PCNL: Recent advances

A) Elevated intra-renal pressures due to narrow infundibulum. B) Intra-renal pressure during PCNL (mmHg) demonstrating Vortex effect

The evolution of percutaneous nephrolithotomy (PCNL) has been marked by the exploration of various positions, techniques, and technologies aimed at optimizing outcomes for patients with kidney stones. The prone position, while familiar to urologists and providing wider access to calyces and easier instrument manipulation, presents challenges such as time-consuming repositioning and potential complications related to anesthesia and abdominal pressure. Conversely, the supine Bart’s Flank Free Position offers advantages like reduced extremity pressure and enhanced access to the renal anatomy, supporting efficient procedures without the need for extensive tilting of the operating table. Studies indicate comparable safety and efficacy profiles between anterior calyceal access in supine PCNL and traditional approaches, with minimal differences in complication rates and stone-free outcomes. The introduction of miniaturized tract techniques, such as the ClearPetra suctioning sheath, has further improved patient experiences by promoting less invasive approaches that reduce blood loss and postoperative pain while maintaining effective stone fragmentation. Recent research emphasizes the importance of minimizing intrarenal pressure during procedures to mitigate renal damage, highlighting the significance of technique choice, such as utilizing smaller sheaths. As PCNL continues to advance, innovations like outpatient procedures and the incorporation of ultrasonography for guidance are paving the way for enhanced recovery and reduced hospital stays. The future of PCNL lies in refining these techniques and technologies, ensuring that patients benefit from safer, more effective treatments, ultimately leading to improved quality of life post-surgery. 

Dr Mantu Gupta

Mount Sinai, New York, USA