Advancements in Performance of Percutaneous Nephrolithotomy in Ambulatory Surgery Centers: Outcomes and Lessons From 1250+ Cases.

OBJECTIVE: To evaluate the safety and efficacy of routine ambulatory percutaneous nephrolithotomy (PCNL) in a freestanding ambulatory surgical center. METHODS: Patients were treated between 2015 and 2022 by one of three experienced endourologists in Maryland. The surgery center is free-standing, with the nearest hospital approximately 10 minutes away. Patient characteristics and surgical datapoints, including need for transfer, were gathered prospectively at the time of surgery. Subset analyses were performed in patients with staghorn calculi or elevated body mass index, as they represent higher-risk populations. RESULTS: A total of 1267 patients underwent ambulatory PCNL with a median stone diameter of 32 mm. The average recovery time was 87 minutes, with 1.7% of patients requiring transfer to the hospital, generally for postoperative hypotension or inadequate pain control. 166 patients with body mass index >40 were safely treated, with no significant difference in transfer rate (P = .5). 2.8% of patients had a complication, with the majority being Clavien-Dindo grade I or II. 88 patients with staghorn calculi were treated, with a 6% transfer rate. Staghorn calculi were the only factor found on multivariable analysis to be a significant predictor of transfer (OR 3.56 (1.17-10.82) P < .05). CONCLUSION: Ambulatory PCNL may safely be performed in a surgery center in most patients. These outcomes reflect the real-world experience of high-volume surgeons and demonstrate a multiyear paradigm shift in PCNL from an inpatient procedure to an outpatient procedure in a surgery center.

Ambulatory Percutaneous Nephrolithotomy in a Free-Standing Surgery Center: An Analysis of 500 Consecutive Cases.

Introduction: Percutaneous nephrolithotomy (PCNL) is an effective procedure for removal of large kidney stones; however, PCNL has traditionally been reserved for inpatient surgery. Certain cases are being performed entirely at an ambulatory surgery center (ASC), known as ambulatory PCNL (aPCNL). Materials and Methods: Five hundred consecutive PCNL procedures performed at a free-standing ASC between April 2015 and February 2019 were analyzed. Patient demographics, stone characteristics, operative characteristics, and postoperative data, including transfer to hospitals, 30-day readmissions, and complications > Clavien I, were recorded. Results: The mean age of patients undergoing PCNL at the ASC was 57 (range: 16-86) and body mass index 30 (16-49). American Society of Anesthesiologists (ASA) compositions are as follows: ASA 1 (6.5%), ASA 2 (56.2%), ASA 3 (37.2%), and ASA 4 (0. 1%). The mean stone burden was 30 mm (5-140). Standard tract dilation (24-30F) comprised 77% of cases. Ninety-two percent of cases were performed with a single tract, and 99% of cases had a ureteral stent as the only form of drainage (tubeless PCNL). The mean operative time was 104 minutes (32-305), and postanesthesia care unit time was 97 minutes (37-247). The predicted stone-free rate was 84%. Twelve patients (2.4%) required transfer to hospital, and the 30-day readmission rate was 4.2%. Conclusion: aPCNL is a safe and feasible procedure if performed by a high volume endourologist, even within the confines of a free-standing ASC. It is our opinion that the utilization of endoscopic combined intrarenal surgery facilitates high stone-free rates with minimal morbidity and low readmission rates. The institutional review board number is WIRB # 20171472.

Endoscopic Combined Intrarenal Surgery Can Accurately Predict High Stone Clearance Rates on Postoperative CT.

OBJECTIVE: To determine stone clearance rates using endoscopic combined intrarenal surgery (ECIRS) and assess the accuracy of intraoperative prediction of stone-free (SF) status compared to postoperative CT scan. METHODS: A single institution, prospectively maintained database of ECIRS was queried for procedures performed 8/2017 to 1/2018. Retrograde access was performed using a ureteral sheath and flexible ureteroscope. Percutaneous nephrolithotomy was performed through a 30fr or 18fr sheath in prone position. Residual stone status was estimated at the end of each procedure and was verified with postoperative CT scan. SF was defined as no single stone >2mm3 on CT. RESULTS: One hundred and ten procedures were reviewed. Average age was 58.9 ± 12.6 years (range 26-87) and 69 (63%) were male. The mean stone size was 33.3 ± 23.5 mm (range 4-140 mm). Ninty-three patients (84.5%) were endoscopically estimated to be SF, of which 84 (90% of predicted SF cohort, 76% of total cohort) were confirmed SF via CT scan. The sensitivity for estimating SF status with ECIRS was 65.4% (95%CI 44.3%-82.8%), specificity was 100% (95%CI 95.7%-100.0%) and accuracy was 91.8% (95%CI 85.0%-96.2%). SF patients had significantly smaller stones than those with residual fragments (28.5 ± 2.1 vs 48.4 ± 5.7mm, P <.0001). On logistic regression, the factors associated with residual stones were preoperative stone burden (OR 1.03 per mm, 95%CI 1.01-1.05, P = .0004) and fluoroscopy time (OR 1.01 per minute, 95%CI 1.0-1.02, P = .0081). CONCLUSION: ECIRS accurately predicts clinical SF status and may obviate the need for additional CT scans. Consistent with prior studies, the primary determinant of residual stone after percutaneous nephrolithotomy is initial stone size.

Outpatient Tubeless Percutaneous Nephrolithotomy Performed in a Freestanding Ambulatory Surgery Center.

Background: Percutaneous nephrolithotomy (PNL) is a procedure that has traditionally been performed in an inpatient or hospital setting. Many surgical procedures have evolved over time from an inpatient/hospital setting to outpatient procedures performed in surgical centers. Outpatient PNL has become an accepted standard in select patients, but to date, the procedure has not been performed in an outpatient surgical center. Case Presentation: We describe our initial experience managing large renal stone burden with PNL performed completely outpatient in a freestanding ambulatory surgery center. The patient was carefully selected as a young, healthy, thin patient with straightforward renal stone burden and favorable anatomy per CT. Access was achieved with a combination of fluoroscopic and endoscopic needle guidance. The procedure was performed with several modifying factors to enable an effective outpatient discharge. Conclusion: Our experience reinforces the outpatient feasibility of PNL and incites the possibility of transitioning the procedure to an ambulatory surgical center in select patients to provide healthcare savings and an improved patient experience.

Are we fearful of tubeless percutaneous nephrolithotomy? Assessing the need for tube drainage following percutaneous nephrolithotomy.

OBJECTIVE: The objective was to demonstrate that percutaneous nephrolithotomy (PCNL) can be safely performed with a tubeless or totally tubeless drainage technique. INTRODUCTION: Standard PCNL includes nephrostomy tube placement designed to drain the kidney and operative tract at the conclusion of the procedure. Modern technique trend is tubeless PCNL and totally tubeless PCNL, which are performed without standard nephrostomy drainage. We aim to reinforce current literature in demonstrating that PCNL can be safely performed using a tubeless technique. With compounded supportive data, we can help generate a trend toward a more cost-effective procedure with improved pain profiles and patient satisfaction, as previously shown with the tubeless technique. METHODS: Retrospective analysis of 165 patients who underwent PCNL treatment was performed. Of this group, 127 patients underwent traditional nephrostomy drainage following PCNL. A tubeless procedure was performed in the remaining 38 patients. Patient's postoperative stone size and burden as well as complication profiles were analyzed. Largest stone size and total stone burden was similar between the groups. RESULTS: Patient characteristics and demographic information were compared and no significant statistical difference was identified between the groups. Complication rates between the groups were compared and no statistical difference was noted. A total of 23 patients had at least one postoperative complication. CONCLUSION: Tubeless and totally tubeless PCNL demonstrates equivalent outcomes in the properly selected patient group when compared to PCNL performed with a nephrostomy tube. Although this is not the first study to demonstrate this, a large majority of urologists continue standard nephrostomy placement after PCNL. More studies are needed that demonstrate safety of this practice to shift the pendulum of care. Thus, tubeless and totally tubeless PCNL can be performed safely and effectively, which has previously been shown to improve cost, patient pain profiles, and length of hospitalization.

A clever technique for placement of a urinary catheter over a wire.

OBJECTIVE: The objective was to present a straightforward, step-by-step reproducible technique for placement of a guide-wire into any type of urethral catheter, thereby offering a means of access similar to that of a council-tip in a situation that may require a different type of catheter guided over a wire. MATERIALS AND METHODS: Using a shielded intravenous catheter inserted into the eyelet of a urinary catheter and through the distal tip, a "counsel-tip" can be created in any size or type of catheter. Once transurethral bladder access has been achieved with a hydrophilic guide-wire, this technique will allow unrestricted use of catheters placed over a wire facilitating guided catheterization. RESULTS: Urethral catheters of different types and sizes are easily advanced into the bladder with wire-guidance; catheterization is improved in the setting of difficult urethral catheterization (DUC). Cost analysis demonstrates benefit overuse of traditional council-tip catheter. CONCLUSION: Placing urinary catheters over a wire is standard practice for urologists, however, use of this technique gives the freedom of performing wire-guided catheterization in more situations than a council-tip allows. This technique facilitates successful transurethral catheterization over wire in the setting of DUC for all catheter types and styles aiding in urologic management of patients at a cost benefit to the health care system.

Hemostatic plug: novel technique for closure of percutaneous nephrostomy tract.

Percutaneous nephrolithotomy (PCNL) is a standard treatment for patients with large or complex kidney stones. The procedure has traditionally included postoperative placement of a nephrostomy tube to allow for drainage and possible reentry. This practice was first implemented after complications incurred after tubeless PCNL in a small patient population. Recently, tubeless PCNL has reemerged as a viable option for selected patients, resulting in decreased pain and analgesic use, shorter hospitalization, quicker return to normal activity, and decreased urine extravasation. Gelatin matrix sealants are occasionally used in nephrostomy tract closure. Techniques for delivery of these agents have been ill described, and placement may be performed with varying results. We present a literature review comparing tubeless PCNL to its traditional variant with indications for use of each, as well as a comparison of agents used in closure. Finally, we outline a novel, reproducible technique for closure of the dilated percutaneous renal access tract.