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Urological Science
J o u r n a l h o m e p a g e : w w w. e - u r o l - s c i . c o m

Original Article

Pressure Compression of the Access Tract for Tubeless

Percutaneous Nephrolithotomy
Shun‑Kai Chang, Ian‑Seng Cheong, Ming‑Chin Cheng*, Yeong‑Chin Jou, Chia‑Chun Chen, Min‑Min Hu
Department of Urology, Ditmanson Medical Foundation Chia‑Yi Christian Hospital, Chiayi, Taiwan

Abstract
Objective: To obtain adequate hemostasis, we compressed the access tract at the end of operation for tubeless percutaneous nephrolithotomy (PCNL).
The clinical results of 216 consecutive patients were evaluated by retrospective chart review. Materials and Methods: After stone extraction,
an 8F Foley catheter was inserted into the renal pelvis and was then inflated and gently retracted. The working sheath was withdrawn to the
renal capsule, the renal access tract was packed with oxidized regenerated cellulose (SurgicelTM) strips, and the tract was compressed with
smaller dilators through the working sheath for 5 min. Results: Of the 216 patients, 139 were male and 77 were female. The mean age was
56.0 ± 11.7 years. The stone characteristics were renal stones in 146 patients, ureteral stones in 47 patients, and kidney with ureteral stones in
23 patients. The average stone size was 3.6 ± 2.1 cm, and the average operation time was 80.5 ± 30.1 min. The target stones were all removed
in each patient and the overall postoperative stone‑free rate was 73.6%. The postoperative blood transfusion rate was 1.4% (three patients).
Postoperative fever was noted in 23 patients (10.6%) and sepsis was noted in three patients (1.4%). The average postoperative hospital stay
was 3.2 ± 1.4 days. Conclusion: Our results suggest that pressure compression may be an alternative method to minimize hemorrhagic
complications during tubeless PCNL.

Keywords: Percutaneous nephrolithotomy, renal stone, tubeless

Introduction nephrostomy tube after PCNL has been challenged in recent

years. Tubeless PCNL was first reported in 1997 by Bellman
Percutaneous nephrolithotomy (PCNL) is a common urological
et al., it has become a well‑accepted alternative modification
procedure for the treatment of complicated upper urinary tract
for percutaneous renal surgery.[2,3] In 2008, Agrawal et  al.
stone disease. It offers the advantages of lower morbidity and
reported a randomized study of tubeless PCNL comparing
mortality rates, faster recovery, easier secondary procedures,
with standard PCNL in 202 patients to evaluate the safety and
and greater cost‑effectiveness compared to open urinary
efficacy of tubeless PCNL. Compared to traditional standard
stone surgery.[1] Placement of a nephrostomy tube after
PCNL, they demonstrated that tubeless PCNL was associated
the completion of the stone extraction has been a standard
with less postoperative urinary leakage, reduced local pain,
procedure following PCNL to promote better hemostasis,
adequate drainage, and the maintenance of an access tract for Address for correspondence: Dr. Ming‑Chin Cheng,
a secondary view. However, the necessity for an indwelling No. 539, Chung‑Hsiao Road, Chiayi, Taiwan.
E‑mail: 02504@cych.org.tw
Received: 07-Jun-2018 Revised: 04-Sep-2018 Accepted: 11-Sep-2018

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DOI: How to cite this article: Chang SK, Cheong IS, Cheng MC, Jou YC,
10.4103/UROS.UROS_94_18 Chen CC, Hu MM. Pressure compression of the access tract for tubeless
percutaneous nephrolithotomy. Urol Sci 2019;30:19-23.

© 2019 Urological Science | Published by Wolters Kluwer - Medknow 19

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Chang, et al.: Tract cauterization for tubeless PCNL

and shorter hospital stay without an increase in postoperative
morbidity.[4] Several studies have demonstrated the benefits of
tubeless PCNL, including a decrease in the length of hospital
stay, an early return to normal activities, and reduced analgesic
requirements without an increase in morbidity.[5] Hemorrhage
is a common and bothersome complication after PCNL,
especially for the tubeless modification which does not have
the tamponade effect of the nephrostomy tube. To diminish
hemorrhagic complications after tubeless PCNL, instillation
of fibrin sealants and various hemostatic agents to seal the
access tract have been reported by several authors.[6‑8] The
applications of fibrin sealants and hemostatic agents have been
demonstrated to improve hemostasis, decrease the incidence of
urine leakage, and reduce analgesic requirements.[9] However,
the most appropriate way to prevent postoperative hemorrhage
after tubeless PCNL is not established yet at present.
Direct pressure compression on bleeding vessels is one of
the most basic and effective methods to achieve adequate
hemostasis. To achieve compression force on the access
tract, the Kaye nephrostomy tamponade catheter has been
developed to achieve hemostasis to control intraoperative
bleeding.[10] In order to improve hemorrhage control for tubeless
PCNL after stone extraction, we packed the renal access tract
with oxidized regenerated cellulose (SurgicelTM) strips and then
applied compression force on the renal access tract. Here, we
retrospectively reviewed the clinical results of the first consecutive
216 patients who underwent this procedure at our hospital.
Materials and Methods
From April 2013 to June 2014, 216 consecutive tubeless PCNL
procedures were performed at our hospital with postoperative
access tract compression by the same well‑experienced
urologic team. The clinical results of these patients were
analyzed by retrospective chart review. The indications for
PCNL included a large urinary renal stone burden, calyceal
stones, abnormal urinary tract anatomy, the failure of
extracorporeal shock wave lithotripsy, and upper urinary tract
stones ever treated by ureteroscopy with failure. All PCNLs
were performed by standardized operative procedures with a
single access tract in the prone position. Blood transfusion was
given in patients whose hemoglobin level fell below 10 g/dL
before the operation, and all patients were determined to have
a hemoglobin level >10 g/dL at the time of operation.
Before renal puncture, an occlusion balloon catheter was
inserted cystoscopically in the supine lithotomy position
for retrograde saline infusion and to prevent the downward
migration of stone fragments. The renal access tract was
obtained through puncture with an 18‑gauge needle under
ultrasound guidance. A 0.038‑inch J‑tip wire was then inserted
and the access tract was dilated with serial coaxial metal
dilators to allow the passage of a 24F nephroscope. Holmium:
yttrium‑aluminum‑garnet laser and pneumatic lithotripter were
used alone or in combination for stone disintegration. A 7F
double‑J catheter was inserted antegradely after the completion
of stone extraction. The irrigant was then changed from
normal saline to distilled water. The bleeding points within
the collection system and renal access tract were cauterized
with an elongated electrode probe attached to the handpiece
of a conventional electric cauterizer.[11]
After access tract cauterization, an 8F Foley catheter was
inserted into the collection system through the working
sheath, then inflated with 3 ml to 5 ml of sterile water and
was slightly retracted to obliterate the inner opening of the
access tract under direct vision nephroscopically. Then, we
tied the Foley catheter beneath the bifurcation and removed
the bifurcation part of the Foley catheter to preserve water in
the balloon and to allow the insertion of the inner working
sheath through the Foley catheter for further compression. The
working sheath was withdrawn to the level of the renal capsule
and the access tract of the renal parenchyma was packed with
SurgicelTM through the nephroscope. The SurgicelTM strips
were compacted with smaller dilators through the working
sheath. After 5 min of compression, the Foley catheter was
deflated and removed, leaving the SurgicelTM plug in the renal
parenchyma. A bloodless tract usually was achieved in these
patients [Figure 1]. Then, the wound was closed with nylon
suture. “Stone‑free” was defined as complete removal of all
stones as evaluated by a postoperative kidney, ureter, and

Figure 1: Procedures for tract tamponade after stone extraction: (1) The sheath was retracted to the inner opening of the access tract. An 8F Foley
catheter was inserted and inflated with 3 ml to 5 ml water, slightly retracted to obliterate the inner opening. (2) Tied the Foley catheter beneath the
bifurcation and removed the bifurcation part to allow the inner working sheath passing through the Foley catheter. (3) The renal parenchyma was
packed with SurgicelTM. (4) The SurgicelTM was compacted with smaller dilators through the working sheath for 5 min, then the Foley catheter was
deflated and removed. (5) The Foley catheter was removed and the SurgicelTM plug was left in the access tract of renal parenchyma

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Chang, et al.: Tract cauterization for tubeless PCNL

bladder (KUB) film or computerized tomography. Hemoglobin

Table 1: Demographic data and stone characteristics of
level was checked in patients experienced severe bleeding
patients
during or after the operation, blood transfusion was given in
patients have their hemoglobin level <10 g/dL or patients with Variables Result
unstable vital signs. Renal ultrasound was performed in each Number of patients 216
patient 1–2 weeks after the operation. Clinical data concerning Age±SD (years) 56.0±11.7 (26‑82)
patients’ age, stone size, operation time, length of postoperative Gender (%)
hospital stay, infection rate, and transfusion rate were analyzed Male 129 (59.7)
by postoperative chart review. Female 77 (40.3)
Stone location (%)
Renal stones except complete staghorn stones 110 (50.9)
Results Ureteral stones 47 (21.8)
Of the 216 patients, 139 are male and 77 are female and the Renal and ureteral stones 23 (10.6)
ages ranged from 26 to 82 years (mean 56.0 ± 11.7 years). Complete staghorn stones 36 (16.7)
The characteristics of the stones treated in this study Mean stone size±SD (cm) 3.6±2.1 (0.9‑10.5)
included renal stones in 146 patients (including 36 patients SD: Standard deviations
with staghorn stones), ureteral stones in 47 patients, and
kidney plus ureteral stones in 23 patients. The stone size was Table 2: Clinical outcomes in the current study
measured on a preoperative KUB radiography film (or from
Variables Result
computerized tomography in patients with radiolucent stones)
Length of hospital stay±SD (days) 3.2±1.4 (2‑8)
using the longest diameter. The average stone size was
Operation time±SD (min) 80.5±30.1 (30‑200)
3.6 ± 2.1 cm (range 0.9–10.5 cm). The demographic data
Stone‑free rate (%) 73.6
and preoperative stone characteristics were summarized
Postoperative UTI (%) 23 (10.6)
in Table 1. The operation time was estimated from the
Sepsis (%) 3 (1.4)
beginning of cystoscopy for the insertion of the occlusion Transfusion rate (%) 3 (1.4)
balloon catheter to the end of the wound closure. The average Conversion to open surgery (%) 0
operation time was 80.5 ± 30.1 min (range 30–200 min). Auxiliary procedures (%)
The target stones were removed in all patients and the Transarterial embolization 0
overall stone‑free rate was 73.6%. The postoperative blood Secondary operation 0
transfusion rate was 1.4% (three patients), and no patients SD: Standard deviations, UTI: Urinary tract infection
underwent angiographic intervention or other procedures
for the treatment of hemorrhagic complications. The change
of hemoglobin was not recorded in the current report due
to retrospective study and postoperative hemoglobin test
was not routinely performed in our practice. As a result,
postoperative follow‑up of serum hemoglobin is not a regular
routine in our hospital. Postoperative spiking fever with
body temperature elevation >38.5°C without evidence of any
other source of infection was considered to be a urinary tract
infection. Postoperative urinary tract infection was noted in
23 patients (10.6%), among them sepsis was noted in three
patients (1.4%); all of these patients recovered well after proper
antibiotic treatments. There was no pulmonary complication
in this study. The average postoperative hospital stay was
3.2 ± 1.4 days (range 2–8 days).
There was no conversion to open surgery in this series. No
patient received a secondary procedure or operation due to Figure 2: Renal ultrasound performed 1–2 weeks after operation revealed
no displacement of the SurgicelTM plug (arrow)
surgery‑related complications. The peri‑ and postoperative
outcomes were revealed in Table 2. No dislodgement of the
SurgicelTM plug, perirenal hematoma, or urinoma formation hemostasis. Without the tamponade effect of the nephrostomy
was noted by postoperative ultrasound survey [Figure 2]. tube, troublesome postoperative tract hemorrhage may be
a nightmare for the operators and patients. Patient’s safety
should always be the first consideration and adequate
Discussion hemorrhage control is a crucial task in tubeless percutaneous
One of the purposes of indwelling nephrostomy tube after renal surgery. To obtain better hemostasis and to improve
percutaneous renal surgery is to obtain tract compression for the efficacy of tubeless PCNL, researchers have reported

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Chang, et al.: Tract cauterization for tubeless PCNL
insertion of various sealants and hemostasis agents in the
renal parenchymal defects. In 2004, Noller et al. first reported
their clinical experience of using fibrin sealant at the renal
parenchymal defect to facilitate nephrostomy tube free PCNL
in 10 renal units. Following percutaneous stone clearance, the
fibrin sealant was injected through an 18‑gauge spinal needle
into the renal parenchyma between the collecting system and
the renal capsule. The authors therefore advocated tubeless
PCNL using fibrin sealant at the renal parenchymal defect and
suggested that the approach appeared to be safe and feasible.[6]
A prospective, randomized study evaluating the safety and
efficacy of fibrin sealant in tubeless PCNL was reported by
Shah et al. in 2006; they found that instillation of fibrin glue
was associated with less postoperative pain and lower analgesic
requirements.[12] Other hemostasis materials such as absorbable
gelatin and SurgicelTM, which are less expensive than fibrin
sealant, have also been used to seal the access tract during
tubeless PCNL. In 2006, Yu packed the nephrostomy cortical
tract with a gelatin patch under nephroscopic vision to prevent
hemorrhage and urine leakage in 15 patients.[13] Singh et al.
prospectively evaluated the use of a gelatin tissue hemosealant
for tubeless PCNL in 50 patients. They reported less pain, lower
analgesia requirements, less urine leakage, and shorter hospital
stay in patients in the gelatin‑assisted tubeless PCNL group.[14]
In a randomized study of 20 tubeless PNL patients reported
by Aghamir et al. in 2006, SurgicelTM has been used to seal
the nephrostomy tract after tubeless PCNL in 10 patients.[8]
The authors claimed that bleeding or extravasation from the
nephrostomy tract treated with SurgicelTM after totally tubeless
PCNL did not decrease, but the sample size was limited in
this study. The authors suggested that a larger sample size is
mandatory to evaluate the effect of SurgicelTM. In our study,
we applied pressure to the access tract using an 8F inflated
Foley catheter, SurgicelTM plug and small dilators through the
working sheath to achieve more effective hemostasis and a low
postoperative blood transfusion rate (1.4%) in 216 patients.
In contemporary studies, the blood transfusion rates after
receiving tubeless PCNL are about 3.4% to 9.1%. [2,15‑18]
The innovative way in SurgicelTM use definitely decreased
the postoperative blood transfusion rate. In our hospital, it
mitigated the blood transfusion rate from 2.5% to 1.4% with
the same tubeless PCNL procedures except for SurgicelTM
use.[3,19] The alteration of hemoglobin is also one of the means
to measure blood loss during tubeless PCNL. Nevertheless,
the hemoglobin level was not collected after tubeless PCNL
in our hospital because it was not a regular routine which was
based on the quite low transfusion rate.
The postoperative hospital stays in this study (3.2 days)
were longer than those in other reported series concerning
tubeless PCNL which were usually <2 days.[3,12] It is because
the National Health Insurance System in Taiwan managed
by the government covers most of the medical fees. Thus,
patients in Taiwan prefer to stay in the hospital until they feel
completely well. However, the postoperative hospital stay in
this study is similar to that of another tubeless PCNL report
22
from Taiwan (3.4 days).[20] There are some limitations of this
study including the retrospective nature and lack of control
study. The shift of serum hemoglobin is also a reliable tool to
evaluate the facility of SurgicelTM but not applied in the current
study. Further comparative and prospective studies are needed
to confirm the efficacy of this procedure.
Conclusion
There are many techniques for improving hemostasis
during tubeless PCNL and we introduce a new technique
for hemostasis of access tract with Surgicel TM. In this
study, we utilized a new scheme for pressure hemostasis
to mitigate access tract bleeding, and our results suggest
that SurgicelTM pressure compression may be an alternative
method to minimize hemorrhagic complications during
tubeless PCNL.
Acknowledgment
We would like to thank Ms. Fang‑Chun Kuo for completing
the article illustration.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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