Percutaneous nephrolithotomy: an extreme technical makeover for an old technique.
INTRODUCTION: Percutaneous nephrolithotomy (PNL) remains the treatment of choice for several forms of stone disease including: large stones, many cystine and struvite calculi, lower pole calyceal calculi, stones associated with anomalous renal anatomy, and stones in morbidly obese patients. Recent advances in the PNL technique appear to improve post-operative outcomes and reduce patient morbidity. MATERIALS AND METHODS: A thorough review of the recent urologic literature was performed to identify these alterations in technique and whether or not these changes have improved stone-free outcomes and/or reduced patient morbidity. RESULTS: Published series from several different centers have recently demonstrated that supine PNL is safe with specific benefits for the patient and several technical advantages for the surgeon. A number of currently available intracorporeal lithotripsy devices, specifically combination pneumatic and ultrasonic lithotrites, have been show to offer improved stone fragmentation and more efficient fragment clearance. Tubeless, stentless PNL appears to offer reduced flank pain and no stent-related symptoms following stone removal. CONCLUSIONS: Further advances in the PNL technique will not only increase stone-free outcomes and reduce post-operative complications, but also significantly reduce peri-operative patient morbidity. Further large scale clinical trails are necessary to better define the benefits of supine PNL, improved intracorporeal lithotripsy devices and tubeless percutaneous nephrolithotomy.
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