Percutaneous stone surgery using a tubeless technique with fibrin sealant: report of our first 107 cases

Abstract

Study Type – Therapy (case series)Level of Evidence 4What's known on the subject? and What does the study add?Small case series support the safety and efficacy of tubeless PCNL with fibrin sealant. However, there is a paucity of data from larger case series supporting this approach.To our knowledge, this is among the largest tubeless PCNL series. We found the use of fibrin sealant for tubeless PCNL was associated with excellent stone‐free rates (approaching 90%), short hospitalisation, and low complication rates. Tubeless PCNL with nephrostomy tract fibrin sealant appears to be viable option for appropriately select patients.OBJECTIVE To report on our first 107 cases of tubeless percutaneous nephrolithotomy (PCNL) using fibrin sealant as a haemostatic agent within the access tract. PCNL is the preferred treatment for patients with large renal stones, and the tubeless technique with the use of fibrin sealant has recently gained popularity. PATIENTS AND METHODS We performed a retrospective review of single‐access, PCNL cases performed without a nephrostomy tube from January 2002 to July 2008. Nephrostomy tracts were sealed at the conclusion of each procedure with fibrin‐containing haemostatic agents. We evaluated demographic variables, tracked complications, and compared pre‐ and postoperative haemoglobin, haematocrit and creatinine levels. On postoperative day 1 computed tomography was used to determine stone‐free rates. Student's t‐test calculations were used to determine statistical significance at P≤ 0.05. RESULTS In all, 59 men and 48 women with a mean age of 43 years were included in the analysis of 107 cases. The mean stone size was 2.9 cm2 and the average hospital stay was 1.07 days. Pre‐ and postoperative changes in serum haemoglobin and serum creatinine were not statistically different. Postoperative haematocrit declined by a mean of 4.5% (P≤ 0.05), but no patients required a transfusion. Stone‐free rates were 72% overall, and 90% when excluding patients with residual fragments of <4 mm. Complications included seven asymptomatic subcapsular haematomas, one pseudoaneurysm requiring selective embolization, one urine leak, and five return visits to the emergency room for pain. CONCLUSIONS The use of fibrin sealant in this large tubeless PCNL series was associated with favourable stone‐free rates, short hospital stays, and low complication rates with no significant bleeding. Tubeless PCNL with nephrostomy tract fibrin sealant appears to be a viable option for appropriately selected patients, but future randomised trials are warranted.

Fibrin Sealant: The Only Approved Hemostat, Sealant, and Adhesive—a Laboratory and Clinical Perspective

“…Multiple additional papers address a variety of other topics and will be presented here in descending order of frequency (Table 5) for the use of fibrin sealant in the form of platelet-rich (PRP) or platelet-poor plasma (PPP) [203–213], hepatic surgery [214–222], neurosurgery [223–233], joint replacement orthopedic surgery [234–241], head and neck surgery [242–248], vascular surgery [61, 249–252], gastrointestinal surgery [253–258], gastroesophageal surgery [259–262], other orthopedic surgery [263–266], renal surgery [267–271], cardiac surgery [272–274], dental surgery [275–277], hemophilia [278–280], obstetrical and gynecological surgery [281–283], pancreatic surgery [284–286], transsphenoidal surgery [287–289], bariatric surgery [290, 291], drug delivery [292, 293], endoscopic polypectomy [294, 295], plastic surgery [83, 296], skull base reconstruction [297, 298], complications [299], trauma [300], and urology [301]. …”

“…The first one describes using fibrin sealant in 107 cases of tubeless percutaneous nephrolithotomy as a method of obtaining hemostasis in the access tract [267] with no patients requiring a blood transfusion and with only one pseudoaneurysm requiring selective embolization. The second describes using a laparoscopic coagulum pyelolithotomy employing fibrin sealant to create a colored (methylene blue added) coagulum capable of helping to extract even more stones than originally documented on X-ray studies [268].…”

Percutaneous nephrolithotomy: Large tube, small tube, tubeless, or totally tubeless?

“…Similarly, totally tubeless approach has also been shown to be safe and effective in selected cases. [57]…”

Hemostatic Plug: Novel Technique for Closure of Percutaneous Nephrostomy Tract

“…3 Placement of the NT drainage postprocedure is standard practice; however, many contemporary studies have challenged this approach. [4][5][6][7][8][9][10][11][12][13] Efforts to minimize postoperative morbidity associated with the NT while preserving efficacy and safety have included use of small-bore percutaneous catheters. [14][15][16] Smaller catheter use has resulted in decreased postoperative pain and narcotic requirements 14,15 and may preclude complications in selected patients; however, placement of these catheters is not benign, regardless of caliber.…”

“…8 Such results have prompted many urologists to reevaluate standard protocol in favor of a tubeless approach. [4][5][6][7][8][9][11][12][13] With mounting evidence in support of this technique, we now routinely conclude PCNL in tubeless or totally tubeless fashion if no indication exists for NT placement (Table 1).…”