Tubeless Ureterorenoscopy-Our Experience Using a 120 W Laser and Dusting Technique: Postoperative Pain, Complications, and Readmissions.

Abstract

Introduction and Objective: Both double J-stent (DJS) and ureter catheter (UC) drainage represent routine practice following ureterorenoscopy. In select situations, a tubeless approach is possible and safe. In tubeless cases, we use a sheathless dusting technique with the Lumenis® MOSES Pulse™120 H Holmium: YAG laser. We evaluated these three drainage subgroups and compared postoperative pain, complications, and readmissions. Methods: A retrospective database of 269 consecutive patients who underwent primary ureterorenoscopy for the treatment of upper urinary tract stones between October 2018 and August 2019. The cohort was divided according to post-operative drainage as Tubeless, UC, and DJS. The decision on whether to perform post-operative drainage was by surgeon preference. Demographic and clinical parameters such as stone location, number, and burden, hydronephrosis grade, and postoperative complications (fever, acute renal failure, and the obstruction of the upper urinary tract by Stone Street) were assessed. Pain was assessed using a 0−10 Visual Analog Scale score (VAS) and the use of analgesics by dose/case in each group. Results: There were 70 (26%) tubeless, 136 (50%) UC, and 63 (24%) DJS cases. Patients drained with DJSs had a significantly higher stone burden, more severe obstruction, and prolonged operative time. Tubeless and UC-drained patients had the same stone characteristics with maximal diameters of 8.4 (6.1−12) mm and 8 (5.2−11.5) mm in comparison to the stented group, with 12 (8.6−16.6) mm, p < 0.01. The operation time was the longest in the stented group at 49 min (IQR 33−60) in comparison to the UC and tubeless groups at 32 min (23−45) and 28 min (20−40), respectively (p < 0.001). Auxiliary procedures were more prevalent in the stented group, but the overall stone-free rate was not significantly different, p = 0.285. Postoperative ER visits, readmissions, and complications were the highest in the UC-drained group, at 20% in the UC vs. 6% in the tubeless and 10% in the stented groups. Post-operative pain levels and analgesic use were significantly lower in the tubeless group with a significant reduction in opiate usage. Conclusions: A tubeless approach is safe in selected cases with fewer post-operative complications. While DJS should be considered in complex cases, UC may be omitted in straightforward cases since it does not appear to reduce immediate postoperative complications. Those fitted for tubeless procedures had improved postoperative outcomes, facilitating outpatient approach to upper urinary tract stone treatment and patient satisfaction.