Traditionally, patients undergoing percutaneous nephrolithotomy (PCNL) have been admitted to the hospital for observation for a variety of reasons, including monitoring for bleeding, sepsis, administration of intravenous antibiotics and pain control. With the shift to tubeless (no nephrostomy tube) or “totally tubeless” procedures and their reduction in pain, hospital stay and recovery time, there has been a renewed interest in considering outpatient surgery.

Can Patients Safely Go Home the Same Day as Their Surgery?

In a small series, Shahrour and Andonian showed the feasibility of same-day discharge for patients undergoing PCNL (see table). The inclusion criteria were strict and consisted of generally healthy patients (American Society of Anesthesiologists® [ASA] score 2 or less), single tract access without any intraoperative complications and without any hemodynamic issues in the postoperative recovery area. Average stone size was 17 mm and body mass index (BMI) was 25.9 kg/m², and the complication rate was 20%. In larger studies, which loosened the inclusion criteria to include patients with staghorn stones and ASA scores greater than 2, outpatient PCNL patients had relatively low complication rates.^1,2 The table summarizes findings of selected studies evaluating outcomes of outpatient PCNL.

Why Should We Consider Day Surgery for PCNL?

Outpatient surgeries offer benefits to both the hospital and patient. Postoperative narcotic use is decreased, the patient is able to sleep in the comfort of his or her own bed, and the hospital saves on inpatient care costs since insurance reimburses as an outpatient procedure. In the era of COVID-19, being able to return home and avoid an overnight hospital stay is particularly attractive.

In our experience at University of California San Diego Health, patients receive intercostal nerve blocks and are placed on an opiate-sparing protocol, which we believe is part of the prerequisite for sending patients home after their procedure. Without proper pain management, outpatient PCNL becomes a challenging endeavor. In our early study comparing inpatient with outpatient PCNL cases, the 2 most common reasons for outpatient PCNL patients staying overnight at the hospital were poor pain control (41%) and social factors (35%).³

Is it Possible for More Complex PCNL Patients to be Discharged Home from the Recovery Area?

Several of the studies in the table included complex patients and reported low complication rates. In our series, in which we did not apply strict selection criteria, 44% of patients had elevated ASA scores (3 and higher), 43% had a stent or nephrostomy tube in place prior to surgery, 45% underwent multiple punctures to achieve access and 17% had more than 1 dilated renal access tract. Despite this more complex cohort, we had acceptable complication rates. In our experience, significant renal bleeding or precursors of infectious complications are apparent perioperatively or immediately postoperatively, allowing for identification of patients needing admission before the time that they would be discharged home.

Nonetheless, patient selection–whether preoperative or postoperative–is essential for the success of outpatient PCNL. For the urologist starting out, selecting healthier patients (low BMI and low ASA) with smaller stones and simple renal anatomy requiring a single access tract likely offers a more feasible route to discharging patients on postoperative day 0. From a patient perspective, they may also be more amenable to going home early if their procedure is “tubeless” (without a nephrostomy tube). It has been shown previously that the presence of a nephrostomy tube introduces significant morbidity after PCNL. Perhaps the clearest indication of whether a patient can be safely discharged on the same day is their clinical status in the postoperative recovery area, including stable vital signs, afebrile status, good pain control and normal voiding function. Clinical factors aside, thorough patient counseling both in the office during the preoperative visit and postoperatively plays a major role in determining the ability to have a successful outpatient PCNL practice. Proper counseling and setting realistic expectations allow the patient to be comfortable with the idea of going home after a surgical procedure.

In an era when hospital beds may be scarce at times and health care costs are rising, PCNL day surgery offers a reasonable strategy to address these issues, albeit in a properly selected patient. In a Canadian cost analysis evaluation of PCNL procedures, outpatient PCNL resulted in $3,000 savings per case.⁴ Factor in the number of cases each year that could potentially be sent home on the same day and the savings overall are substantial. One new addition in recent years to a urologist’s armamentarium has been the mini-PCNL. In small studies, mini-PCNL has been shown to be amenable to same day surgery, although given the narrow inclusion criteria, it is difficult to generalize these promising early results to a wider population.⁵

All in all, same-day discharge for PCNL patients is feasible as long as certain criteria have been met. The goal of outpatient PCNL is to minimize complication rates and maximize patient recovery.

Which patients can be safely discharged home on the day of surgery? The answer ultimately lies in surgeon comfort and clinical judgment, with patient selection criteria as an additional guide.