Urolithiasis is one of the most common urological disorders and represents a significant global healthcare burden[1]. Its increasing prevalence has been attributed to changes in dietary habits, lifestyle, environmental conditions and metabolic risk factors. Renal calculi develop due to urinary supersaturation and crystallization of stone-forming substances, including calcium oxalate, calcium phosphate, uric acid and cystine. Larger calculi may cause persistent pain, urinary obstruction, recurrent infections and deterioration of renal function, frequently necessitating surgical intervention.[2, 3]Advances in endourology have transformed the management of renal calculi, with minimally invasive procedures largely replacing conventional open surgery. Percutaneous nephrolithotomy (PCNL) has emerged as an established treatment modality for large and complex renal stones, particularly calculi measuring more than 2 cm and staghorn stones.[4] The procedure involves establishing percutaneous access to the renal collecting system under imaging guidance, followed by stone fragmentation and extraction using a nephroscope. PCNL offers high stone clearance rates, reduced surgical morbidity and faster postoperative recovery compared with open surgical approaches.[5,6]Conventionally, PCNL is completed by placing a nephrostomy tube through the percutaneous tract, commonly referred to as tubed PCNL. The nephrostomy tube facilitates urinary drainage, provides tamponade to control bleeding, minimizes urinary extravasation and maintains access for secondary procedures when required. However, its placement may contribute to postoperative discomfort, increased pain and analgesic requirements, urinary leakage, delayed mobilization and prolonged hospitalization.[7,8]To overcome these limitations, tubeless PCNL was introduced as a modification of the conventional technique. In this approach, the external nephrostomy tube is omitted, while urinary drainage is generally maintained through an internal double-J ureteral stent or ureteric catheter. Bellman et al. popularized this technique by demonstrating that routine nephrostomy tube placement may not be necessary following uncomplicated PCNL in appropriately selected patients. The principal objective of tubeless PCNL is to minimize tube-related morbidity without compromising procedural effectiveness or patient safety.[9,10]Previous comparative studies have reported several advantages of tubeless PCNL, including reduced postoperative pain, lower analgesic consumption, shorter hospital stay and earlier return to routine activities. Systematic reviews and comparative evidence have also suggested comparable stone-free rates and overall complication profiles between tubeless and conventional tubed PCNL in selected patients.[10,11] Nevertheless, concerns regarding postoperative haemorrhage, urinary extravasation, residual calculi and the potential requirement for secondary intervention remain important considerations when selecting the appropriate drainage technique.[11,12]The safety of tubeless PCNL depends primarily on careful patient selection and intraoperative assessment. Adequate haemostasis, satisfactory stone clearance, absence of significant collecting system injury and no anticipated requirement for second-look nephroscopy are important considerations before omitting nephrostomy drainage. Conventional tubed PCNL may therefore remain preferable in complicated procedures requiring continued external drainage or maintenance of percutaneous access.[11,12]Considering the increasing emphasis on minimizing postoperative morbidity while maintaining procedural efficacy, comparative evaluation of these techniques remains clinically relevant. Therefore, the present study was designed to compare tubeless PCNL with conventional tubed PCNL.

The present randomized comparative study was conducted over a period of 18 months in the Department of Urology at a tertiary care centre. A total of 76 adult patients undergoing percutaneous nephrolithotomy (PCNL) for renal calculi were enrolled after obtaining Institutional Ethics Committee approval and written informed consent. Study Population and Eligibility Criteria Patients aged 18–65 years with renal calculi measuring ≥2 cm, who were fit for general anaesthesia and willing to comply with postoperative follow-up, were included. Patients with bleeding disorders, ongoing anticoagulant therapy, active urinary tract infection, renal insufficiency (serum creatinine >2 mg/dL), previous renal surgery or PCNL, and pregnant women were excluded. Sample Size The sample size was determined using the formula for comparison of two independent means: Considering a 5% significance level, 80% power, standard deviation (σ) of 1.22 and expected mean difference (Δ) of 2.99, a total sample size of 76 patients (38 per group) was adopted. Eligible participants were allocated in a 1:1 ratio using a computer-generated randomization table into: • Group I (n=38): Conventional tubed PCNL. • Group II (n=38): Tubeless PCNL. Preoperative Assessment All patients underwent detailed history-taking, clinical examination and pre-anaesthetic evaluation. Baseline investigations included complete blood count, renal function tests, coagulation profile, urine routine examination and urine culture. Imaging using ultrasonography, X-ray KUB and/or computed tomography (CT) was performed to assess stone size, location, burden and renal anatomy. Surgical Procedure All procedures were performed under general anaesthesia by experienced urologists. Percutaneous renal access was established under fluoroscopic and/or ultrasonographic guidance, followed by guidewire placement, tract dilatation and nephroscope insertion. Stone fragmentation was performed using pneumatic or laser lithotripsy, followed by fragment extraction. In Group I (Tubed PCNL), a nephrostomy tube was placed at the end of the procedure for external urinary drainage and tract tamponade. The tube was generally removed within 24–48 hours, depending on clinical recovery. In Group II (Tubeless PCNL), no nephrostomy tube was placed, and a double-J ureteral stent was inserted to maintain internal urinary drainage. Postoperative Monitoring and Follow-up All patients were monitored for postoperative pain, haematuria, urinary leakage, fever and other complications. Pain was assessed using the Visual Analog Scale (VAS), and analgesics were administered according to a standardized protocol. Operative time, analgesic requirement and duration of hospitalization were recorded. Patients were discharged following satisfactory clinical recovery and were followed up at 1 week, 1 month and 3 months. Clinical examination and appropriate imaging (ultrasonography or CT) were performed to assess stone clearance and delayed complications. Outcome Measures The assessed outcomes included operative time, postoperative VAS pain scores, analgesic requirements, duration of hospital stay, urinary leakage, bleeding, postoperative infection, stone-free rate, requirement for secondary procedures and overall postoperative complications. Statistical Analysis Data were analysed using IBM SPSS Statistics version 25. Continuous variables were expressed as mean ± standard deviation (SD) or median (IQR), while categorical variables were presented as frequencies and percentages. The independent Student's t-test and Mann–Whitney U test were used for normally and non-normally distributed continuous variables, respectively. Categorical variables were compared using the Chi-square test or Fisher's exact test, as appropriate. Pearson correlation analysis was performed to assess associations between stone size and postoperative outcomes. Binary logistic regression was used to identify predictors of prolonged hospital stay, with results reported as odds ratios (ORs) and 95% confidence intervals (CIs). A two-sided p-value of less than 0.05 was considered statistically significant.

A total of 76 patients undergoing percutaneous nephrolithotomy (PCNL) were included in the study, with 38 patients each in the tubeless and conventional tubed PCNL groups.Baseline characteristics were comparable between the groups. The mean age was 42.18 ± 8.12 years in the tubeless group and 43.26 ± 8.45 years in the tubed group (p=0.574), with male predominance in both groups (65.8% vs. 63.2%; p=0.812). No significant differences were observed in BMI, stone laterality, location, stone size, preoperative haemoglobin, serum creatinine or comorbidities (all p>0.05) (Table 1).The mean operative time was comparable between the tubeless and tubed groups (74.86 ± 9.64 vs. 78.42 ± 10.28 minutes; p=0.124). However, haemoglobin reduction was significantly lower following tubeless PCNL (0.84 ± 0.31 vs. 1.31 ± 0.42 g/dL; p<0.001). Postoperative VAS pain scores were significantly lower in the tubeless group at 6, 12, 24 and 48 hours (all p<0.001). Similarly, analgesic consumption (118.4 ± 36.2 vs. 168.7 ± 42.5 mg; p<0.001) and hospital stay (2.64 ± 0.68 vs. 4.42 ± 0.91 days; p<0.001) were significantly reduced following tubeless PCNL (Table 2, Figure 1).Urine leakage was observed in 7.9% of patients in the tubeless group compared with 21.1% in the tubed group (p=0.101), with a shorter mean leakage duration (1.33 ± 0.58 vs. 2.25 ± 0.71 days; p=0.071). Postoperative fever (10.5% vs. 18.4%), infection (7.9% vs. 15.8%) and transfusion requirements (2.6% vs. 10.5%) were numerically lower following tubeless PCNL, although the differences were not statistically significant. Overall complications occurred in 18.4% and 36.8% of patients, respectively (p=0.073) (Table 3).Complete stone clearance was achieved in 92.1% of patients following tubeless PCNL compared with 86.8% following tubed PCNL (p=0.452). Mean residual stone size was 0.53 ± 0.15 cm and 0.66 ± 0.18 cm, respectively (p=0.315). Secondary procedures were required in 5.3% and 13.2% of patients (p=0.235), including double-J stenting, ESWL and re-look PCNL (Table 4).Grade I complications occurred in 10.5% and 18.4% of patients in the tubeless and tubed groups, respectively, while Grade II complications occurred in 7.9% and 15.8%. One Grade III complication (2.6%) was reported in the tubed group, with none in the tubeless group. The difference in complication-grade distribution was not statistically significant (p=0.197) (Table 5, Figure 2).Logistic regression analysis identified tubed PCNL (OR=4.86; 95% CI: 1.72–13.68; p=0.003), stone size >3 cm (OR=2.94; 95% CI: 1.04–8.32; p=0.042), postoperative VAS score >4 (OR=3.76; 95% CI: 1.31–10.78; p=0.014) and postoperative complications (OR=5.21; 95% CI: 1.65–16.42; p=0.005) as significant predictors of prolonged hospitalization (Table 6, Figure 3). Table 1. Comparison of Baseline Demographic, Clinical and Stone Characteristics Between the Two Groups Parameter Tubeless PCNL (n=38) Tubed PCNL (n=38) p-value Statistical Test Age (years), mean ± SD 42.18 ± 8.12 43.26 ± 8.45 0.574 Independent t-test Sex, n (%) 0.812 Chi-square test Male 25 (65.8) 24 (63.2) Female 13 (34.2) 14 (36.8) BMI (kg/m²), mean ± SD 24.28 ± 2.36 24.71 ± 2.51 0.448 Independent t-test Stone laterality, n (%) 0.819 Chi-square test Right 20 (52.6) 19 (50.0) Left 18 (47.4) 19 (50.0) Stone location, n (%) 0.965 Chi-square test Renal pelvis 16 (42.1) 15 (39.5) Upper calyx 5 (13.2) 6 (15.8) Middle calyx 7 (18.4) 7 (18.4) Lower calyx 8 (21.1) 8 (21.1) Multiple calyces 2 (5.3) 2 (5.3) Stone size (cm), mean ± SD 2.82 ± 0.51 2.91 ± 0.56 0.466 Independent t-test Preoperative Hb (g/dL), mean ± SD 12.76 ± 1.18 12.61 ± 1.24 0.590 Independent t-test Preoperative creatinine (mg/dL), mean ± SD 0.92 ± 0.18 0.96 ± 0.21 0.376 Independent t-test Comorbidities, n (%) 0.895 Chi-square test None 24 (63.2) 22 (57.9) Hypertension 6 (15.8) 7 (18.4) Diabetes mellitus 5 (13.2) 6 (15.8) Both HTN and DM 3 (7.9) 3 (7.9) Table 2. Comparison of Operative Parameters, Postoperative Pain and Analgesic Requirements Parameter Tubeless PCNL (n=38) Tubed PCNL (n=38) p-value Statistical Test Operative time (minutes) 74.86 ± 9.64 78.42 ± 10.28 0.124 Independent t-test Haemoglobin drop (g/dL) 0.84 ± 0.31 1.31 ± 0.42 <0.001 Independent t-test Postoperative VAS pain score At 6 hours 4.21 ± 0.91 5.92 ± 1.04 <0.001 Independent t-test At 12 hours 3.82 ± 0.86 5.48 ± 0.98 <0.001† Independent t-test At 24 hours 3.31 ± 0.82 5.12 ± 0.95 <0.001† Independent t-test At 48 hours 2.18 ± 0.71 3.74 ± 0.88 <0.001† Independent t-test Analgesic requirement (mg) 118.4 ± 36.2 168.7 ± 42.5 <0.001 Independent t-test Hospital stay (days) 2.64 ± 0.68 4.42 ± 0.91 <0.001 Independent t-test Table 3. Comparison of Postoperative Complications Between the Two Groups Parameter Tubeless PCNL (n=38) Tubed PCNL (n=38) p-value Statistical Test Urine leakage, n (%) 3 (7.9) 8 (21.1) 0.101 Chi-square test Duration of urine leakage (days), mean ± SD‡ 1.33 ± 0.58 2.25 ± 0.71 0.071 Mann–Whitney U test Postoperative fever, n (%) 4 (10.5) 7 (18.4) 0.326 Chi-square test Postoperative infection, n (%) 3 (7.9) 6 (15.8) 0.287 Chi-square test Hematuria, n (%) 2 (5.3) 5 (13.2) 0.887 Chi-square test Blood transfusion required, n (%) 1 (2.6) 4 (10.5) 0.165 Fisher's exact test Overall complications, n (%) 7 (18.4) 14 (36.8) 0.073 Chi-square test Table 4. Comparison of Stone Clearance, Residual Stone Burden and Secondary Procedures Parameter Tubeless PCNL (n=38) Tubed PCNL (n=38) p-value Statistical Test Stone clearance status, n (%) 0.452 Chi-square test Stone-free 35 (92.1) 33 (86.8) Residual stone present 3 (7.9) 5 (13.2) Residual stone size (cm), mean ± SD§ 0.53 ± 0.15 0.66 ± 0.18 0.315 Mann–Whitney U test Secondary procedure required, n (%) 2 (5.3) 5 (13.2) 0.235 Fisher's exact test Type of secondary procedure, n (%) Double-J stenting 1 (50.0) 2 (40.0) ESWL 1 (50.0) 2 (40.0) Re-look PCNL 0 (0.0) 1 (20.0) Table 5. Distribution of Postoperative Complications According to Clavien–Dindo Classification Clavien–Dindo Grade Tubeless PCNL (n=38) Tubed PCNL (n=38) p-value Statistical Test No complication 31 (81.6%) 24 (63.2%) 0.197 Fisher's exact test Grade I 4 (10.5%) 7 (18.4%) Grade II 3 (7.9%) 6 (15.8%) Grade III 0 (0.0%) 1 (2.6%) Table 6. Logistic Regression Analysis of Factors Associated With Prolonged Hospital Stay (N=76) Predictor Variable Odds Ratio (OR) 95% CI p-value Statistical Test Tubed PCNL (reference: Tubeless PCNL) 4.86 1.72–13.68 0.003 Binary logistic regression Stone size >3 cm 2.94 1.04–8.32 0.042 Postoperative VAS score >4 3.76 1.31–10.78 0.014 Presence of postoperative complications 5.21 1.65–16.42 0.005

The present comparative study evaluated 76 patients undergoing percutaneous nephrolithotomy (PCNL), equally divided into tubeless and conventional tubed PCNL groups. The findings demonstrated significantly lower postoperative haemoglobin reduction, pain scores, analgesic requirements and duration of hospitalization following tubeless PCNL, while operative time, stone clearance and overall complication rates remained statistically comparable.The baseline demographic and clinical characteristics were comparable between the two groups. The mean age was 42.18 ± 8.12 years in the tubeless group and 43.26 ± 8.45 years in the tubed group (p=0.574), with male predominance in both groups (65.8% vs. 63.2%). Similar baseline comparability was reported by Ozturk (2015) [13], Amir et al. (2021) [14] and Reddy et al. (2024) [15]. No significant differences were observed in BMI, stone laterality, location, preoperative haemoglobin, serum creatinine or comorbidities. The mean stone size was also comparable (2.82 ± 0.51 vs. 2.91 ± 0.56 cm; p=0.466), consistent with findings reported by Choi et al. (2014) [16] and Amir et al. (2021) [14].The mean operative time was slightly shorter in the tubeless group (74.86 ± 9.64 minutes) compared with the tubed group (78.42 ± 10.28 minutes), although the difference was statistically insignificant (p=0.124). Garg and Agrawal (2019) [17] similarly reported comparable operative times of 59.97 ± 26.40 and 67.55 ± 28.00 minutes, respectively. Amir et al. (2021) [14] also observed no significant difference, whereas Kamalakshi et al. (2019) [18] and Anand et al. (2022) [19] reported shorter operative duration following tubeless PCNL.Postoperative haemoglobin reduction was significantly lower in the tubeless group (0.84 ± 0.31 vs. 1.31 ± 0.42 g/dL; p<0.001). Istanbulluoğlu et al. (2013) [20] also demonstrated significantly lower haemoglobin decline in patients undergoing haemostatic-agent-assisted tubeless PCNL. However, Ozturk (2015) [13] and Nawaz et al. (2024) [21] reported no statistically significant difference in haemoglobin reduction between tubeless and conventional PCNL. These variations may reflect differences in stone complexity, operative technique and intraoperative haemostatic measures.Postoperative pain scores were significantly lower following tubeless PCNL at all assessed intervals. At 6 hours, the mean VAS score was 4.21 ± 0.91 compared with 5.92 ± 1.04 in the tubed group, decreasing to 2.18 ± 0.71 and 3.74 ± 0.88, respectively, at 48 hours (p<0.001). Similarly, analgesic consumption was significantly lower in the tubeless group (118.4 ± 36.2 vs. 168.7 ± 42.5 mg; p<0.001). Kamalakshi et al. (2019) [18] reported lower VAS scores (3.64 vs. 6.0), while Anand et al. (2022) [19] demonstrated reduced analgesic requirements following tubeless PCNL. Comparable findings were reported by Garofalo et al. (2013) [22], Agrawal et al. (2014) [23] and Garg and Agrawal (2019) [17], supporting the association between omission of the nephrostomy tube and reduced postoperative discomfort.Postoperative urine leakage occurred in 7.9% of tubeless PCNL patients compared with 21.1% of tubed PCNL patients (p=0.101). The mean duration of leakage was also shorter in the tubeless group (1.33 ± 0.58 vs. 2.25 ± 0.71 days; p=0.071), although neither difference reached statistical significance. Agrawal et al. (2014) [23] reported no urinary leakage following tubeless PCNL compared with 4.8% following standard PCNL. Amir et al. (2021) [14] similarly observed lower postoperative wound soakage (1.4% vs. 12.8%), while Gauhar et al. (2022) [24] demonstrated a significantly reduced incidence of postoperative urinary fistula following tubeless PCNL. Postoperative fever (10.5% vs. 18.4%; p=0.326), infection (7.9% vs. 15.8%; p=0.287) and blood transfusion requirements (2.6% vs. 10.5%; p=0.165) were numerically lower in the tubeless group, without statistically significant differences. Chen et al. (2019) [25], in a meta-analysis involving 947 patients, similarly reported comparable infective complications and transfusion requirements between tubeless and standard PCNL. Garofalo et al. (2013) [22] also observed no significant difference in transfusion rates.A major finding of the present study was the significantly shorter mean hospital stay following tubeless PCNL (2.64 ± 0.68 vs. 4.42 ± 0.91 days; p<0.001). Garofalo et al. (2013) [22] reported hospital stays of 3.3 and 4.6 days, while Choi et al. (2014) [16] observed significantly shorter hospitalization following totally tubeless PCNL (1.72 ± 0.58 vs. 4.10 ± 1.88 days). Similar findings were documented by Agrawal et al. (2014) [23], Ozturk (2015) [13], Amir et al. (2021) [14], Anand et al. (2022) [19] and Surag et al. (2023) [26]. Gauhar et al. (2022) [24] also reported a mean reduction of 1.10 days in hospitalization following tubeless PCNL. Reduced postoperative pain and avoidance of external nephrostomy drainage may contribute to earlier discharge.Complete stone clearance was achieved in 92.1% of patients following tubeless PCNL compared with 86.8% following conventional PCNL (p=0.452). Among patients with residual calculi, the mean residual stone size was 0.53 ± 0.15 cm and 0.66 ± 0.18 cm, respectively (p=0.315). Choi et al. (2014) [16] reported comparable stone-free rates of 86.4% and 89.8%, while Ozturk (2015) [13] observed success rates of 96.0% and 96.3% in the two groups. Garofalo et al. (2013) [22], Amir et al. (2021) [14] and Nawaz et al. (2024) [21] also reported comparable stone clearance outcomes.Secondary procedures were required in 5.3% of tubeless PCNL patients compared with 13.2% of tubed PCNL patients (p=0.235). Nawaz et al. (2024) [21] reported significantly lower postoperative ESWL requirements following tubeless PCNL (4% vs. 22%), whereas Kamble et al. (2024) [27] observed no significant difference in secondary intervention rates among standard, tubeless and totally tubeless PCNL groups.Overall postoperative complications occurred in 18.4% of patients in the tubeless group compared with 36.8% in the tubed group (p=0.073). Garg and Agrawal (2019) [17] reported a similar numerical difference in complication rates (27.5% vs. 42.5%), while Garofalo et al. (2013) [22] found no statistically significant difference. In the present study, Grade I and II complications were more frequent in the tubed group, with one Grade III complication reported exclusively in this group. However, the overall Clavien–Dindo complication distribution was statistically comparable (p=0.197), consistent with findings reported by Ozturk (2015) [13]. Correlation analysis demonstrated significant positive associations between stone size and operative time (r=0.472; p<0.001), hospital stay (r=0.421; p<0.001) and postoperative VAS score at 24 hours (r=0.386; p=0.001). Logistic regression further identified tubed PCNL (OR=4.86; p=0.003), stone size greater than 3 cm (OR=2.94; p=0.042), VAS score greater than 4 (OR=3.76; p=0.014) and postoperative complications (OR=5.21; p=0.005) as significant predictors of prolonged hospitalization. Garofalo et al. (2013) [22] similarly identified procedure type, operative time, postoperative fever, transfusion requirement and residual fragments as factors associated with hospital stay.

The present study demonstrated that tubeless PCNL was associated with significantly lower postoperative pain, analgesic consumption, haemoglobin reduction and duration of hospital stay compared with conventional tubed PCNL. Both techniques demonstrated statistically comparable operative time, stone-free rates, secondary intervention requirements and overall postoperative complications. Thus, tubeless PCNL may be considered an effective alternative to conventional tubed PCNL in appropriately selected patients undergoing uncomplicated renal stone surgery. LIMITATIONS The present study was limited by its relatively small sample size (N=76), single-centre setting and short follow-up duration of three months, which may restrict the generalizability of the findings. Additionally, the study did not assess long-term stone recurrence, patient-reported quality of life or detailed cost-effectiveness outcomes.

1. Romero V, Akpinar H, Assimos DG. Kidney stones: a global picture of prevalence, incidence, and associated risk factors. Rev Urol. 2010;12(2-3):e86-e96. 2. Scales CD Jr, Smith AC, Hanley JM, Saigal CS. Epidemiology of kidney stones. Clin J Am Soc Nephrol. 2012;7(12):2069-76. 3. Moe OW. Kidney stones: pathophysiology and medical management. Lancet. 2006;367(9507):333-44. 4. Turk C, Petrik A, Sarica K. EAU guidelines on interventional treatment for urolithiasis. Eur Urol. 2016;69(3):475-82. 5. Fernström I, Johansson B. Percutaneous pyelolithotomy: a new extraction technique. Scand J Urol Nephrol. 1976;10(3):257-9. 6. Zeng G, Mai Z, Zhao Z, Li X, Zhong W, Yuan J, et al. The evolution of percutaneous nephrolithotomy: a review. J Endourol. 2020;34(1):11-19. 7. Pietrow PK, Auge BK, Lallas CD, Santa-Cruz RW, Newman GE, Albala DM, et al. Pain after percutaneous nephrolithotomy: impact of nephrostomy tube size. J Endourol. 2003;17(6):411-4. 8. Shah HN, Sodha HS, Khandkar AA, Kharodawala SJ, Hegde SS, Bansal MB, et al. A randomized trial evaluating type of nephrostomy drainage after percutaneous nephrolithotomy. J Endourol. 2008;22(7):1433-9. 9. Bellman GC, Davidoff R, Candela J, Gerspach J, Kurtz S, Stout L, et al. Tubeless percutaneous renal surgery. J Urol. 1997;157(5):1578-82. 10. Gupta R, Kumar A, Kapoor R, Srivastava A, Mandhani A, Dubey D, et al. Prospective evaluation of safety and efficacy of tubeless PCNL. BJU Int. 2005;95(5):905-8. 11. Zilberman DE, Lipkin ME, de la Rosette JJ, Ferrandino MN, Mamoulakis C, Laguna MP, et al. Tubeless percutaneous nephrolithotomy-the new standard of care? J Urol. 2010;184(4):1261-6. 12. de la Rosette J, Assimos D, Desai M, Gutierrez J, Lingeman J, Scarpa R, et al. The CROES PCNL global study: indications, complications and outcomes in 5803 patients. J Endourol. 2011;25(1):11-17. 13. Ozturk H. Tubeless versus standard PCNL in geriatric population. Actas Urol Esp. 2015;39(8):494-501. 14. Amir ZE, Shahiman MA, Qadeer Z, Mughal RA, Ali A, et al. Percutaneous nephrolithotomy: A comparison of tubeless versus the standard technique. J Rawalpindi Med Coll. 2021;25(1):140-144. 15. Reddy R, Guddeti RS, Naik VV, Siddavaram S, et al. A randomized controlled study of efficacy and safety of standard versus tubeless percutaneous nephrolithotomy. Eur J Cardiovasc Med. 2024;14(4):964-967. 16. Choi SW, Kim KS, Kim JH, Park YH, Bae WJ, Hong SH, et al. Totally tubeless versus standard percutaneous nephrolithotomy for renal stones: analysis of clinical outcomes and cost. J Endourol. 2014;28(12):1487-94. 17. Garg N, Agrawal B, Garg N, Agrawal M. A comparative study of standard PCNL vs tubeless PCNL at a tertiary care hospital. J Evol Med Dent Sci. 2019. 18. Kamalakshi MM, Ramasamy V, Sadasivan D, Raveendran S, Paramasivam S, Ganapathy V, et al. Comparison of standard and tubeless percutaneous nephrolithotomy for renal calculi: a prospective randomized control trial. Int J Clin Trials. 2019;6(4). 19. Anand S, Santosh B, Prasad DVSR, Vinay A, Yogesh, Karthik, et al. A comparative study of PCNL with nephrostomy tube vs tubeless PCNL. Int J Acad Med Pharm. 2022;4(3):52-59. 20. Istanbulluoğlu MO, Kaynar M, Ciçek T, Koşan M, Öztürk B, Özkardeş H, et al. A new hemostatic agent (Ankaferd Blood Stopper) in tubeless percutaneous nephrolithotomy: a prospective randomized study. J Endourol. 2013;27(9):1126-30. 21. Kamble VB, Gupta S, Pal DK. Comparative analysis of standard, tubeless and total tubeless percutaneous nephrolithotomy: A prospective study. Urologia. 2024;91(2):326-331. 22. A, Sohail M, Shah S, Khan MI, Ullah A, et al. A cross-sectional study comparing tubed PCNL and tubeless PCNL: an experience at the Institute of Kidney Diseases (IKD), Peshawar. J Health Res Rev. 2024;4(1). 23. Garofalo M, Pultrone CV, Schiavina R, Brunocilla E, Sanguedolce F, Borghesi M, et al. Tubeless procedure reduces hospitalization and pain after percutaneous nephrolithotomy: results of a multivariable analysis. Urolithiasis. 2013;41(4):347-53. 24. Agrawal MS, Sharma M, Agarwal K. Tubeless percutaneous nephrolithotomy using antegrade tether: a randomized study. J Endourol. 2014;28(6):644-8. 25. Gauhar V, Traxer O, García Rojo E, Scarcella S, Pavia MP, Chan VW, et al. Complications and outcomes of tubeless versus nephrostomy tube in percutaneous nephrolithotomy: a systematic review and meta analysis of randomized clinical trials. Urolithiasis. 2022 Oct;50(5):511-522. 26. Chen ZJ, Yan YJ, Zhou JJ. Comparison of tubeless percutaneous nephrolithotomy and standard percutaneous nephrolithotomy for kidney stones: A meta-analysis of randomized trials. Asian J Surg. 2019. 27. Surag KR, Singh A, Sharma P, Pai V, Choudhary A, Patil S, et al. Comparing tubeless and tubed approaches in percutaneous nephrolithotomy for moderate renal calculi: outcomes on safety, efficacy, pain management, recovery time, and cost-effectiveness. Cureus. 2023;15(5):e39211.