Since its inception, percutaneous nephrolithotomy (PCNL) has transformed the treatment of large & complicated kidney stones[1]. Nephrostomy tubes are typically inserted after surgery to aid with drainage, reduce bleeding, & allow access for follow-up operations. Nephrostomy tubes, however, are linked to increased hospital stays, surgical discomfort, & urinary leakage.

The "tubeless PCNL," which was initially introduced in the late 1990s, uses a ureteral stent for drainage instead of a nephrostomy tube. While preserving safety & stone clearance, this change may lower morbidity[2]. Our study compares Conventional PCNL versus Tubeless PCNL in terms of operating time, postoperative pain, analgesic use, hospital stay, complications, & stone clearance.

Fernstrom & Johannson performed the first percutaneous nephrolithotomy (PCNL) in 1976. This method is currently used to treat upper urinary calculi having diameter greater than 2 cm. Following conventional percutaneous nephrolithotomy, a nephrostomy tube & ureteral stent  is placed[3]. The rationale for nephrostomy tube insertion after PCNL is to ensure adequate drainage (especially in cases of infected system) and to offer a tamponade effect on the tract to decrease bleeding. However, the idea of nephrostomy tube insertion is questioned in uncomplicated and uneventful cases, especially if patients develop nephrocutaneous fistula following tube removal. In few studies, it has been observed that tubeless procedure does not increase the chances of serious bleeding [4-6]. The nephrostomy tube causes pain and discomfort to the patient , especially in cases of intercostal placement of tube and secondly the patients with nephrocutaneous fistula experience pain & discomfort & in both the cases patients require extended hospitalization

This was a prospective randomized study conducted in the Department of Urology at Index Medical College Hospital & Research Centre, Indore for 02 Years.

Sample size: 100 patients with renal calculi >1.5 cm were included.

Group A: Standard PCNL (n=50)

Group B: Tubeless PCNL (n=50)

Inclusion Criteria

• Patients with Single or multiple renal stones >1.5 cm
• Patients with Normal contralateral kidney
• Patients with Negative urine culture before surgery

Exclusion Criteria

• Active urinary infection patients were excluded
• Patients with Coagulopathy
• Solitary kidney patients were excluded
• Requirement for multiple access tracts

Surgeon performed all procedures from June 2023 to June 2025, PCNL was performed under C ARM guidance under general anesthesia. Tract dilation was done using metallic dilators upto 22 Fr. In all patients stent was inserted postoperatively.

• Group A (Standard PCNL): Placement of a 20 Fr nephrostomy tube at the end of the procedure.
• Group B (Tubeless PCNL): No nephrostomy tube; only a 6 Fr DJ stent was placed.

Postoperative Evaluation

• Operative time (min)
• Postoperative pain (VAS score)
• Analgesic requirement (mg Tramadol)
• Hospital stay (days)
• Complications (Clavien–Dindo classification)
• Stone-free rate (assessed by ultrasonography/CT on day 7)

Data were analyzed using SPSS version 25. Statistical significance was set at p < 0.05.

Table 1: Baseline Patient Characteristics

No significant differences between groups in demographic or stone parameters.

Table 2: Intraoperative Parameters

Operative characteristics were comparable between groups.

Table 3: Postoperative Outcomes

Tubeless PCNL showed significantly less pain, lower analgesic use, & shorter hospitalization.

Table 4: Postoperative Complications (Clavien–Dindo Classification)

Complications were slightly lower in the tubeless group, though not statistically significant

This study shows that without sacrificing safety or effectiveness, tubeless PCNL provides notable benefits for postoperative recovery. Stone clearance, blood loss, & operating time were  similar in both the groups , suggesting that surgical success is unaffected by the absence of nephrostomy tube [7].

Consistent with findings from other trials, patients having tubeless PCNL reported less discomfort, fewer analgesic needs, & shorter hospital stay. Both groups experienced few complications, including no significant bleeding or need for follow-up operations. Successful tubeless PCNL still depends on careful hemostasis & appropriate patient selection[8].

PCNL has been used mostly in clinical settings since the 1980s. Compared to open surgery, it offers the advantage of lowering hospital stay & morbidity for treating large kidney stones. In PCNL, the insertion of a nephrostomy tube is seen to be the conventional approach for draining the kidney, preventing urine extravasation, blocking the access, & enabling the necessary secondary nephrostomy procedure[9]. However, there was need felt to improvise this surgery because the tube prolongs hospitalization and cause pain and discomfort.

There are two trends in modifications: the first is minimally invasive, which involves reducing the diameter of percutaneous renal access and using a smaller calibre nephrostomy; the second is making the procedure tubeless. The procedure is often known as completely tubeless PCNL when there is no postoperative nephrostomy tube or ureteral stent[10]. Although this type of clinical practice & study is still in its infancy, the term "tubeless" still corresponds to the conventional meaning of the term, which excludes insertion of nephrostomy tube but includes Double J stent placement.

According to the findings in our study, tubeless PCNL reduce operating time & decreases need of analgesia. The fate of any residual calculi found on postoperative imaging is the  key concern related to tubeless PCNL[11-12]. Additionally, our data demonstrated that tubeless PCNL is a safe alternative without increasing the risk of problems such as residual stones, bleeding, fever, or urine leakage. Additionally, tubeless PCNL is substantially less expensive than standard PCNL, according to Choi et al.. In other words, tubeless PCNL is a practical & safe clinical option.

In their respective studies, Shenet et al[13] and Gonulalan et al[14] observed that patients undergoing surgery with the standard percutaneous nephrolithotomy (PCNL) technique reported heightened pain levels and a greater need for postoperative narcotic analgesics compared to those treated with tubeless method. Our study reflected similar findings

Tubeless PCNL is a safe, feasible, & patient-friendly modification of standard PCNL. It significantly reduces postoperative pain & hospital stay without increasing complications or compromising stone clearance. This approach should be considered in appropriately selected patients.

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