With the concept of rapid rehabilitation surgery, minimally invasive surgery has gradually been valued by surgeons. The choice of anesthesia is also an important part of rapid rehabilitation surgery. The kidney and ureter are subject to sympathetic and parasympathetic innervation. The sensory nerves follow the sympathetic and parasympathetic branches. The kidneys and ureters are not sensitive to cauterization and cutting. They are mainly sensitive to traction and increased ureteral pressure in the renal pelvis. The pain is generally dull, which may be associated with sympathetic stimulation, such as bloating, nausea, vomiting and so on. Because of these characteristics of the distribution of urinary nervous system, local anesthesia can meet the surgical requirements. Most hospitals use epidural anesthesia or general anesthesia for surgery. However, compared with epidural and general anesthesia, local anesthesia has the lowest complication and mortality  in our hospital. Most patients underwent PCNL under local anesthesia, except for infants and young children. The results of this study show that PCNL under local anesthesia has the following advantages: Firstly, PCNL can avoid the bad impact on cardiopulmonary function of patients under local anesthesia. Secondly, pethidine hydrochloride has a good effect on internal organs pain, and lidocaine has a good effect on the pain caused by puncture. Communicating with the patient during the operation can relieve the patient's nervousness and anxiety in time so that the patient can better tolerate and cooperate with the operation. In epidural anesthesia, due to visceral reflex pain, anesthesiologists are accustomed to use sedative drugs. Patients are often prone to restlessness, position changes which affect surgical operations. Thirdly, patients do not need enema and fasting before surgery and can eat immediately after surgery; Last but not least, PCNL under local anesthesia can reduce treatment costs and hospital stays. The results of this study show that PCNL has a wide range of indications under local anesthesia, and patients can tolerate except for infants and young children. The minimum age of this group is 20 years old and the maximum age is 78 years old. All patients have successfully completed the operation. Some patients who cannot use epidural anesthesia and general anesthesia can also perform PCNL in local anesthesia. In this group of,2 patients aged 78 years old were completed by PCNL under local anesthesia。The contraindications for PCNL under local anesthesia in addition to infants and young children are the same as conventional PCNL.
PCNL is the preferred method for the treatment of kidney stones and partial ureteral stones which were larger than 2 cm in diameter. In recent years, studies have reported the use of new technologies and improved protocols, such as minimally invasive PCNL, tubeless PCNL, and PCNL under local anesthesia to reduce postoperative analgesia and hospital stay[10, 11]. The tubeless PCNL was first proposed by Bellman et al in 1997. Since then, research reports on the safety and effectiveness of tubeless PCNL have emerged. There are some advantages of tubeless PCNL group over traditional PCNL including faster recovery, shorter hospital stays, lower hospitalization costs, less postoperative pain, less analgesic drugs usage . But there was no difference between the two groups in postoperative complication. Recently, Shen and Zhong et al [14, 15] compared the tubeless PCNL with the common PCNL by meta-analysis, which confirmed that the postoperative analgesia requirement of the tubeless PCNL was lower and the hospital stay was shorter. And in recent years, the application of tubeless PCNL has become more and more extensive, including bilateral kidney stones and isolated kidney stones [16, 17].
The results of this study showed that the operation time of group 2 was slightly longer than the group 1, which mainly because it took a certain time to place and fix the fistula. But the operation time between the two groups was not significantly different. In the postoperative hospital stay, group 2 was significantly longer than group 1, which was consistent with the current study results. The postoperative pain VAS score of group 2 was significantly higher than group 1. The reasons are as follows: First, the sputum tube stimulates the intercostal or subcostal nerve; Second, The fistula tube produces irritation to the renal pelvis and renal pelvis wall. Pain after PCNL is generally mild, and most of them can be relieved without treatment or non-steroidal drugs. Only a small number of patients required narcotic analgesia. Group 2 patients with narcotic analgesic drugs were significantly more than group 1, the difference was statistically significant, and which was consistent with the VAS score. The reason why the postoperative hospital stay of group 1 was significantly shorter than that of group 2 was mainly because we routinely indwelled the fistula for 4 ~ 5 days. Furthermore, after extubation, patients were generally observed after 1 day and then discharged. However, patients with untreated PCNL are usually discharged on the third day after surgery if they are asymptomatic. The removal of the renal fistula was generally performed without the fever, pain and urine leakage after the clamped tube, so the VAS score at the time of discharge was not significantly different between the two groups. There were no blood transfusion, interventional hemostasis, pneumothorax and delayed bleeding in all patients. With respect to puncture site, hemoglobin decline, postoperative fever rate between the two groups were not significantly different. No blood transfusion and interventional hemostasis were performed in either group, and no pneumothorax or delayed bleeding occurred in all patients.
In this study, 135 patients underwent mPCNL under local anesthesia with no serious complications and rapid postoperative recovery. This study showed that PCNL surgery under local anesthesia is simple, safe and effective, and worthy of clinical application. Tubeless mPCNL treatment of kidney stones can significantly reduce postoperative pain and discomfort and shorten hospital stays. But it is a retrospective study with possible selection bias, it is necessary to avoid some syndromes, such as intraoperative bleeding, ureteral obstruction, severe perforation of the collection system and residual stones.