Tubeless percutaneous nephrolithotomy

Introduction and Objective: Placement of a percutaneous nephrostomy tube for drainage has been an integral part of the standard percutaneous nephrolithotomy (PCNL) procedure. However, in recent years, the procedure has been modified to what has been called ‘tubeless’ PCNL, in which nephrostomy tube is replaced with internal drainage provided by a double-J stent or a ureteral catheter. The objective of this article is to review the evidence-based literature on ‘nephrostomy-free’ or ‘tubeless’ PCNL to compare the safety, effectiveness, feasibility, and advantages of tubeless PCNL over standard PCNL. Materials and Methods: We performed a MEDLINE database search to retrieve all published articles relating to ‘tubeless’ PCNL. Cross-references from retrieved articles as well as articles from urology journals not indexed in MEDLINE, were also retrieved. Results: The majority of the studies have shown ‘tubeless’ PCNL to be a safe and economical procedure, with reduced postoperative pain and morbidity and shorter hospital stay. tubeless PCNL has been found to be safe and effective even in patients with multiple stones, complex staghorn stones, concurrent ureteropelvic junction obstruction, and various degrees of hydronephrosis. The technique has been successful in obese patients, children, and in patients with recurrent stones after open surgery. Conclusion: Tubeless PCNL can be used with a favorable outcome in selected patients (stone burden <3 cm, single tract access, no significant residual stones, no significant perforation, minimal bleeding, and no requirement for a secondary procedure), with the potential advantages of decreased postoperative pain, analgesia requirement, and hospital stay. However, for extended indications, like supine PCNL, multiple, complex and staghorn stones, and concurrent PUJ obstruction, the evidence is insufficient and should come from prospective randomized trials.


INTRODUCTION
The important milestones in the history of percutaneous renal surgery include Goodwin's description of percutaneous nephrostomy in 1955 [1] and Fernstrom and Johannson's fi rst publication of percutaneous nephrolithotomy (PCNL) in 1976. [2] Wickham in 1979 described the staged approach, [3,4] starting with percutaneous nephrostomy under local anesthesia, followed by the dilatation of the tract serially over the next few days, with subsequent stone removal under general anesthesia using a rigid 30° cystoscope. Alken used this technique as a salvage procedure to remove remaining stones after open surgery, through an operatively established nephrostomy tract. [5] With the expanding experience of both the radiologists and the surgeons, the success rate of this procedure increased dramatically. [6,7] In 1984, Wickham described his fi rst 100 patients undergoing one-stage PCNL, [8] where, once the puncture and dilation were complete, stone extraction was performed using an Amplatz sheath and a specially designed nephroscope. Over the past two decades, PCNL has evolved considerably, refl ecting improvements in technology and surgical skill. [9][10][11][12] In recent years, 'Mini percutaneous nephrolithotomy' ('mini-perc') [13][14][15] and 'Tubeless PCNL' have been introduced with the aim to decrease the morbidity of this already established procedure.

MINI PERCUTANEOUS NEPHROLITHOTOMY
Chan et al. described 'mini-PCNL' with a 13F nephroscope followed by the placement of an 8F nephrostomy tube with a 7F double pigtail ureteric stent. [15] Maheshwari et al. [16] reported lower analgesic requirement with a 9F pigtail nephrostomy tube as compared to a 28F nephrostomy tube. The smaller tube also provided a signifi cantly shorter duration of nephrostomy tract leakage after tube removal. Several other studies have supported the use of smallbore nephrostomy tube in terms of reducing morbidity after PCNL. [17][18][19] However, 'mini-perc' suffer from the disadvantage of poorer visualization due to smaller optics and diffi culty with the use of relatively delicate nephroscopic graspers.

TUBELESS PERCUTANEOUS NEPHROLITHOTOMY
Previously it was thought that nephrostomy tubes provide hemostasis along the tract, avoid urinary extravasation, and maintain adequate drainage of the kidney. [20] However, based on the concept that the purpose of the tube is only to maintain adequate drainage of the kidney, a 'tubeless' approach has been developed by placing a ureteral stent or catheter to provide drainage after PCNL in lieu of a nephrostomy tube.
It may be interesting to note that the idea of 'tubeless' existed even in the early years of evolution of PCNL. In 1984, Wickham [8] published the results of 100 patients in which no internal or external drainage tubes were used at the conclusion of case. Authors stated that with this approach, patients could leave the hospital within 24 h and the procedure was safe and effi cient with a shorter hospital stay. However, subsequently Winfi eld et al. [20] reported two patients with complications of premature nephrostomy-tube removal after the extraction of simple upper-tract calculi, who experienced serious hemorrhage and marked urinary extravasation necessitating transfusion, internal stenting, and prolonged hospitalization. They recommended that nephrostomy tube drainage should be provided during the fi rst 24 to 48 h after percutaneous stone extraction, which subsequently became the standard practice for PCNL worldwide.
In 1997, Bellman and associates [21] challenged the requirement for the routine placement of a nephrostomy tube after percutaneous renal surgery. Their 'tubeless' procedure involved the placement of an internal ureteral stent without any nephrostomy tubes. The study group consisted of 50 patients, who were compared with a control group of 50 patients undergoing percutaneous renal surgery with the standard nephrostomy tube. The hospitalization time, analgesia requirements, time to return to normal activities, and cost were signifi cantly less with this new technique.
Candela et al. [22] showed the cost of a 'tubeless' procedure to be $1,638 compared with $3,750 for traditional percutaneous surgery. Several studies in subsequent years found tubeless PCNL to be effective and safe with low morbidity that provides satisfactory results in selected cases. [23][24][25][26] In most studies, inclusion criteria for this technique were a single puncture tract, procedure lasting less than 2 h, less than three stones with a diameter Ͻ25 mm, complete extraction of all stones, and no signifi cant bleeding at the end of the operation [ Table 1].

PROSPECTIVE RANDOMIZED TRIALS
To the best of our knowledge, there are only few studies in the literature comparing tubeless PCNL with standard nephrostomy drainage in randomized fashion [ Table 2].
In the largest prospective randomized trial published yet, in 202 patients treated at our center, [27] tubeless PCNL (101 patients) was found to have signifi cant advantages over standard PCNL (101 patients) in terms of postoperative pain, morbidity, hospital stay, and period of convalescence. The average visual analogue scale (VAS) pain score on postoperative day 1 for tubeless group patients was 31 mm compared with 59 mm in standard PCNL (P Ͻ 0.01). The difference in average blood loss and urinary infection for the two groups was not statistically signifi cant. The incidence of urinary leakage from the nephrostomy site was signifi cantly less for the tubeless group (0/101), compared with the standard PNL group (7/101). The average hospital stay in the tubeless group was less than 24 h (21.8 ± 3.9 h) and was signifi cantly shorter than that of the standard PCNL group (54.2 ± 5 h) (P Ͻ 0.01). Tubeless group patients took 5-7 days for complete convalescence, whereas standard PCNL patients recovered in 8-10 days. No long-term sequelae were noticed in the median follow-up period of 18 months in any patient.
Shah et al. [31] compared the outcome of tubeless PCNL with small-bore nephrostomy drainage after PCNL. In this study, patients undergoing tubeless PCNL experienced signifi cantly less postoperative pain, needed less analgesia, and were discharged 9 h earlier than patients in the other group. However, 39.4% of patients in the tubeless group had bothersome stent-related symptoms, of which 61.5% needed analgesics and/or antispasmodic agents.
In contrast, a randomized study by Marcovich and coworkers [32] showed no signifi cant difference between a 24F re-entry tube, an 8F pigtail catheter, and a double-J stent. However, their technique involved, along with a double-J stent, the placement of a 20F Councill-tip catheter, which was removed on fi rst postoperative day.

PERCUTANEOUS NEPHROLITHOTOMY WITH AN EXTERNALIZED URETERAL CATHETER
Additional variations of the tubeless procedures have been described. Goh and Wolf [33] , Lojanapiwat et al., [34] and Mouracade et al. [35] reported the placement of an external ureteral stent postoperatively in tubeless PCNL [ Table 1]. Compared with a control group with routine placement of nephrostomy tubes, the tubeless group with ureteral catheter had signifi cant reduction in the length of hospitalization and postoperative analgesic requirement.
Karami et al. [36] reported their 5-year experience in 201 patients undergoing tubeless PCNL with only an externalized ureteral catheter, and concluded that it was a safe, effective, and economical option. Similar results were reported by Ashraf Abou-Elela et al. [37] in 128 patients and Gupta et al. [38] in a study of 69 patients [ Table 1].
Gonen et al. [39] prospectively analyzed the outcomes of tubeless PCNLs using two different stenting techniques, externalized ureteral catheter versus double-J stent placement. They concluded that externalized ureteral catheter is as feasible as a double-J stent. Moreover, stentrelated discomfort and the need for postoperative cystoscopy to remove the double-J stent can be avoided with an externalized ureteral catheter. However, they suggested that in patients who are not completely stone-free at the end of the procedure, use of a double-J stent may be more benefi cial as it may help in spontaneous passage of small residual fragments.

TUBELESS PERCUTANEOUS NEPHROLITHOTOMY WITH A TETHER
One major disadvantage of tubeless PCNL with double-J stent is the need for postoperative cystoscopy to remove the stent. Bellman et al. [40] suggested the placing of a 7F/3F tailed stent with an attached string exiting the urethral meatus, which can be used to pull the stent out afterward in offi ce setting to avoid the need of cystoscopy. However this procedure has the disadvantage that some patients may remove their stents prematurely by inadvertently pulling on the tether [ Table 1].
The use of tether was further modifi ed by Bellman et al. [41] by placing double-J stent with its tether exiting the nephrostomy tract. This allows the stent to be removed directly from the fl ank in the offi ce setting 3-12 days postoperatively by gently pulling on the tether without the need for cystoscopy.
The principle of maintaining the tether exiting from the fl ank may have several applications beyond routine stent placement after tubeless PCNL. In a standard PCNL, nephrostomy tube is left in when a second-look procedure is anticipated. However, it may be possible to leave only a stent with a tether in these cases as well. At the time of the second-look procedure, the tether could be used to pull the end of the stent to the level of the skin, and a guide wire could be passed antegrade into the bladder, thus reestablishing the access tract.
Berkman et al. [42] presented the use of the Polaris ® Loop stent to facilitate tubeless PCNL and minimize pain and narcotic use. The Polaris stent has two fi ne loops distally to minimize  (2) bladder irritation. Following PCNL, Polaris stent was placed antegradely in reverse orientation. The pigtail rested in the bladder and the loops in the nephrostomy tract with the string tether secured at the skin for simple, atraumatic removal. Authors reported that tubeless PCNL with the Polaris stent decreased postoperative pain and narcotic use, and allowed earlier discharge from the hospital.

T O TA L LY T U B E L E S S P E R C U TA N E O U S NEPHROLITHOTOMY
Totally tubeless approach was fi rst reported by Wickham and coworkers. [8] They stated that 'provided the kidney is stone-free, the collecting system remains intact and there is not excessive bleeding, there is no need of nephrostomy tube'. After Winfi eld's unsuccessful trial with totally tubeless PCNL in two cases in 1986, [20] there have been few successful reports of totally tubeless PCNL [ Table 3]. [43][44][45][46][47][48][49] In a randomized study of 60 patients, Aghamir et al. [50] assessed the outcome and safety of the totally tubeless PCNL in renal anomalies (horseshoe kidney, rotational anomalies of pyelocaliceal system, and ectopic kidney). The differences between tubeless and standard PCNL groups in terms of operation time, transfusion rates, complications, retreatment, and overall stone-free rate were not statistically signifi cant. The hospitalization period, analgesia requirements, and return to normal activities were signifi cantly less in totally tubeless group.
These studies favor the suggestion that the best available drainage of the kidney is the normal peristalting ureter. According to this school of thought, the only indication for the placement of a ureteral stent is in the situation when the ureteropelvic junction (UPJ) or upper ureter is infl amed and edematous, or where there is UPJ obstruction, managed or unmanaged. However, this approach has not formed universal acceptability due to the concerns relating to the obstruction of ureter due to clots or stone fragments. Most authors seem to favor some kind of internal drainage in tubeless procedures.

TUBELESS PERCUTANEOUS NEPHROLITHOTOMY WITH THE PATIENT IN SUPINE POSITION
The traditional prone position used in PCNL is diffi cult and risky for patients with cardiopulmonary ailments and compromised respiratory functions, and in markedly obese patients. Sometimes it is impossible for the patient to lie prone because of problems with body habitus such as ankylosing spondylitis, severe lordosis or kyphosis, or hip or lower limb contractures.
Supine PCNL, in addition to saving operating room time, has several benefi ts. Because the tract is inclined downward and more dependent in relation to the renal pelvis, the pressure within the pelvicaliceal system is low, and stone fragments tend to fall out spontaneously. The possibility of a stone falling into the renal pelvis and the ureter is also minimized. It also permits the patient to remain in the lithotomy position for simultaneous ureteral instrumentation if necessary. [51,52] On the other hand, PCNL in the supine position has limitations in upper caliceal puncture as the upper pole is more medial and posterior, and concealed deeply in the rib cage. Classical prone position provides a larger surface area for the choice of puncture site and a wider space for instrument manipulation.
Rana et al., [53] in a study of 184 patients undergoing tubeless supine PCNL, reported stone clearance of 84%, with a mean stone size of 3.5 cm. No vascular or splanchnic injury was observed. Total 4% patients required transfusion, and 1 patient each had a perinephric collection and pleural effusion.

TUBELESS PERCUTANEOUS NEPHROLITHOTOMY WITHOUT STRICT INCLUSION CRITERIA
For reasons of safety, most investigators have focused on using tubeless PCNL only in selected patients with uncomplicated stones. The selection criteria for tubeless Shah et al. [54] reported the results of successful tubeless PCNL in patients with expanded indications including solitary kidneys, larger stones, deranged renal function and in patients requiring multiple access tracts, supracostal puncture, or bilateral simultaneous PCNL.
Rana and Mithani [55] reported 80% stone-free rates in tubeless PCNL in 110 patients. Mean hospital stay was 16-20 h. They also concluded that the degree of obstruction, anatomic variation of renal shape and position, solitary kidney, and elevated serum creatinine are not contraindications to tubeless PCNL.
Sofer et al. [56] reported the applicability of tubeless PCNL without imposing preoperative restrictions in a prospective series of 126 patients. Staghorn stones, supracostal puncture, multiple accesses, anatomic anomalies, previously operated kidneys, solitary kidneys, and operative time were not considered contraindications in this study. They performed 66 tubeless and 60 regular PCNLs and reported complication rate of 9% versus 13%, respectively.
Malcolm et al. [57] published a retrospective review of 42 patients (47 renal units) who were treated with tubeless PCNL for complex renal stone disease (5 bilateral, 25 total/ partial staghorn, 12 renal insuffi ciency, and 10 infundibular stenosis or caliceal diverticulum). Mean length of hospital stay was 2.1 days. One patient required a blood transfusion and one patient developed urosepsis.
Jou et al. [58] performed a retrospective study to assess the outcome and safety of nephrostomy tube-free PCNL (64 procedures in 62 patients) with calculi 3 cm or greater. An 82.8% stone-free rate was reported in this study, and they concluded that with adequate hemostasis, nephrostomy tubefree PCNL can be performed in patients with complicated urolithiasis without any increase in morbidity.
Falahatkar et al. [59] achieved 88.09% stone-free rate in tubeless PCNL in 42 renal units with staghorn stones requiring multiple access tracts, and reported it to be a safe procedure with no signifi cant complications.

TUBELESS PERCUTANEOUS NEPHROLITHOTOMY IN CHILDREN
Salem et al. [60] assessed the effectiveness of tubeless PCNL in 20 children with a mean age of 7.5 (4-15) years. Mean operative time was 115 (45-180) min with no signifi cant bleeding intra-or postoperatively. Tubeless PCNL had the advantages of being less painful, less troublesome, and shortening the hospital stay of the child, as compared to a group of 10 patients with similar criteria operated with PCN tube.

TUBELESS PERCUTANEOUS NEPHROLITHOTOMY WITH PREVIOUS OPEN SURGERY
Shah et al. [61] reported that tubeless PCNL was feasible in a study of 25 patients with a history of ipsilateral open renal surgery, and associated with decreased analgesia requirement and hospital stay without compromising stonefree rates or increasing complications. Exclusion criteria were patients needing more than two percutaneous tracts, signifi cant bleeding, and a signifi cant residual stone burden that would necessitate a staged PCNL.

B I L AT E R A L T U B E L E S S P E R C U TA N E O U S NEPHROLITHOTOMY
Several centers have reported their experience with bilateral tubeless PCNL. [62,63] Shah and colleagues [64] found no increase in the complication rate when comparing their series of 10 bilateral tubeless PCNLs with 10 prior procedures with nephrostomy tube.

'AMBUL ATORY ' TUBELESS PERCUTANEOUS NEPHROLITHOTOMY
Singh and co-workers [65] performed tubeless PCNL in 10 consecutive patients under spinal anesthesia (spinal low-dose anesthesia with low-dose bupivacaine plus fentanyl). No complications were noted, and all patients were discharged home the following day. The mean time to return of S1 sensation, motor block, and walking were 183,118, and 196.6 min respectively. Regional block with tubeless PCNL speeds up recovery and shortens the length of hospitalization and the analgesic requirement.

TUBELESS PERCUTANEOUS NEPHROLITHOTOMY IN ECTOPIC KIDNEY
Tubeless PCNL also has been performed in patients with ectopic kidneys. Matlaga and associates [66] reported their successful experience with laparoscopy-assisted tubeless PCNL in six patients with pelvic kidneys.

TUBELESS PERCUTANEOUS NEPHROLITHOTOMY IN OBESE PATIENTS
Yang et al. [67] reported safe and effective tubeless percutaneous renal surgery in overweight, obese, and morbidly obese patients. They analyzed the data of 45 patients who were considered normal weight (body mass index [BMI] 18.5-25), 55 overweight (BMI 25-30), 28 obese (BMI 30-40), and 5 morbidly obese (BMI 40 or greater). A stone-free rate of 94.5% was achieved. Two patients required readmission for gross hematuria and low hematocrit. One patient required selective angiographic embolization of a pseudo-aneurysm.

TUBELESS PERCUTANEOUS NEPHROLITHOTOMY WITH SUPRACOSTAL ACCESS
Tubeless PCNL using supracostal access was done for 72 patients by Shah et al. [68] The outcome of these patients was compared with that of a historic cohort of similar patients with a nephrostomy tube. Two patients in the study group and three patients in the control group had postoperative hydrothorax, all of whom, except for one in the control group, were managed conservatively.
In a study by Sofi kerim et al., [69] 48 patients were randomized to either an 18F reentry nephrostomy tube or a 6F double-J stent. The number of supracostal accesses was signifi cantly higher in tubeless group (P ϭ 0.02). One of the seven patients with supracostal access in the tubeless PCNL group experienced pleural effusion and was treated conservatively.

HEMOSTASIS IN TUBELESS PERCUTANEOUS NEPHROLITHOTOMY
Two hemostatic agents have been commonly used in PCNL: Gelatin matrix hemostatic sealant (GMHS) and fi brin glue [ Table 4]. Gelatin matrix hemostatic sealant forms a fi ne suspension of particles on contact with urine in vitro. [70,71] Fibrin glue creates a thicker mucoid material on contact with urine that fails to dissolve even after 5 days. [72] Because of experimental evidence of the lithogenic properties of hemostatic agents implanted in the collecting system, an occlusion balloon is placed in the collecting system to prevent hemostatic agents from entering and causing possible obstruction.
Nagele and Schilling et al. [73,74] reported the use of gelatinethrombin-hemostatic sealant following mini-PCNL in a tubeless setting. Mikhail et al. [75] were the fi rst to use fi brin glue as a hemostyptic sealant in 20 patients during PCNL. Several other studies have used fi brin glue with good effects. [76][77][78] Aghamir and colleagues [79] used oxidized cellulose (Surgicel ® ) to seal the working tract and concluded that such sealing of the nephrostomy tract after totally tubeless PCNL did not decrease bleeding or urinary extravasation. In a prospective study of 50 patients, Singh et al. [80] evaluated the role, safety, and effi cacy of using absorbable gelatin tissue hemosealant (Spongostan ® ) in tubeless PCNL. They observed lower wound soakage/discomfort in the gelatin-assisted tubeless PCNL group as compared to controls.
In 51 patients, Jou et al. [81] reported cauterization of the access tract after completing the PCNL with a double-J stenting. Aron et al. [82] also reported diathermy coagulation of the intrarenal bleeders and tract in 20 consecutive patients of tubeless PCNL and reported that fulguration of visible intrarenal and tract bleeders is a simple, safe, and effective hemostatic adjunct. Mouracade et al., [27] in their study of 37 patients, electrocoagulated the nephrostomy tract by a blunt electrocautery loop mounted on a 26F resectoscope. The mean decrease in hemoglobin was 0.95 g/dl. No blood transfusion was required.

ADVANTAGES OF TUBELESS PERCUTANEOUS NEPHROLITHOTOMY
• Patients who undergo tubeless PCNL have signifi cantly less pain postoperatively and require less analgesia dosage. • Tubeless PCNL minimizes the hospital stay, allowing many patients to be discharged from hospital in less than 24 h. • A tubeless procedure offers the advantage of passive dilation of the ureter caused by the indwelling double-J stent to facilitate passage of any unrecognized small stone fragments. • The omission of a nephrostomy tube with the placement

DISADVANTAGES OF TUBELESS PERCUTANEOUS NEPHROLITHOTOMY
• The general consensus is that the tubeless approach is feasible only in a selected population that generally excludes cases requiring two or more accesses, signifi cant intraoperative bleeding, or situations with a likelihood of residual stone fragments. • The other limitations to tubeless PCNL are the possibility of missed residual stone fragment (4-5 mm, invisible on initial postoperative fl uoroscopy) that become apparent later, as a tubeless operation precludes a 'second-look' procedure. • The need for an additional procedure, that is, cystoscopy, to remove the double-J stent. • 'Stent dysuria', which can be troublesome in some patients, and may even warrant the need of early double-J removal. • One of the criticisms of this approach is that the ureteral stent does not necessarily provide drainage of the kidney. It is well established in animal models that stents cause a degree of obstruction and raise intrapelvic pressure. [83] CONCLUSION However, for all these extended indications, the available evidence is insuffi cient, and needs to be substantiated by prospective randomized trials.
Placement of a nephrostomy tube after percutaneous nephrolithotomy (PCNL) is considered as a standard practice. The advantages of nephrostomy tube drainage include adequate renal drainage, temponade of tract bleeding, reduced urinary extravasation and allowance of nephrostomy tract to mature for a second look procedure. PCNL without a nephrostomy and without ureteral catheters, double J stents and nephrostomy is termed tubeless PCNL and totally tubeless PCNL, respectively. [1,2] Advances in the technique, better patient selection, use of smaller caliber nephroscopes, cauterization of the tracts and use of hemostatic agents have contributed to establishing tubeless PCNL as minimally morbid, safe and day care procedure. There are many prospective randomized controlled studies [3][4][5] which conclude that patients with nephrostomy have more post operative discomfort, analgesic requirement and prolonged hospital stay as compared to tubeless PCNL. According to the recent European Association of Urology, tubeless PCNL is an acceptable procedure for the treatment of large renal calculi in selected patients. [6] Level 1 and 2 evidence indicates that tubeless PCNL may become standard of care for selected patient groups like stone size less than 3 cm, single tract access, no serious bleeding or perforation of the pelvicalyceal system (PCS) and complete clearance at the end of the procedure as judged by the intraoperative use of fl uoroscopy. [7] Many authors have extended the indications of doing tubeless PCNL. There are single center Level 4 evidences to suggest that it may be done in patients with solitary kidneys, pediatric patients, larger stone burden, deranged renal function, multiple tracts, supra costal access and bilateral simultaneous procedure.
The criticism for tubeless procedure includes concerns regarding compromised clearance, perioperative complications such as early hematuria, urinary extravasation, clot colic and delayed complications such as need for ancillary procedure for removal of double J stents and stent dysuria. The stone clearance with the tubeless PCNL has been reported between 73-100%. [7] It is now proved that clinically insignifi cant residual fragments (CIRF) may lead to symptomatic episodes in future and hasten stone recurrence. Raman et al. [8] showed that residual fragment post PCNL of size as small as 2 mm may produce stone related event in 43% patients. We were critical of the residual fragment incidence in cases apt for tubeless PCNL. Therefore, in 22 consecutive cases, we performed non-contrast CT scan on fi rst postoperative day and found the incidence to be 23% 9 (accepted BJU, Ahead of print). Routine use of postoperative non-contrast CT may lead to over detection of CIRF, which is clinically relevant. Routine tubeless PCNL are followed by double J stenting, the purpose of which is to facilitate expulsion of these CIRF.
Standard PCNL have been followed by nephrostomy tube drainage. The advantages of nephrostomy tube drainage include acute compression of the tract bleeding and utilizing the same tract for check nephroscopy if required. There is also an undoubted level 1 evidence to suggest the safety of tubeless procedure. If the tubeless procedure is carried out, the fl ank is compressed for a brief period to temponade the bleeding. We feel that with the increasing use of smaller tracts, the tract bleeding is signifi cantly less, so the need for temponade is lesser. Also, various types of tissue sealants have been described like fi brin glue, gel matrix, diathermy cauterization of tract and occlusion balloon. The reports of early hematuria and urinary extravasation with these additional procedures are only anecdotal. Antegrade drainage via double j stents or Ureteric catheter also contributes to lower the early postoperative complications.
Shah et al. [9] reported symptoms in 30% patients of whom 60% required medications. Crook analyzed totally tubeless