||| Original Article ||| DOI: 10.3329/bsmmuj.v11i2.35932 |
Percutaneous nephrolithotomy with or without nephrostomy tube
Mohammed Aulad Hossain, S. M. Yunus Ali, Mohammad Saiful Islam, Md. Jahangir Alam, Mollah Md. Abu Sayed and A. K. M. Khurshidul Alom
Department of Urology, Faculty of Surgery, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka, Bangladesh
The study has been designed to compare the outcome of percutaneous nephrolithotomy with (Group A) or without nephrostomy tube (Group B) for the management of renal stone disease. JJ stents were given to all cases of both groups. Comparison of outcome between groups shows that urinary leakage time was significantly longer in Group B than that in Group A (24.0 ± 6.2 vs 7.3 ± 3.9 hours; p<0.001). Visual analogue pain score was also significantly high in Group B than in Group A (4.7 ± 0.8 vs 2.4 ± 0.5; p<0.035). Patients in Group B stayed in hospital on an average 4 days, while the Group A patients stayed in hospital on an average 2.5 days (p<0.029). The mean hemoglobin level decreased in 24 hours in Group B and in Group A (0.5 ± 0.4 and 0.5 ± 0.4 respectively) did not show any significant difference (p<0.895). In conclusion, percutaneous nephrolithotomy without nephrostomy tube can be practiced in the management of selective cases of renal stones diseases.
Urinary calculi are one of the common diseases of the urinary tract.1 The goal of surgical stone management is to achieve maximal stone clearance with minimal morbidity to the patients. Some related factors like size, number, location, composition of stone, renal anatomy, and patients clinical factors all come in consideration in conjunction with the morbidity associated with various surgical modalities and the availability of equipment before the preferred surgical approach is selected.2
Percutaneous nephrolithotomy, as a primary procedure, was first described by Fernstrom and Johanson in 1976.3 Subsequent report on percutaneous nephrolithotomy from the Mayo Clinic4 and the University of Minnesota5 and from West Germany6 and England7 established percutaneous nephrolithotomy and refined the technique. It is currently the procedure of choice for removing large and complex renal calculi and refractory to ESWL.8 This method of removing renal stones was a dramatic improvement over open surgical procedures and was shown to shorten hospital stay and decrease complications.9 Traditionally, a large bore (20-26 F) nephrostomy tube was left in place after percutaneous nephrolithotomy to facilitate hemostasis and urinary drainage.10 There are many prospective randomized controlled studies which concluded that patients with a nephrostomy have more post-operative discomfort, analgesic requirement and prolonged hospital stay than those with a tubeless percutaneous nephrolithotomy.11-13
The term tubeless percutaneous nephrolithotomy was first reported in 1997.14 In this method the percutaneous nephrostomy was replaced by an indwelling ureteric stent at the end of an uncomplicated percutaneous nephrolithotomy. Since then there have been increasing reports of tubeless percutaneous nephrolithotomy, but in most of them tubeless percutaneous nephrolithotomy was advocated only in appropriately selected patients.15, 3, 16, 17 Reported benefits of the tubeless approach include reduced admission durations, lower analgesia requirements, faster time to return to normal activities, and lower cost.14, 18
The present study compares tubeless percutaneous nephrolithotomy with conventional percutaneous nephrolithotomy in regard to post-operative outcome, complications and safety.
Placement of a nephrostomy tube and ureteric stent or ureteric catheter after completing a percutaneous procedure is commonly practiced. A nephrostomy tube is placed in patient in situ for reasons like: Tamponade of bleeding, to permit second look, to prevent peri-nephric collection and retroperitoneal hematoma. But recent studies to show advantages of the tubeless percutaneous nephrolithotomy approach like: Reduced analgesic requirements, low post-operative pain, shorter hospitalization and convalescence, less complications like urinary leakage, infection at the site of wound, post–operative UTI, fever, post-operative hydronephrosis.
This study was performed to compare post-operative complications and outcome between percutaneous nephrolithotomy without nephrostomy tube and percutaneous nephrolithotomy with nephrostomy tube.
Patients with renal stones who underwent percutaneous nephrolithotomy after admission in the Department from January 2014 to July 2015, were included in this study. According to selection criteria, they were assigned for percutaneous nephrolithotomy. After completion of percutaneous nephrolithotomy but before giving nephrostomy tube and exclusion of cases according to selection criteria, cases were allocated in study group, Group A (without nephrostomy tube) and Group B (with nephrostomy tube) by simple random sampling, following conventional sampling formula and calculated 18 sample in each group with a total 36 samples. Patients with age 18-65 years, stone size up to 4 cm, stone refractory to ESWL, single tract access, complete clearance of stone, normal serum creatinine were included in the study. Patients with significant bleeding during the procedure and calyceal perforation, major anatomical anomalies of kidney stone size more than 40 mm, making multiple access tracts, radiolucent stone, patients need for blood transfusion, patients who did not give consent were excluded.
All the required investigations for confirmation of diagnosis and anesthetic fitness were performed. Patients under general anesthesia ureteral catheterization on the site of percutaneous nephrolithotomy followed by image-guided puncture of appropriate calyx. A safety guide wire was inserted through the puncture needle in the collecting system up to the bladder. After tract dilatation over the guide wire a 24-30 F Amplatz sheath was inserted. A 24 or 26 Fr nephroscope was used, and fragmentation of stone was done and removed. Then JJ stents were given in all patients. Nephrostomy wound was closed by single skin stitch but without keeping a nephrostomy tube in Group A. Group B patients were managed by putting a nephrostomy tube within the tract.
Out of 40 cases, 4 cases were excluded from the study, among which 2 cases needed multiple punctures and complete clearance was not possible in 2 cases. The procedure of rest 36 cases fulfilled the criteria of this study.
An ultrasonogram of the renal region was done on 2nd post-operative day to see any perirenal collection which may be urinoma or hematoma. Hemoglobin was estimated in post-operative ward and on 1st post-operative day, also urine color was monitored and recorded. By this way amount of post-operative blood loss was measured from differences of the two values. Operating time was recorded from the time of puncture to closing of nephrostomy tract. The pain was measured by the visual analogue pain scale questionnaire and recorded as mild (score 0 to 3) moderate (score 4 to 6) and severe (score 7 to 10).19 The patient was discharged after urine appeared clear, cessation of urine leakage, adequate relief of pain and normal body temperature. For analysis of the study the age of patient, gender stone size was taken as baseline variable and urine leakage time, perirenal collection on ultrasonogram, post-operative hemoglobin decrease, operation time, post-operative pain score, hospital stay were taken as the outcome variable.
Statistical analysis
Data were analyzed using SPSS (statistical package for social science) 22 version. The test statistics used to analyze the data were descriptive statistics, Chi-square and student’s t-test. The data measured on a continuous scale were presented as mean and SEM compared between groups using Student’s t-test, while categorical data were expressed as the percen-tage and compared between groups with the help of Chi-squared test.
9Most of the patients were between 30-50 years of age. Males were 12 in Group A and 15 in Group B. The male female ratio was 2:1 in Group A whereas 5:1 in Group B. There was no statistically significant (p=0.260) difference in age and sex in between two groups.
The stones size in 11 patients in Group A and 9 patients in Group B were 8-20 mm. No significant difference was observed between the groups in terms of stone size (20.4 ± 10.2 vs 21.9 ± 8.7 mm, p=0.381) (Table I).
Group A (n=18) |
Group B (n=18) | |
|---|---|---|
| Stone size (mm) | ||
|
11 | 9 |
|
4 | 5 |
|
3 | 4 |
| Outcome | ||
|
0.5 ± 0.4 | 0.5 ± 0.4 |
|
52.5 ± 9.6 | 54.4 ± 7.3 |
|
7.3 ± 3.9 | 24.0 ± 6.2 |
|
2.4 ± 0.5 | 4.7 ± 0.8 |
|
2.5 ± 0.5 | 4.1 ± 0.9 |
No patient of Group A or B was found to have any perirenal collection on ultrasonographic examination of the kidney on 2nd post-operative day.
In Group A, 44.4% patients and in Group B 50% patient’s hemoglobin were decreased ≥0.5 mg/dL after 24 hours. On the other hand, 24 hours hemoglobin decrease was <0.5 mg/dL in 55.6% patients of Group A and 50% patients of Group B.
In Group A, only 5.6% patients stayed for more than 3 days but over 66.7% of patients in Group B stayed in the hospital for more than 3 days following operation.
Only 11.1% of patients in Group A continued urine leakage for >24 hours but 100% of patients in Group B continued urine leakage for >24 hours following operation.
Post-operative pain on first post-operative day in Group A was assessed and 94.4% had mild pain, 5.6% had moderate pain and none had severe pain. In Group B 11.1% had mild pain, 77.8% had moderate pain and 11.1% had severe pain.
Comparison of outcome between groups shows that continuation of urine leakage was significantly longer in Group B than that in Group A (7.3 ± 3.9 vs 24.0 ± 6.2 hours, p<0.001). Visual analogue pain score was also significantly high in Group B than in Group A (2.4 ± 0.5 vs 4.7 ± 0.8, p<0.035). Patients in Group B stayed in hospital on an average 4 days, while the Group A patients stayed in hospital on an average 2.5 days (p<0.029). The mean hemoglobin level decreased in 24 hours in Group B and A (0.5 ± 0.4 and 0.5 ± 0.4 respectively) did not show any significant difference (p<0.895). Operation time in Group B and A was 52.5 ± 9.6 and 54.4 ± 7.3 min respectively and there was no significant difference (p=0.401).
The age of the patients, size, composition and location of stones, renal anatomy and functional status are the main factors to achieve maximum stone clearance and least morbidity for the surgical management of renal stone diseases.2, 3, 14 The tubeless percutaneous nephrolithotomy and placement of ureteric catheter for 48 hours done by other studies on tubeless percutaneous nephrolithotomy where the age range and stone burden was more or less similar to the present study.15, 20, 21
After completion of the procedure, we evaluated the patient by post-operative pain assessment, hemoglobin decrease, urinary leakage time through the percutaneous tract, peri-renal collection and hospital stay. Percutaneous nephrolithotomy tract urine leakage, peri-renal collection were negligible in this study. In comparison to other studies, the post-operative pain score was significantly low in nephrostomy tubeless group in this study due to adequate use of weight-adjusted dose of analgesic and strict hospital pain management protocol. No patients’ needs post-operative blood transfusion.5, 8, 12 The post-operative hospital stay in both groups in this study were also significantly correlated to other studies. In this study, all the above mentioned evaluated post-procedure factors were similar to other studies with low pain score in tubeless percutaneous nephrolithotomy.20, 22
Percutaneous nephrolithotomy without nephrostomy tube is safer than percutaneous nephrolithotomy with nephrostomy tube in the management of renal stone in selected cases.
1. Stoller ML. In: Smith’s General urology. Tanagho EA, McAninch JW (eds). 18th ed. USA, McGraw Hill, 2000, pp 249-51.
2. Yang J, Wang KJ, Li H, Wang L. Tubeless versus standard percutaneous nephrostolithotomy for treating kidney stones. The Cochrane Collaboration, John Wiley and Sons, 2013, pp 1-3.
3. Gupta V, Sadasukhi TC, Sharma KK, Yadav RG, Mathur R. Tubeless and stentless percutaneous nephrolithotomy. BJU Int. 2005; 95: 905-06.
4. Segura JW, Patterson DE, LeRoy AJ. Percutaneous stone removal of kidney stones: Preliminary report. Mayo Clin Proc. 1982; 57: 611-19.
5. Clayman RV. Techniques in percutaneous removal of renal calculi. J Urol. 1984; 23: 11-19.
6. Alken P, Hustschenreiter G, Gunther R. Percutaneous stone manipulation. J Urol. 1981 125: 461-63.
7. Wickham JE, Kellett MJ. Percutaneous nephrostolithotomy. Br J Urol. 1981; 53: 296-99.
8. Deane LA, Clayman RV. Advances in percutaneous nephrostolithotomy. Urol Clin North Am. 2007; 34: 383-95.
9. Shah H, Khandkar A, Sodha H, Kharodawala S, Hegde S, Bansal M. Tubeless percutaneous nephrolithotomy: Three years of experience with 454 patients. BJU Int. 2009; 104: 840-46.
10. Winfield HN, Weyman P, Clayman RV. Percutaneous nephrostolithotomy: Complications of premature nephrostomytube removal. J Urol. 1986; 136: 77-79.
11. Feng MI, Tamaddon K, Mikhail A, Kaptein JS, Bellman GC. Prospective randomized study of various techniques of percutaneous nephrolithotomy. Urology 2001; 58: 345-50.
12. Desai MR, Kukreja RA, Desai MM. A prospective randomized comparison of type of nephrostomy drainage following percutaneous nephrostolithotomy: Large bore versus small bore versus tubeless. J Urol. 2004; 172: 565-67.
13. Li R, Louie MK, Lee HJ, Osann K, Pick DL, Santos R, McDougall EM, Clayman RV. Prospective randomized trial of three different methods of nephrostomy tract closure after percutaneous nephrostolithotomy. Br J Urol. 2011; 107: 1660-65.
14. Bellman GC, Davidoff R, Candela J, Gerspach J, Kurtz S, Stout L. Tubeless percutaneous renal surgery. J Urol. 157: 1997; 1578-82.
15. Aghamir SMK, Hosseini SR, Gooran S. Totally tubeless percutaneous nephrostolithotomy. J Endo Urol. 2004; 18: 647-48.
16. Shah HN, Kausik VB, Hegde SS, Shah JN, Bansal MB. Tubeless percutaneous nephrolithotomy: A prospective feasibility study and review of previous reports. BJU Int. 2005; 96: 879-83.
17. Bhuiyan NI, Islam MF, Khan SA, Bhuiyan ZH, Towhid KMH, Ahmed NIU. Tubeless and stentless PCNL in selected cases: Our experience in Bangladesh. J Surg Sci. 2012; 16: 18-25.
18. Wickham JE, Miller RA, Kellett MJ, Payne SR. Percutaneous nephrolithotomy: One stage or two? Bri J Urol. 1984; 56: 582-85.
19. Wewers ME, Lowe NK. A critical review of visual analogue scales in the measurement of clinical phenomena. Res Nurs Health. 1990; 13: 227-36.
20. Lojanapiwat B, Soonthornphan S, Wudhikarn S. Tubeless percutaneous nephrostolithotomy in selected patients. J Endourol. 2001; 15: 711-13.
21. Limb J, Bellman GC. Tubeless percutaneous renal surgery: Review of first 112 patients. Urology 2002; 59: 527-31.
22. Goh M, Wolf S Jr. Almost totally tubeless percutaneous nephrostolithotomy: Future evaluation of the technique. J Endourol. 1999; 13: 177-08.