A Randomized Controlled Trial Of Nephrostomy Placement Versus Tubeless Percutaneous Nephrolithotomy

Main Category: Urology / Nephrology
Article Date: 26 Sep 2008 - 5:00 PDT

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UroToday.com - In 1985, I visited with the venerable Mr. John Wickham at the Institute of Urology in London. At that time, percutaneous stone removal was in its heyday and I was very much in the thick of it. In discussion with Mr. Wickham, I learned that he was not placing nephrostomy tubes in "selected" patients immediately after percutaneous stone removal (i.e. stone free, intact collecting system, and absence of excessive bleeding). I returned to Washington University imbued with new found knowledge and in the next two patients in whom a single stone was removed in its entirety (i.e. "grab and run"), the collecting system was intact, and there was no bleeding at the end of the procedure, I removed the guide wire and left no nephrostomy tube. The result was a less than sanguine experience resulting in a case report of a subsequent postoperative hydrothorax with chest tube drainage and a retroperitoneal bleed requiring transfusion.

When I queried Mr. Wickham about my travails with this approach, I was informed that I had obviously selected the wrong patients. I fell into a Will Rogers "stock market" conundrum ("The way to make money in the stock market is to buy a stock, and when it doubles in price, sell it; if it doesn't double, then don't buy it."), from which I have only slowly recovered, thanks to the work of Gary Bellman. Presently, I am no longer leaving nephrostomy tubes, but covering my tracks (literally and figuratively) with a hemostatic agent and an indwelling stent with patients being discharged to home usually on the first postoperative day. I now learn that this may well be North American overkill and indeed, in the afore described "select" patients, in this randomized, albeit unblinded study, neither indwelling stent nor nephrostomy tube is needed. Impressively, there was less bleeding and understandably a shorter hospital stay (2.3 vs. 3.4 days - p< .05) and a trend toward less use of pain medications in the tubeless group of 25 patients versus the 26F nephrostomy group (with no indwelling stent).

My hat is off to the authors for performing this randomized study. It would appear that it is time (perhaps long overdue) to revisit this approach as certainly the absence of both nephrostomy tube and indwelling stent would be beneficial to patients both from a quality of life as well as a financial standpoint.

(Caveat: The authors used a 7Fr. retrograde ureteral catheter during the procedure, it is not stated in the manuscript when this retrograde catheter and the Foley catheter were removed. Also, if one is using a ureteral access sheath, even if only 11F, then I believe an indwelling stent may be advisable unless a retrograde ureteral catheter is to be left in place for 24-48 hours.)

Crook TJ, Lockyer CR, Keoghane SR, Walmsley BH
J Urol. 2008 Aug;180(2):612-4.
doi:10.1016/j.juro.2008.04.020

Written by UroToday.com Medical Editor Ralph V. Clayman, MD

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