What type of suture is recommended for Percutaneous Nephrolithotomy (PCNL) removal?

Suture Types for PCNL Removal

For PCNL tract closure, a running subcuticular suture of 4-0 poliglecaprone with cyanoacrylate adhesive skin closure is recommended when performing tubeless PCNL. 1

PCNL Drainage Options and Considerations

The European Association of Urology (EAU) and American Urological Association (AUA) guidelines provide several options for post-PCNL drainage management:

Tubeless vs. Standard PCNL

• Tubeless PCNL (no nephrostomy tube, only ureteral stent) is recommended for uncomplicated cases as it:

  • Reduces pain and hospital length of stay 2
  • Is safe and effective when performed by experienced surgeons 3
  • Has become increasingly common, with 99% of ambulatory PCNL cases using this approach in large series 4

• Totally tubeless PCNL (no nephrostomy tube or stent) can be effective in carefully selected uncomplicated cases 2

• Standard PCNL (with nephrostomy tube) should be considered when:

  • Residual stones are present
  • Active bleeding occurs
  • Urine leakage is observed
  • Risk of infection exists
  • Another percutaneous procedure is anticipated 2, 5

Tract Closure Techniques for Tubeless PCNL

When performing tubeless PCNL, several tract closure techniques have been described:

1. Subcuticular Suture with Skin Adhesive:

   • Running subcuticular suture using 4-0 poliglecaprone
   • Cyanoacrylate adhesive for skin closure
   • No dressing required 1

2. Tract Sealing Techniques:

   • Hemostatic gelatin matrix (FloSeal) application to the nephrostomy tract
   • Use of an occlusion balloon during application to prevent obstruction
   • Placement of a double pigtail ureteral stent to ensure drainage 1

3. Tract Cauterization:

   • Cauterization of bleeding points in the access tract
   • Placement of a Penrose drain overnight
   • Insertion of a double-J ureteral stent 6

Best Practice Recommendations

1. Patient Selection for Tubeless PCNL:

   • Uncomplicated cases with complete stone clearance
   • No significant bleeding
   • No need for second-look procedures
   • No significant collecting system perforation 5

2. Safety Considerations:

   • Always use a safety guidewire during the procedure 2
   • Consider preoperative imaging to identify interposed organs 2
   • Administer appropriate antimicrobial prophylaxis 2

3. Tract Closure Protocol:

   • For tubeless PCNL: Use 4-0 poliglecaprone subcuticular suture with cyanoacrylate adhesive skin closure
   • Consider tract sealing with hemostatic agents in patients at higher risk of bleeding
   • Place a ureteral stent to ensure proper drainage

Potential Complications and Management

• Bleeding: One of the most common complications (7% transfusion rate) 2

  • Tract cauterization or hemostatic agents may reduce this risk 6

• Infection: Fever (10.8%), sepsis (0.5%) 2

  • Appropriate antibiotic prophylaxis is essential 2

• Other complications: Thoracic complications (1.5%), organ injury (0.4%), urinoma (0.2%) 2

The choice of PCNL drainage and closure technique should be based on intraoperative findings, with tubeless PCNL using subcuticular suture closure being appropriate for most uncomplicated cases.