Technique of Totally Tubeless Percutaneous Nephrolithotomy with a Safety Suture Thread

Introduction: Placement of a nephrostomy tube at the conclusion of percutaneous nephrolithotomy (PCNL) has been traditionally considered a standard practice. However, in the past decade, tubeless or totally tubeless PCNLs have been performed more frequently. We present our technique of tubeless mini percutaneous nephrolithotomy (mPNL), utilizing a safety suture thread that still allows surgeons transitioning to a totally tubeless technique to maintain access to the percutaneous tract. Materials and Methods: After informed consent, we performed the technique on 40 patients undergoing mPCNL. During the final stage of uncomplicated mPCNL we perform an antegrade pyelography to confirm satisfactory evacuation of the contrast agent from the renal collecting system. Next, a safety suture (Prolene No. 0, length 150 cm) is inserted into the distal lumen of the ureteral catheter and passed retrograde through the ureteral catheter into the renal pelvis. Once in the renal collecting system, the safety suture thread is grasped with forceps inserted through the nephroscope and removed through the flank. The ureteral catheter is then pulled backward by the urethral tip so that the distal end of a safety suture thread remains outside the urethra. The nephroscope sheath is removed while visually inspecting the tract for bleeding. The skin incision is closed and the proximal end of the suture thread is fixed to the skin, whereas the distal (urethral) end of the safety suture is affixed to a Foley catheter with adhesive tape. In case of bleeding, upper tract obstruction, or fever, the suture can be used as a guidewire. This is accomplished by pulling the safety suture at both ends and either inserting a nephrostomy tube at the proximal side of the suture into the percutaneous tract to stop bleeding, or placing a nephroureteral stent along the suture, in a retrograde or antegrade manner. Results: We utilized this technique in 40 patients undergoing mPNL. In 38 patients, no adverse events were noted in the postoperative period, and the safety suture thread was removed on postoperative day 1 with the Foley catheter without difficulty. In one patient, because of delayed bleeding from the percutaneous tract, the safety suture was utilized for antegrade placement of a nephrostomy tube as demonstrated in the video. Drain placement occurred in the procedure room on the ward under local anesthesia with ultrasonography guidance. In another patient, because of persistent leak from the percutaneous tract on postoperative day 1, decision was made to place a ureteral stent in an antegrade manner over the safety suture. Both of these cases avoided the use of operating room, general anesthesia, and cystoscopy. Conclusions: The technique mimics a totally tubeless mPCNL, with a safety suture thread allowing maintenance of control over the percutaneous tract and the collecting system. In case of bleeding in the early postoperative period, it is possible to place a nephrostomy tube along the suture thread for hemostasis and drainage of the collecting system. The technique may be helpful as an intermediate step for surgeons who are considering transition to a totally tubeless PCNL technique. No competing financial interests exist. Runtime of video: 8 mins 35 secs