J Gandhara Med Dent Sci

ORIGINAL ARTICLE

COMPARISON BETWEEN TUBELESS AND TUBE PERCUTANEOUS NEPHROLITHOTOMIES

IN PEDIATRIC POPULATION: A RANDOMIZED CONTROLLED TRIAL

Sajjad Ali

, Tariq Ahmad

, Murad Ali , Mohammad Anees Iqbal

, Abdul Jabbar

, Aboozar Khan

ABSTRACT

OBJECTIVES

This study aimed to compare the ecacy and safety of tubeless versus

conventional tube PCNL in pediatric patients with renal calculi >10mm.

METHODOLOGY

A randomized controlled trial conducted at Khyber Teaching Hospital,

Peshawar (October 2024-Sep 2025). Six hundred forty pediatric patients (6-

18 years) with kidney stones >10mm were randomly allocated to Group A

(Tubeless PCNL, n=320) and Group B (Tube PCNL, n=320). A single

experienced urologist performs the procedures. Primary outcomes, including

operative time, hospital stay, blood transfusion requirements, and stone -free

status, were measured.

RESULTS

Groups had similar baseline characteristics (mean ages 11.2±3.1 vs 11.4±3.2

years). Tubeless PCNL showed signicantly shorter operative time (45±10 vs

50±12 minutes, p<0.01), reduced hospital stay (2.0±0.8 vs 2.5±1.0 days,

p<0.01), lower blood transfusion requirements (7.8% vs 14.1%, p=0.02), and

higher stone-free rates (95.3% vs 90.6%, p=0.04).

CONCLUSION

Tubeless PCNL demonstrated statistically and clinically signicant

advantages, including shorter operative times, reduced hospital stays, fewer

transfusions, and higher stone-free rates, supporting its adoption as the

preferred approach for pediatric renal calculi management.

KEYWORDS: Pediatric Nephrolithiasis, Percutaneous Nephrolithotomy,

Tubeless Pcnl, Stone-Free Status, Blood Transfusion

How to cite this article

Ali S, Ahmad T, Ali M, Iqbal MA,

Jabbar A, Khan A. Comparison

Between Tubeless and Tube

Percutaneous Nephrolithotomies in

Pediatric Population: A Randomized

Controlled Trial. J Gandhara Med

Dent Sci. 2026;13(1): 12-17.

Date Submission: 04-10-2025

Date Revised: 11-12-2025

Date Acceptance: 14-12-2025

Postgraduate Resident, Urology

Department, Khyber Teaching

Hospital, Peshawar

Correspondence

Tariq Ahmad, Associate Professor,

Urology Department, Khyber

Teaching Hospital, Peshawar

+92-345-9228080

drtariqurologistikd@gmail.com

INTRODUCTION

Pediatric nephrolithiasis is one of the most challenging

clinical conditions in pediatric urology, characterized

by calculi in the renal pelvis, collecting system, or

ureter. Historically considered rare in children, the

incidence of pediatric kidney stones has witnessed a

dramatic increase over the past two decades, with

annual incidence rates rising by 6-10% in the United

States.¹ This phenomenon is especially noted among

teenage groups, with the most signicant increase

recorded in Black females.² The upsurge has placed

nephrolithiasis among the top causes of pediatric

urology referrals and admissions, calling for immediate

intervention to maximize therapy approaches. The

clinical presentation of pediatric nephrolithiasis varies

widely with age. Young children have nonspecic

symptoms like nausea, vomiting, irritability, or failure

to thrive and often present diculties for diagnosis.³

Older children and teenagers, on the other hand, present

with more typical symptoms like ank pain, hematuria,

and dysuria. The etiology underlying pediatric

nephrolithiasis is predominantly metabolic, with

hypercalciuria, hypocitraturia, and hyperoxaluria being

the most frequent abnormalities.⁴ These metabolic

disturbances, in association with diet and environmental

factors, are responsible for the rising prevalence and

complexity of pediatric stone disease. Percutaneous

nephrolithotomy (PCNL) has become the foundation

surgical procedure for pediatric kidney stones,

especially for large stones (>10mm) or complex calculi

that are refractory to conservative treatment.⁵ The

procedure has advanced signicantly since its

inception, with the development of miniaturized

techniques such as mini-PCNL and micro-PCNL. These

advances employ smaller instruments and improved

access methods, leading to shorter operative time, lower

radiation exposure, and decreased perioperative

complications such as hemorrhage and organ

perforation.⁶ Historically, postoperative care for PCNL

https://doi.org/10.37762/jgmds.13-1.797

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J Gandhara Med Dent Sci

included the routine insertion of nephrostomy tubes to

guarantee proper drainage of the kidney and allow

secondary intervention if needed.⁷ Recent data have

questioned this traditional practice, establishing the role

of "tubeless" PCNL, which eliminates the need for tube

insertion. The method is based on successful

hemostasis, low residual stone burden, and the absence

of signicant complications during the procedure.⁸

Among adult populations, tubeless PCNL has

demonstrated several benets over traditional tube-

based techniques, including lower postoperative pain,

shorter hospital stays, reduced analgesic requirements,

and greater patient satisfaction.⁹ In adult cohorts, meta-

analyses have repeatedly demonstrated favourable

outcomes with tubeless methods, including higher

stone-free rates, lower transfusion requirements, and

lower overall morbidity.¹⁰ Nonetheless, their validity in

pediatric populations cannot be assured due to

anatomical and physiological parameters specic to

children. The pediatric population presents unique

challenges and considerations that may inuence the

safety and ecacy of tubeless PCNL. Children have

smaller renal dimensions, dierent tissue

characteristics, and varying tolerance to surgical

procedures compared to adults.¹¹ Additionally, the

psychological impact of prolonged hospitalization and

invasive drainage procedures may be more pronounced

in pediatric patients, potentially aecting recovery and

long-term outcomes.¹² Despite the theoretical

advantages of tubeless PCNL in pediatric patients,

comprehensive comparative data remain limited. Most

existing studies focus on adult populations, with

pediatric data often extrapolated from small case series

or retrospective analyses.¹³ This gap in the evidence-

based literature limits pediatric urologists' ability to

make informed decisions about the optimal surgical

approach for children with nephrolithiasis. The current

study addresses this critical knowledge gap by

conducting a comprehensive randomized controlled

trial comparing tubeless and conventional tube PCNL

in a large pediatric cohort. By focusing specically on

stones larger than 10mm, this research aims to provide

robust evidence to guide clinical decision-making and,

if successful, establish tubeless PCNL as the preferred

approach in appropriately selected pediatric patients.

METHODOLOGY

This randomized controlled trial was conducted at the

Department of Urology, Khyber Teaching Hospital,

Peshawar, from 1

October 2024 to 10

September

2025. Khyber Teaching Hospital is a high-volume

Regional Referral Center for pediatric stone disease,

with a specialized Paediatric Urology department. The

study protocol was approved by the hospital’s

institutional review board and ethics committee, and

written informed consent was obtained from parents or

guardians of all participants, with assent obtained from

children aged 12 years and above. This study is

registered at ClinicalTrials.gov under the identier

NCT07183930. Sample size was calculated based on

the primary outcome of blood transfusion requirements,

with expected rates of 5.5% in the tubeless PCNL group

and 11.7% in the tube PCNL group, as reported in the

literature. Using an 80% power, an alpha error of 5%,

and a 10% dropout rate, a minimum of 320 patients per

group was required, totaling 640 patients. A total of 640

pediatric patients aged 6-18 years with newly diagnosed

kidney stones were consecutively screened and enrolled

during the study period. Inclusion criteria included: (1)

pediatric patients aged 6-18 years of either gender, (2)

renal calculi larger than 10mm in greatest diameter as

confirmed by computed tomography, (3) failed

conservative management or extracorporeal shock wave

lithotripsy, and (4) normal renal function. Exclusion

criteria comprised: (1) history of previous ureteral

stenting or renal surgery, (2) congenital urological

abnormalities, (3) active urinary tract infection at time

of surgery, (4) bleeding disorders or anticoagulant use,

(5) signicant medical comorbidities, and (6)

pregnancy (for adolescent females). Participants were

randomly allocated into two equal groups using

computer-generated blocked randomization with

variable block sizes of 4, 6, and 8. Group A received

tubeless PCNL, while Group B underwent conventional

tube PCNL. Randomization was performed by an

independent statistician not involved in patient care,

with allocation concealed using sequentially numbered

opaque sealed envelopes. Postoperative assessments for

pain scores (VAS) and patien t/family satisfaction were

performed by a research nurse who was blinded to the

patient's allocation group (Tubeless vs. Tube PCNL).

All procedures were performed by a single experienced

pediatric urologist with over ve years of PCNL

experience to minimize operator-dependent variability.

The standard preoperative evaluation included a

complete blood count, comprehensive metabolic panel,

coagulation studies, urinalysis, urine culture, plain

abdominal radiography (KUB), and contrast-enhanced

computed tomography. All patients underwent general

anesthesia with endotracheal intubation. Initial

cystoscopy was performed with placement of a 4Fr or

5Fr ureteral catheter for retrograde pyelography and

safety wire insertion. Patients were then placed in the

prone position, and percutaneous access was obtained

under uoroscopic guidance using the bull’s-eye

technique. Tract dilatation was performed using

Amplatz dilators up to 18 Fr for a mini-PCNL

approach. Stone fragmentation was achieved using

pneumatic lithotripsy, with fragments extracted using

Comparison between Tubeless and Tube Percutaneous

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J Gandhara Med Dent Sci

grasping forceps. In Group A (Tubeless PCNL), after

complete stone clearance and conrmation of adequate

hemostasis, a double-J stent was placed through the

access sheath and appropriately positioned. The access

sheath was removed, and the tract was allowed to seal

naturally without placement of a nephrostomy tube. In

Group B (Tube PCNL), after stone clearance, a 14Fr

nephrostomy tube was placed through the access tract

and secured to the skin. A double-J stent was also

placed in most cases at the surgeon’s discretion.

Primary outcomes included operative time (minutes)

measured from skin incision to skin closure, hospital

stay duration (days) from surgery to discharge, blood

transfusion requirements dened as need for

perioperative blood transfusion, and stone-free status on

discharge dened as absence of residual fragments

>2mm on low-dose non-contrast computed tomography

(NCCT) performed 24-48 hours post-operatively. All

NCCT scans were independently reviewed by a senior

radiologist who was blinded to the patient's treatment

allocation. Secondary outcomes included postoperative

pain scores using the Visual Analog Scale (VAS),

analgesic requirements in morphine equivalents,

postoperative complications graded according to the

Clavien-Dindo classication, time to resumption of

regular activity, and patient and parent satisfaction

scores. Return to regular activity was dened as the

ability to resume normal daily activities without

restrictions, as reported by the patient or caregiver.

Baseline demographic data, stone characteristics, and

surgical parameters were recorded using a standardized

data collection form. Postoperative monitoring included

daily assessment of vital signs, pain scores, urine

output, and hemoglobin levels. Imaging studies

(ultrasound and/or CT scan) were performed within 24-

48 hours post-operatively to assess stone-free status and

identify complications. Data analysis was performed

using SPSS version 20.0. Descriptive statistics were

calculated for all variables, with continuous data

presented as mean ± standard deviation and categorical

data as frequencies and percentages. Normality of

continuous variables was assessed using the Shapiro

Wilk test. Independent t-tests were used for normally

distributed continuous variables, and Mann-Whitney U

tests were used for nonparametric data. Categorical

variables were compared using chi-square tests or

Fisher’s exact test as appropriate. Stratied analysis was

performed by age group, gender, stone size,

socioeconomic status, and BMI. Statistical signicance

was set at p<0.05, with 95% condence intervals

calculated for all estimates. The study was conducted in

accordance with the Declaration of Helsinki and Good

Clinical Practice guidelines. All procedures were

performed as part of standard clinical care, with the

only dierence being randomization to the tubeless or

tube approach. Parents and guardians were fully

informed about the study objectives, procedures,

potential risks, and benets. Participants were free to

withdraw from the study at any time without aecting

their clinical care.

RESULTS

A total of 700 pediatric patients were assessed for

eligibility, of whom 60 were excluded (40 did not meet

the inclusion criteria and 20 declined to participate).

The remaining 640 patients were successfully enrolled

and randomized, with 320 per group. Because the

primary outcomes were measured during the immediate

postoperative period and mandatory 48-hour

postoperative imaging, all 640 randomized patients

were available for analysis of the primary outcomes;

therefore, the primary analysis was performed under the

Intention-to-Treat principle (n=320 per group).

However, for the secondary outcomes, three patients

were lost to follow-up after discharge and did not

complete the subsequent 6-week clinic visit. These

patients were excluded only from the secondary

outcome analysis, representing a minimal attrition of

0.47%. Both groups demonstrated good comparability

in baseline characteristics, conrming successful

randomization (Figure 1).

Figure 1: Consort Flow Diagram

Comparison between Tubeless and Tube Percutaneous

Figure 2: Comparison of Primary Outcomes between T ubeless

Percutaneous Nephrolithotomy (PCNL) (Group A) and Tube

PCNL (Group)

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J Gandhara Med Dent Sci

Table 1: Baseline Characteristics and Primary Outcomes

Variables

Group A

(Tubeless)

n=320

Group B

(Tube)

n=320

95% CI P-value

Age (years,

mean±SD)

11.2±3.1 11.4±3.2 - 0.45

Male gender,

n (%)

160 (50.0) 160 (50.0) - 1.00

BMI (kg/m²,

mean±SD)

17.5±3.2 18.0±3.5 - 0.14

Stone size(cm

,mean±SD)

1.5±0.5 1.6±0.6 - 0.15

Operative

time (min,

mean±SD)

45±10 50±12 -6.7 to -3.3 <0.01*

Hospital stay

(days,

mean±SD)

2.0±0.8 2.5±1.0 -0.67 to -

0.33

<0.01*

Blood

transfusion, n

(%)

25 (7.8) 45 (14.1) -10.6% to -

2.0%

RR: 0.55

(0.35-0.87)

NNT: 16

0.02*

Stone-free

status, n (%)

305 (95.3) 290 (90.6) 0.1% to

9.3%

RR: 1.05

(1.00-1.10)

0.04*

Post-op pain

(V AS,

mean±SD)

3.2±1.1 5.1±1.4 -2.05 to -

1.75

<0.001*

Morphine

equivalents

(mg,

mean±SD)

12.3±4.2 18.7±5.8 -7.38 to -

5.42

<0.001*

Time to

normal activi

ty (days)

5.2±1.8 7.8±2.3 -2.86 to -

2.34

<0.001*

*Statistically signicant (p<0.05)

Table 2: Postoperative Complications and Satisfaction Scores

Variable Group A

(Tubeless,

n=320)

Group

B (Tube,

n=320)

95% CI P-value

Minor

Complications

(Clavien I–II), n(%)

12 (3.8) 18 (5.6) -4.9% to

1.3%

0.28

Major

Complications

(Clavien ≥III), n(%)

02 (0.6) 5 (1.6) -2.6% to

0.6%

0.25

Overall

Complications,n(%)

14 (4.4) 23 (7.2) -6.8% to

1.2%

0.19

Mortality, n (%) 0 0 - -

Patient/family

Satisfaction Score

(mean±SD)

8.7±1.2 7.1±1.5 1.33 to

2.07

<0.001*

DISCUSSION

This randomized controlled trial supports tubeless

percutaneous nephrolithotomy over conventional tube

PCNL in pediatric patients with renal calculi larger than

10mm. The ndings demonstrate statistically

significant and clinically meaningful improvements

across all primary outcome measures, including

operative time, hospital stay, blood transfusion

Comparison between Tubeless and Tube Percutaneous

requirements, and stone-free status. The reduction in

operative time observed with tubeless PCNL (45 vs 50

minutes) might reect the elimination of nephrostomy

tube placement and positioning procedures. This 5-

minute reduction, while seemingly modest, translates to

meaningful benets, including reduced anesthesia

exposure in children, improved operating room

efciency, and potentially decreased perioperative

complications.¹⁴ The 5-minute reduction in operative

time, although statistically signicant, may not translate

into major clinical benets in routine practice, but it

could still oer advantages in high-volume settings or

for improving operating room eciency. The 20%

reduction in hospital stay represents one of the most

clinically signicant ndings of this study. A decrease

from 2.5 to 2.0 days may appear modest in absolute

terms, but the relative impact on pediatric patients and

their families is substantial.¹⁵ Shorter hospitalization

reduces the psychological trauma associated with

prolonged separation from the home environment,

minimizes the risk of nosocomial infections, and

provides considerable economic benets to healthcare

systems.¹⁶ This nding aligns with adult literature

demonstrating similar reductions in hospital stay with

tubeless approaches.⁹ The signicant reduction in blood

transfusion requirements (7.8% vs 14.1%) represents a

critical safety advantage of tubeless PCNL. This 45%

relative risk reduction can be attributed to several

factors. First, the absence of nephrostomy tube

placement eliminates the potential for tract bleeding

and tube-related hemorrhage.¹⁷ Second, the decision to

proceed with a tubeless approach inherently requires

adequate intraoperative hemostasis, thereby requiring a

more meticulous surgical technique.¹⁸ Finally, the use

of miniaturized instruments in both groups contributed

to overall reduced bleeding, with the tubeless approach

providing additional hemostatic advantages.¹⁹ The

stone-free rate achieved with tubeless PCNL (95.3% vs

90.6%) is an unexpected yet welcome nding.

Traditional teaching suggests that stone clearance

should be independent of drainage method, as the

fragmentation and extraction techniques remain

identical.²⁰ However, several factors may explain this

observation. Surgeons performing tubeless procedures

may be more meticulous in ensuring complete stone

clearance, knowing that secondary procedures would be

more challenging without established drainage.²¹

Additionally, the absence of nephrostomy tubes may

allow for more aggressive stone extraction maneuvers

without concern for tube displacement.²² While this

does not align with the standard 4-6 weeks used in most

studies, we felt it provided a functional early

assessment of stone clearance. This observation is

based on a hypothesis and warrants further dedicated

research. The pain reduction demonstrated in the

tubeless group (VAS 3.2 vs 5.1) represents a clinically

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J Gandhara Med Dent Sci

significant improvement in patient comfort.

Nephrostomy tubes are well-recognized sources of

postoperative pain, causing discomfort through several

mechanisms, including tract irritation, tube movement,

and bladder spasms from associated ureteral stents.²³

The elimination of these pain sources reduces analgesic

requirements and improves patient satisfaction, critical

considerations in pediatric populations.²⁴ A comparison

with the existing literature reveals consistent ndings

across dierent populations and settings. Adult studies

have consistently demonstrated similar advantages of

tubeless PCNL, including reduced hospital stays,

decreased pain, and improved patient satisfaction.⁹

However, pediatric-specic data have been limited to

small case series and retrospective analyses.²⁵ This

study provides the rst large-scale randomized

evidence supporting these benets in children. The

safety prole observed in this study supports the

feasibility of tubeless PCNL in appropriately selected

pediatric patients. The low overall complication rate in

both groups (3.8% vs 5.6%) reects careful patient

selection and experienced surgical technique. The

absence of major complications specic to the tubeless

approach suggests that, with proper case selection

criteria, this technique can be safely implemented in

pediatric practice.²⁶ Several factors contribute to the

success of tubeless PCNL in children. The smaller body

habitus of pediatric patients may facilitate natural tract

sealing without the need for external drainage.

Additionally, children typically have greater tissue-

healing capacity and fewer comorbidities that might

impair recovery.²⁷ The psychological benets of

avoiding external drainage tubes may be particularly

pronounced in children, contributing to improved

cooperation and faster recovery.²⁸ The economic

implications of these ndings extend beyond immediate

hospitalization costs. Reduced hospital stays, fewer

complications, and decreased need for secondary

procedures translate to substantial cost savings for

healthcare systems. Additionally, the reduced time

away from school and everyday activities provides

societal benets that are dicult to quantify but

clinically meaningful.²⁹

LIMITATIONS

Several limitations must be acknowledged. First, the

single-surgeon design, while minimizing technical

variability, may limit generalizability to centers with

varying levels of expertise. Second, the relatively short

follow-up period may not capture long-term outcomes

or late complications. Third, excluding patients with

complex stone burden or signicant comorbidities may

limit applicability to more challenging cases. Fourth, a

formal cost-eectiveness analysis was not conducted,

limiting the assessment of the full economic impact of

Comparison between Tubeless and Tube Percutaneous

the reduction in hospital stays. Although blinding of

patients and surgeons was not feasible, outcome

assessors and statisticians were blinded to group

allocation to minimize bias in data analysis. We

employed gender-stratied enrolment quotas, leading to

gender-confounding bias. Finally, the study was

conducted at a single high-volume center, and results

may dier in lower-volume settings. These ndings

have signicant implications for pediatric urological

practice. The evidence supports considering tubeless

PCNL as the preferred approach for appropriately

selected pediatric patients with renal calculi.

Implementation should be gradual, with careful

attention to case selection criteria and surgeon

experience. Centers beginning tubeless programs

should start with straightforward cases and expand

indications as experience grows. Long-term follow-up

studies are needed to assess recurrence rates, renal

function outcomes, and patient-reported quality-of-life

measures. Comparative eectiveness research

examining cost-benet ratios would provide additional

evidence for policy decisions. Investigation of optimal

patient selection criteria and technical modications

specific to pediatric populations would further rene

the approach.

CONCLUSIONS

These findings support the use of tubeless PCNL as an

effective and safer alternative to conventional tube

PCNL in managing pediatric nephrolithiasis in

appropriately selected cases. Implementation should be

accompanied by careful attention to case selection

criteria, surgeon training, and institutional protocols to

ensure optimal outcomes.

CONFLICT OF INTEREST: None

FUNDING SOURCES: None

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AUTHORS CONTRIBUTION

The authors accept responsibility for all aspects of the work

and will ensure that any concerns regarding the accuracy or

integrity of any part are properly investigated and resolved.

Sajjad Ali - Concept & Design; Data Acquisition; Drafting

Manuscript; Final Approval

Tariq Ahmad- Concept & Design; Data Acquisition; Drafting

Manuscript; Critical Revision; Supervision; Final Approval

Murad Ali - Concept & Design; Data Analysis/Intepretation;

Drafting Manuscript; Final Approval

Mohammad Anees Iqbal - Concept & Design; Data

Acquisition; Data Analysis/Interpretation; Drafting

Manuscript; Final Approval

Abdul Jabbar - Concept & Design; Data Acquisition; Drafting

Manuscript; Critical Revision; Final Approval

Aboozar Khan - Concept & Design; Data Acquisition; Drafting

Manuscript; Final Approval

January - March 2026