Totally Tubeless Percutaneous Nephrolithotomy for Upper Pole Renal Stone Using Subcostal Access Seyyed Mohammad Kazem Aghamir, M.D., 1 Seyed Saeed Modaresi, M.D., 1 Mehdi Aloosh, M.D., 1,2 and Ali Tajik, M.D. 3 Abstract Purpose: To assess the outcome and safety of the totally tubeless percutaneous nephrolithotomy (PCNL) from subcostal access in patients with renal stone in the upper pole of the kidney. Patients and Methods: Seventy patients with upper pole renal stones were enrolled in a randomized clinical trial from April 2003 to November 2008. The inclusion criteria were the existence of solely upper pole stones, stone size >1.5 cm, extracorporeal shockwave lithotripsy failure or stone in closed calix and diverticulum, and successful subcostal access for reaching the stone. The exclusion criteria were unsuccessful subcostal access, more than two percutaneous accesses, prominent collecting system perforation, intraoperative significant bleeding, ureteral ob- struction, and renal anomaly. The totally tubeless procedure was performed on 35 patients (group A); another 35 patients (group B) underwent standard PCNL. The incidence of complications, hospital stay, transfusion rate, stone- free rate, and analgesics use as well as return to normal activity were compared during a 1-month study period. Results: The mean stone burden was 2.81 (standard deviation [SD] ¼ 0.59) in group A vs 2.87 (SD ¼ 0.62) cm 2 in group B. Hospitalization averaged 1.49 (SD ¼ 0.7) vs 2.89 (SD ¼ 0.99) days (P < 0.001), and the average analgesics use was 8.2 (SD ¼ 3.59) mg vs 14.3 (SD ¼ 5.99) mg of morphine, respectively (P < 0.001). The patients returned to normal activity in 11 (SD ¼ 4.2) days in group A vs 17.6 (SD ¼ 4) days in group B (P < 0.001). Operative time, transfusion rate, complications, re-treatment, and the overall stone-free rate were not different significantly, and no major complication was seen in the study as well. Conclusion: Totally tubeless PCNL for the upper pole renal stone from subcostal access is accompanied by decreased hospital stay and analgesics use and a rapid return to normal activity. It can be considered as an accepted and cost-beneficial procedure for upper pole renal stones. Introduction T he placement of a percutaneous nephrostomy tube and an internal ureteral stent after the completion of percu- taneous renal surgery is a standard practice; in recent years, however, the literature has gradually suggested that total tubeless percutaneous nephrolithotomy (PCNL) is presum- ably a better practice 1–6 and that it may replace the standard practice in the future. For instance, totally tubeless PCNL is a preferred approach in cases of uncomplicated PCNL, lack of significant perforation of the collecting system and bleeding, no more than two accesses, and even in the case of renal anomalies. 1–3 To the best of our knowledge, subcostal totally tubeless PCNL for solely upper pole renal stones has not been studied previously. Thus, we designed this study to evaluate totally tubeless PCNL for this case in comparison with standard practice. Patients and Methods We used a randomized trial study design, after receiving the approval from the ethical committee of Tehran University of Medical Sciences. Between April 2003 and November 2008, informed consent was obtained from all 87 eligible patients at the time of admission. Then patients underwent subcostal PCNL for upper pole renal stones. The inclusion criteria were the existence of solely upper pole stones, stone size >1.5 cm, extracorporeal shockwave lithotripsy (SWL) failure or stone in closed calix and diverticulum, and successful subcostal access for reaching the stone. The exclusion criteria were unsuccessful subcostal access for reaching the stone, more than two percutaneous accesses, significant perforation of the collecting system, intraoperative significant bleeding, ureteral obstruction in addition to renal anomaly. By using exclusion criteria, 17 patients were excluded and 70 patients were enrolled to the study. 1 Department of Urology and 2 Research Development Center, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran. 3 Department of Epidemiology and Bioinformatics, Tehran University of Medical Sciences, Tehran, Iran. JOURNAL OF ENDOUROLOGY Volume 25, Number 4, April 2011 ª Mary Ann Liebert, Inc. Pp. &&&–&&& DOI: 10.1089=end.2010.0064 1