Presented by: Natalia L. Arias Villela MD
Chesapeake Urology

Introduction

Percutaneous nephrolithotomy (PCNL) has traditionally been considered an inpatient surgery due to the risk of bleeding and systemic infection. The evolution of technology and surgical approaches, such as the application of endoscopic combined intrarenal surgery (ECIRS) and mini-PCNL (mPCNL), have increased the safety of this procedure. In this series, we show that ambulatory PCNL (aPCNL) may be safely and efficaciously performed in most patients. 

Materials

We analyzed patients who underwent aPCNL, including standard PCNL (24-30Fr) and mPCNL (14-23Fr), at two free-standing ambulatory surgery centers (ASCs) between 2015-2022. Patient exclusion criteria for the ASC included BMI > 50, severe cardiopulmonary conditions, and history of prior anesthetic complication. Patients were positioned either prone or in the Galdakao-modified Valdivia supine position. Standard practices included ECIRS technique for renal access, ureteral stent only for drainage with a thrombin-soaked hemostatic plug in the access tract, and surgeon-administered intercostal rib block to optimize pain control. Patients were observed in the post-anesthesia care unit (PACU) for 90 minutes and were sent home without a Foley catheter. Patient demographic, pre-operative, and post-operative data were prospectively collected. Descriptive statistics were used for data analysis. 

Results

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A total of 1610 cases were available for analysis (Table 1). The mean age of patients was 57.4, mean BMI was 33.1, and mean ASA score was 2.3. 27% of patients had diabetes and 59% had hypertension. 17% of patients had a positive urine culture treated pre-operatively. The mean stone burden was 31.4mm. Standard tract PCNL was used in 66% of cases and 92% of cases were done through a single tract. 99% of cases had a ureteral stent as the only form of drainage. The mean treatment time was 18 minutes and mean PACU time was 84 minutes. There was no planned second look in 90% of cases. The average estimated blood loss was 41mL. 1.9% of patients had a Clavien-Dindo complication > grade 2, but none were grade 5. Only 1.7% of patients required hospital transfer.

Conclusion

aPCNL is efficacious and safe in appropriately selected patients. In our high-volume series, we found a low morbidity rate and low risk for hospital transfer. Unless there are medical or social factors precluding same day discharge, PCNL should be routinely performed as an ambulatory procedure. 

Funding

None

Lead Authors

Max R. Drescher, MD
Chesapeake Urology

Co-Authors

Andy J. Martinez Morales, MD
Chesapeake Urology

Suneet Waghmarae, BA
University of Maryland School of Medicine

Daniel C. Rosen, MD
Chesapeake Urology

Meagan M. Dunne, MD
Chesapeake Urology

Joel E. Abbott, MD
Chesapeake Urology

Julio G. Davalos, MD
Chesapeake Urology