Urology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India.
BJU Int. 2010 Oct;106(7):1045-8; discussion 1048-9. doi: 10.1111/j.1464-410X.2010.09223.x. Epub 2010 Feb 11.
To establish the efficacy of early removal of a nephrostomy tube after percutaneous nephrolithotomy (PCNL), to challenge the wisdom of tubeless PCNL, as we hypothesized that it would result in a shorter hospital stay, comparable benefit and safety, while maintaining the option of check nephroscopy ensuring far superior stone clearance.
In all, 22 patients were prospectively randomized equally into two groups, group 1 (early nephrostomy removal) or group 2 (tubeless) during a 1-month study period. Inclusion criteria for the study were: a simple stone of <3 cm, no significant bleeding, no perforation, single-tract access and 'on-table' complete stone clearance. In group 1, a 20 F nephrostomy, 6 F retrograde ureteric catheter and a Foley catheter were used, while in group 2 only a 6 F retrograde ureteric catheter and Foley catheter were placed at the end of the procedure. Computed tomography (CT) with no contrast medium was done on the first morning after surgery before removing all catheters/tubes, and patients discharged subsequently. The variables assessed were stone clearance, hospital stay, analgesic requirement, postoperative complications and auxiliary procedures.
The mean (SD) stone bulk was similar between the groups, at 2737 (946.9) and 2934.2 (2090.7) µL, respectively. Despite an on-table complete clearance, clearance assessed by CT was nine of 11 vs eight of 11 in groups 1 and 2, respectively. CT showed a 6 mm stone in one patient in group 1, while the remaining patients had stones of <4 mm. The mean (SD) analgesic requirement, haemoglobin decrease, urine leak and hospital stay in the two groups were 72.7 (51.8) vs 68.2 (46.2) mg of tramadol (P= 0.25), 1.6 (0.7) vs 1.6 (0.9) g/dL (P= 0.39), 13.9 (6.3) vs 7.1 (14.2) h (P= 0.018) and 72.8 (2.1) vs 70.2 (18.5) h (P= 0.09), respectively. Complications noted were early haematuria in none vs three (P= 0.21), urinoma none vs one, and fever in two vs one, respectively; one patient in group 1 required a check nephroscopy for a residual fragment. Overall clearance including re-treatment was 10/11 vs eight of 11 (P= 0.009), respectively.
Early tube removal after PCNL results in an equivalent analgesic requirement, decrease in haemoglobin and hospital stay as tubeless PCNL. It has a significantly lower incidence of early haematuria, better clearance rates and preserves the option of check nephroscopy. It can be considered as an accepted standard of care, with the preserved advantages of tubeless PCNL.
通过对经皮肾镜取石术后早期拔除肾造瘘管的疗效进行评估，以挑战无管经皮肾镜取石术的合理性，因为我们假设这将导致住院时间更短、获益和安全性相当，同时保持检查性肾镜检查的选择，从而实现更好的结石清除效果。
在一个月的研究期间，共有 22 名患者被前瞻性随机平均分为两组，组 1（早期肾造瘘管拔除）或组 2（无管）。研究纳入标准为：单纯性结石＜3cm，无明显出血，无穿孔，单通道，“台上”结石完全清除。组 1 中使用 20F 肾造瘘管、6F 逆行输尿管导管和 Foley 导管，而组 2 仅在手术结束时放置 6F 逆行输尿管导管和 Foley 导管。术后第一天早晨，在所有导管/管均未拔除前，进行无对比剂 CT 检查，随后患者出院。评估的变量包括结石清除率、住院时间、镇痛需求、术后并发症和辅助治疗。
两组的结石块大小相似，分别为 2737（946.9）和 2934.2（2090.7）µL。尽管“台上”结石完全清除，但 CT 评估的结石清除率分别为组 1 的 11 例中有 9 例，组 2 的 11 例中有 8 例。CT 显示组 1 中有 1 例患者有 6mm 的结石，而其余患者的结石均＜4mm。两组的平均（SD）镇痛需求、血红蛋白下降、尿漏和住院时间分别为 72.7（51.8）vs 68.2（46.2）mg 曲马多（P=0.25）、1.6（0.7）vs 1.6（0.9）g/dL（P=0.39）、13.9（6.3）vs 7.1（14.2）h（P=0.018）和 72.8（2.1）vs 70.2（18.5）h（P=0.09）。注意到的并发症分别为早期血尿无 vs 3 例（P=0.21）、尿囊肿无 vs 1 例、发热 2 例 vs 1 例，组 1 中有 1 例患者需要进行检查性肾镜检查以清除残留结石碎片。总的结石清除率（包括再次治疗）分别为 10/11 例 vs 8/11 例（P=0.009）。
经皮肾镜取石术后早期拔除肾造瘘管可获得与无管经皮肾镜取石术相当的镇痛需求、血红蛋白下降和住院时间。它具有更低的早期血尿发生率、更高的结石清除率，并且保留了检查性肾镜检查的选择。它可以被认为是一种可接受的治疗标准，同时保留了无管经皮肾镜取石术的优势。
