Journal of Indian Association of Pediatric Surgeons
Journal of Indian Association of Pediatric Surgeons
                                                   Official journal of the Indian Association of Pediatric Surgeons                           
Year : 2018  |  Volume : 23  |  Issue : 1  |  Page : 16--21

Tubeless pediatric percutaneous nephrolithotomy: Assessment of feasibility and safety

Ramaiah Keshavamurthy, Sumit Kumar, Vilvapathy Senguttuvan Karthikeyan, Ashwin Mallya, Girish Gurubasappa Nelivigi 
 Department of Urology, Institute of Nephro Urology, Bengaluru, Karnataka, India

Correspondence Address:
Vilvapathy Senguttuvan Karthikeyan
Department of Urology, Institute of Nephro Urology, Bengaluru - 560 002, Karnataka


Introduction: Tubeless pediatric percutaneous nephrolithotomy (TL-PCNL) is evolving and adult criteria are being safely applied to children. We examine the feasibility, safety, and outcomes of pediatric TL. Materials and Methods: A retrospective review of pediatric (≤18 years) PCNL patients at our institute was done. Patients eligible for TL but underwent tube (T) PCNL due to surgeon choice or protocol were compared with TL. Only children with 100% stone clearance were included, and those receiving nephrostomy for intraoperative complications were excluded from the study. Demographic, baseline, and stone characteristics were matched. Safety, outcome, and complications were assessed. Group T was classified into large bore (22F-LB) and small bore (16F-SB) based on nephrostomy size. Statistical analysis was done. Results: A total of 46 children were eligible - TL in 17 (37%) and T in 29 (63%). Among T, SB was performed in 6/29 (20.7%) and LB in 23/29 (79.3%). TL had fewer complications. Urinary leak developed in 2 (6.9%) patients in T. Eight (27.6%) patients in T and 3 (17.7%) patients in TL had supracostal access with complications similar to infracostal access. SB had significantly lesser and analgesic requirement than LB. SB and TL had similar LOH and analgesic requirement. Adult expanded criteria such as supracostal access, 2 punctures, prior renal surgery, and larger tract size were feasible. Conclusions: TL is safe, feasible, and less morbid alternative to T in uncomplicated pediatric nephrolithiasis. TL is feasible with supracostal access, 2 punctures, adult tract size (24F), and anomalous kidneys. SB nephrostomy is reasonable when tube is indicated.

How to cite this article:
Keshavamurthy R, Kumar S, Karthikeyan VS, Mallya A, Nelivigi GG. Tubeless pediatric percutaneous nephrolithotomy: Assessment of feasibility and safety.J Indian Assoc Pediatr Surg 2018;23:16-21

How to cite this URL:
Keshavamurthy R, Kumar S, Karthikeyan VS, Mallya A, Nelivigi GG. Tubeless pediatric percutaneous nephrolithotomy: Assessment of feasibility and safety. J Indian Assoc Pediatr Surg [serial online] 2018 [cited 2019 Aug 22 ];23:16-21
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Pediatric stone disease though relatively rare is endemic in some South Asian, African, and South American states.[1] The prevalence has increased from 7.9/100000 (1996) to 18.5/100000 patients in 2007 with a narrowed gender gap.[2] Although shockwave lithotripsy (SWL) is the first choice for most pediatric stones, percutaneous renal surgery is preferred for larger and complex stones. The indications and surgical technique are similar in children and adults.[1] The earlier belief that the use of adult-sized instruments, in association with increased number of tracts and sheath size contributes to increased blood loss and morbidity and that small caliber instruments are safe for pediatric percutaneous nephrolithotomy (PCNL) has been challenged. Adult-sized instruments have been safely used in pediatric PCNL.[3] Multiple access, operation time, and type of lithotripter have no effect on glomerular filtration rate in adults.[4] While tubeless (TL) PCNL has proven safety and efficacy in adults, it is increasingly being applied in children with uncomplicated surgery for stones <2 cm.[1],[5] Our study compares the feasibility, safety, efficacy, and outcomes of large tube, small tube, and TL PCNL in pediatric cases.

 Materials and Methods

This was a retrospective record review of the feasibility, safety, efficacy, and outcomes of PCNL from a database of pediatric patients (≤18 years) between January 2012 and August 2015 in the Department of Urology in a tertiary care institute, in South India performing approximately 150 PCNL per year. Institutional review board approval was obtained.


Preoperative evaluation included hemoglobin, serum creatinine, electrolytes, ultrasound, and plain X-ray of the kidneys, ureter, and bladder region (XRKUB), intravenous urogram, or contrast enhanced computed tomography of the KUB region, urine analysis, and culture. Contrast study of the kidneys was done when serum creatinine was normal. Postoperative serum creatinine, electrolytes, and hemoglobin were performed. XRKUB was performed at 48 h after PCNL. Urine culture was performed when children developed fever.


Demographic data including age, gender, height, weight, and body mass index (BMI), presenting symptoms, urinary tract malformations, and prior surgical history were recorded. Stone characteristics such as number of stones, size, location, and configuration were assessed. Intraoperative data included side of operation, access site (supracostal/infracostal), calyces punctured, number of tracts, tract size, operative time and placement of nephrostomy, ureteric catheter (UC), or double J stent (DJS). Outcomes assessed included drop in hemoglobin level, stone-free status (SFS) at discharge, length of hospitalization (LOH), analgesic requirement, complications, and readmission rates. The occurrence of complications was graded according to the modified Clavien classification system and only the complication of the highest grade was analyzed.[6] Analgesic requirement was depicted as the total dose of paracetamol suppository and diclofenac suppository given during the hospital stays and total number of days of analgesic requirement in the hospital.

Surgical procedure

All PCNL were performed at our institute by expert endourologists having at least 10 years of experience in doing PCNL. Under general anesthesia, 4 or 5F UC was inserted using pediatric cystoscope (15F) or 8/9.8F semirigid 12° ureteroscope (Richard Wolf Medical Instruments Corporation, United States). Then, child was turned prone and retrograde pyelography was done for delineation of pelvicalyceal system under fluoroscopy. Appropriate calyx was punctured with an 18G/15 cm diamond-shaped trocar needle and tract dilated up to 24F or 18F depending on stone burden, renal anatomy, and surgeon's comfort. Amplatz sheath of 24 or 18F was placed and slender 22F or 17F rigid Karl Storz (Karl Storz Endoscopy, Tuttlingen, Germany) nephroscope was used, respectively, for the procedure. Intracorporeal lithotripsy was performed using pneumatic Lithoclast (Nidhi Lith Digi, Nidhi Meditech Systems, India). Postoperative drainage was based on intraoperative factors and at the operating endourologist's discretion.

TL PCNL was done in patients with no stone fragments on fluoroscopy at the end of the procedure, no significant bleeding or extravasation or intraoperative adverse events. SFS was defined as no residual stones on postoperative XRKUB done at 48 h after surgery.[5] We included only those patients who achieved complete stone clearance in both the groups. Patients with radiolucent stones, serious pelvicalyceal system perforation requiring DJS and prolonged length of hospitalization (LOH), serious intraoperative bleeding requiring blood transfusion, renal failure, bilateral PCNL, and abandoned and relook PCNL were excluded from the study. Since it was a retrospective study, we included only those patients in PCNL with tube category who could have been managed without tube based on current criteria but had a nephrostomy inserted due to operating endourologist's discretion. Nephrostomy tube was removed after 48 h or after hematuria or fever settled. Patients were usually discharged when there was no urine leak from nephrostomy site, pain, fever, or hematuria. None of the children required adjunctive procedures such as relook PCNL, SWL, or ureterorenoscopy.

Statistical analysis

The data were analyzed using SPSS v. 20.0 (IBM Corp., Armonk, NY, USA). The variables were summarized using mean, standard deviation, median, interquartile range (IQR), and percentages based on the characteristics of the variable. Student's t-test (two-tailed, independent) or one-way ANOVA were used to compare normally distributed continuous variables as appropriate. Mann–Whitney U-test or Kruskal–Wallis test was used in discrete variables as appropriate. Chi-square and Fisher's exact test were used to evaluate parameters on categorical scale. The P < 0.05 was considered statistically significant.


A total of 46 patients were eligible for analysis. For tabulation and analysis, the children were grouped into tube (T) PCNL and TL PCNL. Further subgroup analysis was done as small bore (SB) (16F) versus large bore (LB) (22F) T PCNL with TL PCNL. TL was done in 17 (37%) and T in 29 (63%) children. SB PCNL was done in 6/29 (20.7%) and LB PCNL was performed in 23/29 (79.3%) The demographic, stone, and operative characteristics were comparable across the T and TL groups [Table 1] and [Table 2]. The median (IQR) age was 14(5) years, 25 (54.3%) were boys, and median (IQR) BMI was 15.5 (2.05) kg/m 2. The median (IQR) stone size was 1.6 (1) cm. All the patients were in class I ASA. None of the children needed readmission.{Table 1}{Table 2}

Tubeless percutaneous nephrolithotomy

The median stone burden was 1.3 (0.7) cm and operative time was 60.0 (7.5) minutes. LOH, drop in hemoglobin, paracetamol, and diclofenac requirements and number of days of analgesia are shown in [Table 3]. TL was performed in 3 anomalous kidneys – 2 horseshoe kidneys and 1 with duplex collecting system. Complications occurred in 4/17 (23.5%) patients. Three children had postoperative fever and one child developed paralytic ileus for 48 h. None of these children encountered major complications. None of these children needed to return to the operating room for complications such as bleed or nephrostomy site leak. DJS was placed in 5 patients (5/17; 29.4%) in this group. Mean LOH was 2.8 days. UC was placed in 12 patients (70.6%) with mean LOH of 3 days.{Table 3}

Tube percutaneous nephrolithotomy

The median stone burden was 1.8 (0.6) cm and operative time was 75 (30) minutes. LOH, drop in hemoglobin, paracetamol, and diclofenac requirements and number of days of analgesia are shown in [Table 3]. Complications developed in 18 (18/29; 62.1%) patients. Postoperative fever was the most common complication detected in 14 (14/29; 48.3%) patients. Fever subsided after suppository paracetamol in 12 patients while infusion paracetamol and antibiotic change based on urine culture was required in 2 patients. Urinary leak developed in 2 patients (2/29; 6.9%) after removal of UC. Postoperative paralytic ileus developed in 2 (2/29; 6.9%) children which settled in 48–72 h. None of these children encountered major complications including hydro thorax or pneumothorax. No child needed readmission. Children with SB PCNL had significantly lesser LOH and analgesic requirement. Operation time and complication rates were similar [Table 4]. SB PCNL and TL had similar LOH and analgesic requirement [Table 5]. Minor complications (Clavien 1, 2) were encountered in 3/6 patients in SB PCNL. Besides, 8 patients (8/29; 27.6%) in T group and 3 patients (3/17; 17.7%) in TL group underwent supracostal PCNL with no pneumothorax, hydrothorax, and a similar complication rate as infracostal PCNL.{Table 4}{Table 5}


Percutaneous renal surgery is still the preferred modality of management of renal stones in both children and adults in spite of retrograde intrarenal surgery making inroads. Conventionally, nephrostomy tube drainage is an integral part of standard PCNL. The advantages of nephrostomy include adequate urinary drainage, hemostatic tamponade along the fresh percutaneous tract and as an access tract for relook PCNL.[7]

Placement of nephrostomy tubes in the vicinity of a rib contributes to postoperative pain and complications.[7] Bellman challenged the routine placement of nephrostomy tubes and advocated TL.[8] A recent meta-analysis of 14 randomized controlled trials in adults comparing 776 subjects revealed statistically significant differences in LOH, postoperative analgesic requirement, and urine leak between standard and TL; however, stone-free rate, postoperative fever, and blood transfusion rates were similar.[9] Desai et al. randomized 30 adults into LB (20F), SB (9F), and TL groups and concluded patients undergoing TL had significantly better reduced need for analgesia, shorter LOH, and lesser morbidity than SB and LB.[7] Etemadian et al. retrospectively reviewed the records of 38 children who underwent PCNL using adult-sized instruments with tract size between 26 and 30F and concluded that adult-sized instruments can be safely employed in pediatric patients with significantly decreased LOH in TL.[3] Khairy Salem et al. reported that the mean pain score and median LOH were lesser in TL (pain score: 5.5 in T vs. 4.6 in TL; LOH: 2.8 days in T vs. 1.7 days in TL) in a prospective study.[10]

Tube versus tubeless percutaneous nephrolithotomy

In our study, TL had fewer complications. Due to retrospective nature of our study, even in patients eligible for TL based on current literature, tube was placed. In the initial period, tube PCNL was performed as a protocol and as experience was gained, TL was routinely performed only in uncomplicated cases.[11] This gave us unique comparative groups to compare T and TL in this retrospective study. To the best of our knowledge, only one randomized trial assessing the feasibility of totally TL pediatric PCNL exists and they found that it is safe and cost beneficial in selected patients.[12] TL contributes to significantly reduced LOH, lesser analgesic requirement, and decreased rate of postoperative fever and urinary leak. Our outcomes are similar to the results of Khairy Salem et al.[10] We also observed that supracostal approach is safe in pediatric PCNL.

Small bore nephrostomy (16F) versus tubeless percutaneous nephrolithotomy

Contrary to our results, Shah et al. reported in adults undergoing TL significantly lesser postoperative pain, lesser analgesic requirement, and shorter LOH than SB.[13] In a randomized trial in adults, Marcovich et al. found no significant difference between a 24F reentry tube, an 8F pigtail catheter, and DJS.[14] This difference could be due to the adult population in aforesaid studies, the smaller number of patients undergoing SB nephrostomy in our study and the use of 16F nephrostomy tube as SB as compared to 8 or 9F in other studies. To sum up, SB and TL are similar in outcomes but superior to LB nephrostomy with respect to LOH and analgesic requirement. To the best of our knowledge, this is the first study comparing LB and SB with TL in pediatric population.

Double J Stent versus ureteric catheter in tubeless percutaneous nephrolithotomy

Placement of DJS contributes to similar LOH but has the disadvantages of stent dysuria, increased risk of urinary tract infections, and most importantly, the requirement of an additional procedure for DJS removal under GA in children with need for the absence from school.

Expanded criteria for tubeless percutaneous nephrolithotomy

Previous studies on TL have proven its safety in selected patients with operative duration <1 h, stone size <3 cm, a single access tract, with no noticeable hemorrhage or significant pelvic or ureteric perforations during the operation or residual stones for secondary percutaneous surgery and absence of distal stone obstruction, ureteric stricture, or severe prostate hyperplasia.[15] Sofer et al. reported in a prospective series of 126 adult patients the applicability of TL even to patients with supracostal puncture, multiple accesses, anatomic anomalies, previously operated kidneys, staghorn stones, solitary kidneys, and increased operative time. They performed 66 TL and 60 regular PCNL and reported complication rate of 9% versus 13%, respectively.[16] Smaller tract size (18F) was associated with reduced complication rate and lesser LOH though the difference was not statistically significant. In our study, we observed that expanded criteria for TL in adults as proposed by Sofer et al. and Shah et al., that is, supracostal approach, 2 punctures, anomalous kidneys, prior renal surgery, and larger tract size are feasible in children.[16],[17] Based on this, multicentric prospective studies with a larger sample size can be helpful in laying down expanded criteria for pediatric TL.


Due to the retrospective design of this study, there are limitations. Surgeon bias to tube in the initial period in our institute as explained, however, provided a unique comparative group to compare TL versus T for stones <2 cm. Small sample size and small representative samples in subanalysis groups may also be a limiting factor for outcomes in our study. As minimum size of nephrostomy tube used in our study was 16F, this might not be truly representative of SB drainage although there was a significant difference in outcomes as compared to the LB group. Pain could not be assessed by visual analog pain score, however, this limitation was overcome by comparing the total dose and duration of requirement of analgesia in both the groups as a surrogate measure.

Future randomized controlled trials would be helpful to analyze the safety, feasibility, and outcomes of TL in children. Besides, 8–9F nephrostomy tubes can be used as SB nephrostomy in future studies for comparison with LB nephrostomy and TL PCNL to assess the outcomes and morbidity.


TL PCNL is a safe, effective, and less morbid alternative technique to T PCNL in uncomplicated pediatric nephrolithiasis. It is feasible in PCNL with supracostal access, 2 punctures, adult tract size (24F), and anomalous kidneys. SB nephrostomy is a reasonable alternative in patients requiring a tube.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Türk C, Petrík A, Sarica K, Seitz C, Skolarikos A, Straub M, et al. EAU guidelines on diagnosis and conservative management of urolithiasis. Eur Urol 2016;69:468-74.
2Roudakova K, Monga M. The evolving epidemiology of stone disease. Indian J Urol 2014;30:44-8.
3Etemadian M, Maghsoudi R, Shadpour P, Mokhtari MR, Rezaeimehr B, Shati M. Pediatric percutaneous nephrolithotomy using adult sized instruments: Our experience. Urol J 2012;9:465-71.
4Bayrak O, Seckiner I, Erturhan SM, Mizrak S, Erbagci A. Analysis of changes in the glomerular filtration rate as measured by the cockroft-gault formula in the early period after percutaneous nephrolithotomy. Korean J Urol 2012;53:552-5.
5Delnay KM, Wake RW. Safety and efficacy of tubeless percutaneous nephrostolithotomy. World J Urol 1998;16:375-7.
6Tefekli A, Ali Karadag M, Tepeler K, Sari E, Berberoglu Y, Baykal M, et al. Classification of percutaneous nephrolithotomy complications using the modified Clavien grading system: Looking for a standard. Eur Urol 2008;53:184-90.
7Desai MR, Kukreja RA, Desai MM, Mhaskar SS, Wani KA, Patel SH, et al. Aprospective randomized comparison of type of nephrostomy drainage following percutaneous nephrostolithotomy: Large bore versus small bore versus tubeless. J Urol 2004;172:565-7.
8Bellman GC, Davidoff R, Candela J, Gerspach J, Kurtz S, Stout L. Tubeless percutaneous renal surgery. J Urol 1997;157:1578-82.
9Yuan 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.
10Khairy Salem H, Morsi HA, Omran A, Daw MA. Tubeless percutaneous nephrolithotomy in children. J Pediatr Urol 2007;3:235-8.
11Agrawal MS, Agrawal M. Tubeless percutaneous nephrolithotomy. Indian J Urol 2010;26:16-24.
12Aghamir SM, Salavati A, Aloosh M, Farahmand H, Meysamie A, Pourmand G. Feasibility of totally tubeless percutaneous nephrolithotomy under the age of 14 years: A randomized clinical trial. J Endourol 2012;26:621-4.
13Shah 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.
14Marcovich R, Jacobson AI, Singh J, Shah D, El-Hakim A, Lee BR, et al. No panacea for drainage after percutaneous nephrolithotomy. J Endourol 2004;18:743-7.
15Rifaioglu MM, Onem K, Buldu I, Karatag T, Istanbulluoglu MO. Tubeless percutaneous nephrolithotomy: Yes but when? A multicentre retrospective cohort study. Urolithiasis 2014;42:255-62.
16Sofer M, Beri A, Friedman A, Aviram G, Mabjeesh NJ, Chen J, et al. Extending the application of tubeless percutaneous nephrolithotomy. Urology 2007;70:412-6.
17Shah HN, Kausik VB, Hegde SS, Shah JN, Bansal MB. Tubeless percutaneous nephrolithotomy: A prospective feasibility study and review of previous reports. BJU Int 2005;96:879-83.