COMPARISON OF STANDARD AND TUBELESS PERCUTANEOUS NEPHROLITHOTOMY IN A TERTIARY CARE HOSPITAL IN EASTERN NEPAL

The study was conducted from January 2017 to December 2017 involving 50 pa ents undergoing PCNL randomized into standard PCNL group (S group) and tubeless PCNL group (T group) each arm containing 25 pa ents. Pa ents with congenital renal anomalies, solitary func oning kidney, previous renal surgery, clinically significant residual stones/fragments, perfora on of pelvi-calyceal system and requiring conversion were excluded. Data analyzed using SPSS 20, chi-square test and Student's t test was used where appropriate. A p-value of <0.05 was considered significant.


Methodology
The study was conducted from January 2017 to December 2017 involving 50 pa ents undergoing PCNL randomized into standard PCNL group (S group) and tubeless PCNL group (T group) each arm containing 25 pa ents.Pa ents with congenital renal anomalies, solitary func oning kidney, previous renal surgery, clinically significant residual stones/fragments, perfora on of pelvi-calyceal system and requiring conversion were excluded.Data analyzed using SPSS 20, chi-square test and Student's t test was used where appropriate.A p-value of <0.05 was considered significant.

Results
Mean age, mean stone size, preopera ve hemoglobin level and crea nine level in group S and T were comparable.Similarly, postopera ve hemoglobin level and crea nine level in groups S and T were comparable.The mean opera ng me in group S was 99.38± 16.24min and 89.38 ± 12.27min in group T ( p=0.02).Postopera vely, VAS in group S was 5.25± 0.94 and 2.88± 1.68 in group T ( p<0.001).Complica ons occurred in 9 pa ents in S group as postopera ve anemia (hemoglobin <10gram/dl)-3 cases, superficial surgical site infec on-4 and urine leak-2 while it was seen in 3 pa ents in T group as stoma site hematoma-2 and anemia-1( p= 0.04).Three pa ents in group S and 1 pa ent in group T respec vely required transfusion (p= 0.82).Postopera ve analgesic requirement in S and T groups were 13.08± 2.39 and 9.03± 2.44 grams of paracetamol respec vely ( p<0.001).The hospital stay was 3.79± 0.58 days in S group and 2.54 ± 0.50 days in T group (p<0.001).

Conclusion
Tubeless PCNL is a safe op on in selected cases.It is associated with significantly less postopera ve pain, analgesic requirement, postopera ve complica on and shorter dura on of hospital stay minimizing treatment cost.

INTRODUCTION
Nephrolithiasis is a common condi on affec ng about 10% The Standard PCNL include percutaneous access to collec ng system, dila on of the tract, nephroscopy, stone fragmenta on and removal and placement of ureteral stent and nephrostomy tube.But inser on of nephrostomy tube can cause complica ons like more pain, increase dura on of hospital stay and increase treatment cost.Tubeless PCNL was developed as an alterna ve method to decrease 5,6 complica ons associated with standard PCNL.In tubeless 7 PCNL, no nephrostomy tube is inserted.The aim of this study was to compare outcome of standard andtubeless PCNL.

METHODOLOGY
The study was conducted in the Urology unit, Department of Surgery, Birat Medical College-Teaching Hospital, Biratnagar, Nepal over a period of one year (January 2017 to December 2017).Fi y pa ents were included in the study each arm containing 25 pa ents.Pa ents with congenital renal anomalies, previous renal surgery, clinically significant residual stones/fragments, perfora on of pelvi-calyceal system, requiring conversion from tubeless to standard PCNL and solitary func oning kidney were excluded.One pa ent from the standard PCNL group was excluded as he required staged procedure and one pa ent from tubeless group was excluded because of intraopera ve bleeding requiring nephrostomy tube placement ( Fig. 1).The study was approved by hospital administra on.
A er informed consent and preopera ve prepara on, pa ents were randomized into two groups-standard PCNL group (S) and tubeless PCNL group (T) each having 25 pa ents by computer generated random numbers.One pa ent from each group was excluded because of staged procedure and bleeding manda ng nephrostomy tube respec vely.All pa ents underwent PCNL using standard protocol.Baseline characteris cs, intraopera ve events andopera ng me were recorded.Pa ents in S group received 22 F nephrostomy tube postopera vely in addi on to 6F, 26cm both end open double J stent while nephrostomy tube was omi ed in the pa ents in T group.Stone clearance was assessed by postopera ve KUB (Kidney-ureter-bladder) x-ray.In S group, nephrostomy tube was removed on first postopera ve day a er confirma on of no clinically significant residual fragment and foley's cather was removed on second postopera ve day in both groups.Postopera ve pain was assessed by visual analogue scale (VAS), analgesic requirement (Paracetamol 1 gram/dose), postopera ve complica ons and hospital stay was recorded.Double J stent was removed a er 2 weeks in both groups.

Sta s cal Analysis
Data were analysed using SPSS 20, chi-square test and Student's t test were used where appropriate.A p-value of <0.05 was considered significant.

DISCUSSION
This study aimed at comparing outcome of pa ents undergoing standard PCNL and tubeless PCNL performed by a single urologist in a ter ary care hospital in the eastern part of Nepal.
The mean age of pa ents in this study was 37 years in both groups which is comparable with the studies of Jagadeeshwar et al (39.5 years in group S and 33.9 years in group T) and groups was not sta s cally significant (p= 0.32).

CONCLUSION
Tubeless PCNL is a safe op on in selected cases.It is associated with significantly less postopera ve pain, analgesic requirement, postopera ve complica on and shorter dura on of hospital stay minimizing treatment cost.

RECOMMENDATION
High quality larger trials with longer follow-up is recommended.

LIMITATION OF THE STUDY
The study is limited by less number of pa ents and observer bias as it was not blinded.

Table 2 :
Postopera ve parameters Gupta et al (32.6years in S group and 34.4 years in T Out of 24 cases, complica ons occurred in 9 cases in S group and 3 cases in T group (p= 0.04).Three cases required postopera ve blood transfusion, 4 cases had superficial surgical site infec on and 2 cases had urine leak from nephrostomy site requiring re-suturing of the stoma in S group.Similarly, 2 cases developed stoma site hematoma requiring evacua on and 1 case required postopera ve transfusion in T group.The transfusion requirement in both 8shorter in tubeless group.Gupta et al reported shorter opera ng me in tubeless group but the difference was not sta s cally significant.Similary, Wang et al in a meta-analysis of six studies could not found sta s cally 9,10 significant difference in opera ng me in both groups.However, in another meta-analysis by Xun and colleague involving 14 RCTs and 1148 pa ents, they reported