The Use of Haemostatic Agents in Percutaneous Nephrolithotomy: A Systematic Review

Abstract

Percutaneous nephrolithotomy (PCNL) is the gold standard treatment for large renal and ureteric stones. A nephrostomy tube is often inserted post-operatively to reduce complications such as tract haemorrhage and infection. However, nephrostomy tubes cause significant discomfort, increasing both analgesic requirements and length of inpatient stay. Whilst tubeless PCNL has been shown to be safe in low-risk patients, the risk of above complications remains. To address these concerns, clinicians have trialled applying haemostatic agents (HA) to the tract, with varied results. We aim to determine if HA are safe and clinically beneficial in PCNL. Systematic review of literature yielded 97 original research articles. Seventeen papers were deemed suitable after abstract screening and eligibility criteria application. These 17 research studies compared either tubeless PCNL vs PCNL with HA or PCNL with nephrostomy tube vs PCNL with HA. Within these studies a wide range of HA with differing mechanisms were used. Outcomes compared, where available, included bleeding (as determined by Hb drop or transfusion rates), pain scores, analgesic requirements, length of hospital stay and complication rates. We conclude that low-risk patients undergoing tubeless PCNL are unlikely to benefit from HA. However, potential remains in using HA to complement or replace nephrostomy tube in patients with significant intraoperative bleeding. Further studies are required to determine the optimal patient demographic who may benefit from HA, with a focus on cost-benefit analysis. Whilst HA were found to be safe, concerns remain regarding inadvertent collecting system injection and long-term effects, as well as increased cost.