, leakage because of the passing of small fragments, or clots should be considered, and more studies are needed.

From this study, results show that it is the time for the new era of tubeless PNL. It provides more availability to all varieties and situations of PNL with a large number (253 patients) of different stone sizes, locations, numbers, positions (prone, supine), approaches (supracostal, subcostal), tracts (single, double, triple), with previous ipsilateral surgery (40 cases), solitary (15 cases) renal impairment (creatinine 1.5 to 2.5 mg/dl in 20 patients), and simultaneous bilateral TPNL (2 patients). The need for analgesia was decreased markedly (12.65%), hospital stay was also decreased (1.6 days), and the utilization of an externalized ureteric catheter for a short period of time (26.65 hours) was also an advantage, without the need for additional intervention.

Hemostatic substances like SURGICEL, GELFOAM, and Spongstan to secure the bleeding site were used in 50 patients and were compared to another 50 patients with whom these substances were not used. The Hb drop was 0.3 to 4 gm (mean 1.2 gm) and 0.3 to 5 gm (mean 1.7 gm) with no significant difference as the p value was 0.455. Complications occurred in (7.9%) of the patients and were mostly minor, with a minimal number of major complications; they were managed conservatively (Table 3). Blood transfusions were needed in 3.95% of the sample, which is acceptable. We took a deep stitch of 0 silk to control the bleeding after the removal of the sheath, and in multiple puncture cases we kept the sheath or tube temporarily in place until the end of the procedure.


The era of nephrostomy tube post PNL should be halted to give the era of TPNL a chance to take priority. Only cases with big residuals, which need a second look, should use the older method. TPNL should be extended to include big stones, multiple stones, multiple punctures, prone or supine positions, subcostal or supracostal, recurrent cases, solitary kidneys or with increased serum creatinine, bleeding, and bilateral simultaneous procedures. TPNL is safe and effective, with acceptable complications and many advantages such as decreased postoperative pain, decreased analgesia, and decreased hospital stay.


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