Association of Postoperative Drainage Strategy with Persistent Urinary Leakage and Clinical Outcomes Following Percutaneous Nephrolithotomy.

Background and Objectives: Persistent postoperative urinary leakage may delay recovery after percutaneous nephrolithotomy (PCNL). This study evaluated the association between postoperative drainage strategy, persistent urinary leakage, and clinical outcomes following prone PCNL. Materials and Methods: This retrospective, non-randomized cohort analysis included 606 consecutive eligible patients undergoing prone PCNL between 2015 and 2026 from a prospectively maintained institutional database. Patients received either an external ureteral catheter (n = 529) or primary antegrade double-J (DJ) stent (n = 77). Perioperative outcomes were compared, and factors associated with persistent urinary leakage were evaluated in the ureteral-catheter group. Results: Operative and nephroscopy times were longer in the DJ-stent group (110.4 ± 47.2 vs. 100.6 ± 37.9 min, p = 0.041; 50.0 vs. 40.0 min, p = 0.002). Persistent urinary leakage occurred in 39 patients (7.4%) with ureteral catheters and in none with primary DJ stents (p = 0.006). After stabilized IPTW, the risk difference for primary DJ stenting versus ureteral-catheter drainage was -7.45 percentage points (95% bootstrap CI, -9.77 to -5.33). The distributions of nephrostomy tube removal time and hospital stay differed between the drainage groups (DJ stent vs. ureteral catheter: 2.0 [IQR, 2.0-2.0] vs. 2.0 [IQR, 2.0-2.5] days, p = 0.028; and 3.0 [IQR, 2.0-3.0] vs. 3.0 [IQR, 3.0-4.0] days, p = 0.004, respectively), although the corresponding Hodges-Lehmann estimated differences were small (0 days [95% CI, 0 to 0] and 0 days [95% CI, 0 to 1], respectively). In multivariable analysis, residual stone presence was associated with higher odds of persistent urinary leakage (adjusted OR 2.16, 95% CI 1.09-4.28; p = 0.027). Conclusions: Primary antegrade DJ stenting was associated with lower urinary leakage rates. Although the distributions of nephrostomy tube removal time and hospital stay also favored the DJ-stent group, the absolute between-group differences were small. Residual stone presence remained independently associated with higher odds of persistent urinary leakage.