Comparison of standard and tubeless percutaneous nephrolithotomy for renal calculi: a prospective randomized control trial

Manu Muraleedharan Kamalakshi, Vasantharaja Ramasamy, Darsan Sadasivan, Sunil Raveendran, Selvam Paramasivam, Venugopal Ganapathy


Background: In the current era of minimally invasive interventions, the mainstay of treatment of renal stones larger than 2 cm is Percutaneous nephrolithotomy (PCNL). PCNL underwent various evolutionary changes minimizing morbidity to the patients. We prospectively compared the outcome of tubeless PCNL (without nephrostomy drainage tube) to reduce the pain and discomfort caused by tube with standard PCNL in the treatment of renal stones.

Methods: In this Randomized control trial (RCT), we divided patients satisfying the inclusion criteria of consenting for trial, single access puncture, less than 3 stones each less than 3 cm, operative duration of less than 2 hours into two groups, standard PCNL (group 1) and tubeless PCNL (group 2) with 25 patients each. Randomization and group assignment were done after complete clearance of renal stones.

Results: Patient’s age, gender, sides of stone and stone size were comparable between two groups (standard versus tubeless PCNL). Postoperative hemoglobin drop, bleeding, pyrexia, urine leak, and blood transfusion requirement did not show a statistically significant difference between the two groups. Analgesic requirement (190 mg versus 80 mg of tramadol), operative duration (49.80 min versus 38.60 min), postoperative pain score (6/10 versus 3.64/10-visual analog scale) and duration of hospital stay (68.48 hours versus 41.12 hours) showed statistically significant difference favoring tubeless PCNL.

Conclusions: Tubeless PCNL may be a safe, acceptable and effective modality of treatment for renal calculi in carefully selected patients comparing standard PCNL resulting in less operative duration, lower postoperative pain, reduced analgesic requirement and shorter hospital stay.


Percutaneous nephrolithotomy, Tubeless, PCNL, Randomized control trial, Renal calculi

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Fernstrom I, Johansson B. Percutaneous pyelolithotomy. A new extraction technique. Scand J Urol Nephrol. 1976;10:257-9.

de Rosette J, Assimos D, Desai M, Gutierrez J, Lingeman J, Scarpa R, et al. The clinical research office of the endourological society percutaneous nephrolithotomy global study: indications, complications, and outcomes in 5803 patients. J Endourol 2011;25:11-7.

Paul EM, Marcovich R, Lee BR, Smith AD. Choosing the ideal nephrostomy tube. BJU Int. 2003;92:672-7.

Srinivasan AK, Herati A, Okeke Z, Smith AD. Renal drainage after percutaneous nephrolithotomy. J Endourol. 2009;23:1743-9.

Maheshwari PN, Andankar MG, Bansal M. Nephrostomy tube after percutaneous nephrolithotomy: large-bore or pigtail catheter? J Endourol. 2000;14:735-7.

Pietrow PK, Auge BK, Lallas CD, Santa-Cruz RW, Newman GE, Albala DM, et al. Pain after percutaneous nephrolithotomy: Impact of nephrostomy tube size. J Endourol. 2003;17:411-4.

Desai MR, Kukreja RA, Desai MM, Mhaskar SS, Wani KA, Patel SH, et al. A prospective randomized comparison of the type of nephrostomy drainage following percutaneous nephrolithotomy: large bore versus small bore versus tubeless. J Urol. 2004;172:565-7.

Ni S, Qiyin C, Tao W, Liu L, Jiang H, Hu H, et al. Tubeless percutaneous nephrolithotomy is associated with less pain and shorter hospitalization compared with standard or small bore drainage. Urol. 2011;77:1293-8.

Borges CF, Fregonesi A, Silva DC, Sasse AD. Systematic review and meta-analysis of nephrostomy placement versus tubeless percutaneous nephrolithotomy. J Endourol. 2010;24:1739-46.

Bellman GC, Davidoff R, Candela J, Gerspach J, Kurtz S, Stout L. Tubeless percutaneous renal surgery. J Urol. 1997;157:1578-82.

Saltzman B. Ureteral Stents. Indications, variations, and complications. Urol Clin North Am. 1988;15:481-91.

Tefekli A, Altunrende F, Tepeler K, Tas A, Aydin S, Muslumanoglu AY. Tubeless percutaneous nephrolithotomy in selected patients: A prospective randomized comparison. Int Urol Nephrol 2007;39:57‑63.

Crook TJ, Lockyer CR, Keoghane SR, Walmsley BH. A randomized controlled trial of nephrostomy placement versus tubeless percutaneous nephrolithotomy. J Urol. 2008;180:612-4.

Geraghty R, Jones P, Somani BK. Worldwide trends of urinary stone disease treatment over the last two decades: a systematic review. J Endourol. 2017;31:547-56.

Ganpule AP, Vijayakumar M, Malpani A, Desai MR. Percutaneous nephrolithotomy (PCNL) a critical review. Int J Surg. 2016;36:660-4.

Yuan H, Zheng S, Liu L, Han P, Wang J, Wei Q. The efficacy and safety of tubeless percutaneous nephrolithotomy: a systematic review and meta-analysis. Urol Res. 2011;39:401-10.

Jackman SV, Hedican SP, Peters CA, Docimo SG. Percutaneous nephrolithotomy in infants and preschool age children: experience with a new technique. Urol. 1998;52(4):697-701.

Li LY, Gao X, Yang M, Li JF, Zhang HB, Xu WF, et al. Does a smaller tract in percutaneous nephrolithotomy contribute to less invasiveness?. Urol. 2010;75(1):56-61.

Xun Y, Wang Q, Hu H, Lu Y, Zhang J, Qin B, et al. Tubeless versus standard percutaneous nephrolithotomy: an update meta-analysis. BMC Urol. 2017;17(1):102.

Limb J, Bellman GC. Tubeless percutaneous renal surgery: review of first 112 patients. Urol. 2002;59:527-31.

Singh I, Singh A, Mittal G. Tubeless percutaneous nephrolithotomy: is it really less morbid? J Endourol. 2008;22:427-34.

Mandhani A, Goyal R, Vijjan V, Dubey D, Kapoor R. Tubeless percutaneous nephrolithotomy- should a stent be an integral part? J Urol. 2007;178:921-4.

Istanbulluoglu MO, Ozturk B, Gonen M, Cıcek T, Ozkardes H. Effectiveness of totally tubeless percutaneous nephrolithotomy in selected patients: a prospective randomized study. Int Urol Nephrol. 2009;41:541-5.

Aghamir SMK, Modaresi SS, Aloosh M, Tajik A. Totally tubeless percutaneous nephrolithotomy for upper pole renal stone using subcostal access. J Endourol. 2011;25:583-6.

Chang CH, Wang CJ, Huang SW. Totally tubeless percutaneous nephrolithotomy: a prospective randomized controlled study. Urol Res. 2011;39:459-65.

Lu Y, Ping JG, Zhao XJ, Hu LK, Pu JX. Randomized prospective trial of tubeless versus conventional minimally invasive percutaneous nephrolithotomy. World J Urol. 2013;31:1303-7.

Agrawal MS, Sharma M, Agarwal K. Tubeless percutaneous Nephrolithotomy using Antegrade tether: a randomized study. J Endourol. 2014;28:644-8.

Kumar S, Singh S, Singh P, Singh SK. Day care PNL using “Santosh-PGI hemostatic seal” versus standard PNL: a randomized controlled study. Cent European J Urol. 2016;69:190-7.

Sebaey A, Khalil MM, Soliman T, Mohey A, Elshaer W, Kandil W, et al. Standard versus tubeless minipercutaneous nephrolithotomy: a randomised controlled trial. Arab J Urol. 2016;14:18-23.

Choi M, Brusky J, Weaver J, Amantia M, Bellman GC. Randomized trial comparing modified tubeless percutaneous nephrolithotomy with tailed stent with percutaneous nephrostomy with small-bore tube. J Endourol. 2006;20(10):766-70.

Shah HN, Sodha HS, Khandkar AA, Kharodawala S, Hegde SS, Bansal MB. A randomized trial evaluating type of nephrostomy drainage after percutaneous nephrolithotomy: small bore v tubeless. J Endourol. 2008;22:1433-9.

Agrawal MS, Agrawal M, Gupta A, Bansal S, Yadav A, Goyal J. A randomized comparison of tubeless and standard percutaneous nephrolithotomy. J Endourol. 2008;22:439-42.

Shoma AM, Elshal AM. Nephrostomy tube placement after percutaneous nephrolithotomy: critical evaluation through a prospective randomized study. Urol. 2012;79:771-6.

Sharifi Aghdas F, Akhavizadegan H, Aryanpoor A, Inanloo H, Karbakhsh M. Fever after percutaneous nephrolithotomy: contributing factors. Surg Infect (Larchmt). 2006;7:367-71.

Jou YC, Lu CL, Chen FH, Shen CH, Cheng MC, Lin SH, et al. Contributing factors for fever after tubeless percutaneous nephrolithotomy. Urol. 2015;85:527-30.

Ansari H, Tomar V, Yadav SS, Agarwal N. Study of predictive factors affecting the prolonged urinary leakage after percutaneous nephrolithotomy. Urol Ann. 2016;8:60-5.

Abbott JE, Deem SG, Mosley N, Tan G, Kumar N, Davalos JG. Are we fearful of tubeless percutaneous nephrolithotomy? Assessing the need for tube drainage following percutaneous nephrolithotomy. Urol Ann. 2016;8:70-5.