Is Totally Tubeless Percutaneous Nephrolithotomy a Safe and Efficacious Option for Complex Stone Disease?

Background: Percutaneous nephrolithotomy is the gold standard treatment for large, complex intrarenal stones. Historically, this was performed using a nephrostomy tube (PCN) and/or internalized ureteral stent at the end of the procedure. However, totally tubeless nephrolithotomy (tt-PCNL) is a novel technique where no tubes (no stent nor nephrostomy tube) are left post-operatively. We review the literature on this subject regarding peri-operative outcomes, post-operative outcomes, and potential complications of the procedure, discuss our technique, and make recommendations on implementation for centers not currently utilizing the procedure. Materials and methods: We performed a comprehensive search of the literature on totally tubeless nephrolithotomy using MEDLINE database search. Our search included prior review articles, meta-analyses, systematic reviews, primary research articles, case reports, and case studies. Results: In comparison to prior approaches where a stent or nephrostomy tube is placed, tt-PCNL has a similar complication rate and better post-operative outcomes. Totally tubeless PCNL has similar operative times and similar changes in hemoglobin. However, it had shorter length of stays across all studies. The mean difference in length of stay in the studies reviewed was 1.96 days. Additionally, tt-PCNL had decreased post-operative analgesic requirements and pain scores. Conclusions: This review highlights totally tubeless percutaneous nephrolithotomy as a safe and feasible surgical technique with improved outcomes in properly selected patients.