Ultrasound for kidney access in percutaneous nephrolithotomy: a contemporary review

Alexandru Iordache, Catalin Baston, Silviu-Stelian Guler-Margaritis, Emil Angelescu, Vasile Cerempei, Traxer Olivier, Ioanel Sinescu


Nowadays percutaneous nephrolithotomy (PCNL) is the standard of care for renal staghorn calculus or large (>20 mm) pelvic or caliceal stones, as well as for the failure of other treatment options. This review aims to evaluate the contemporary use of ultrasound imaging in PCNL, by comparing it to conventional fluoroscopy, reviewing data regarding the complication and success rate of nephrostomy tract creation and stone free rate (SFR), as well as data concerning the learning curve for these procedures and cost indicators. The evidence acquired shows that the ultrasound guided access (USGA) is a comparable method with the classic fluoroscopic guided access (FGA), with a similar safety profile, with a significant reduction in radiation exposure, up to radiation free complete PCNL. USGA PCNL seems to lead to decreased bleeding and need for transfusion, especially when the Doppler mode is used, and also to a slightly higher SFR than conventional FGA PCNL. USGA PCNL reduces the overall costs of the procedure by about 30% and can be safely learnt and performed by urologists. For an experienced endourologist, familiar with
FGA PCNL, the learning curve for shifting to USGA PCNL is of approximately 20 procedures.



ultrasound; fluoroscopy; percutaneous nephrolithotomy; urolithiasis

Full Text:



Fernström I. and Johansson B. Percutaneous pyelolithotomy. A new extraction technique. Scand. J Uro. Nephrol 1976;10:257–259.

Türk C, Neisius A, Petrik A et al. EAU Guidelines on Urolithiasis. Limited update March 2017.

Assimos D, Krambeck A, Miller NL et al. Surgical Management of Stones: American Urological Association/Endourological Society Guideline, PART II. J Urol 2016;196:1161–1169.

Preminger GM, Assimos D, Lingerman et al. Chapter 1: AUA guideline on management of staghorn calculi: diagnosis and treatment recommendations. J Urol 2005; 173:1991–2000.

Oberlin DT, Flum AS, Bachrach L, Matulewicz LS, FlurySC. Contemporary surgical trends in the management of upper tract calculi. J Urol 2015;193:880–884.

Doizi S, Raynal G, Traxer O. Évolution du traitement chirurgical de la lithiase urinaire sur 30 ans dans un centre hospitalo-universitaire. Prog en Urol 2015;25:543–548.

Morris DS, Wei JT, Taub DA, Dunn RL, Wolf SJr, Hollenbeck BK. Temporal trends in the use of percutaneous nephrolithotomy. J Urol 2006;175:1731–1736.

Miller NL, Matlaga BR, Lingeman JE. Techniques for Fluoroscopic Percutaneous Renal Access. J Urol 2007;178:15–23.

Kalogeropoulou C, Kallidonis P, Liatsikos EN. Imaging in percutaneous nephrolithotomy. J Endourol 2009;23:1571–1577.

Wickham JE, Kellett MJ. Percutaneous nephrolithotomy. Br J Urol 1981;53:297–299.

Steinberg PL, Semins MJ, Wason SEL, Matlaga BR, Pais VMJr. Fluoroscopy-Guided Percutaneous Renal Access. J Endourol 2009;23:1627–1631.

Park S, Pearle MS. Imaging for Percutaneous Renal Access and Management of Renal Calculi. Urol Clin North Am 2006;33:353–364.

Ganpule AP, Vijayakumar M, Malpani A, Desai MR. Percutaneous nephrolithotomy (PCNL) a critical review. Int J Surg 2016, doi: 10.1016/j.ijsu.2016.11.028.

Tzou DT, Usawachintachit M, Taguchi K, Chi T. Ultrasound Use in Urinary Stones: Adapting Old Technology for a Modern-Day Disease. J Endourol 2017, doi: 10.1089/end.2016.0584.

Galonnier F, Traxer O, Rosec M et al. Surgical Staff Radiation Protection During Fluoroscopy-Guided Urologic Interventions. J Endourol 2016;30:638–643.

Ritter M, Schmitt M, Siegel F et al. The DEFI-Study - Dosimetry in endourologic fluoroscopic interventions - risk of radiation exposure for endourologic surgeons. Eur Urol Suppl 2011;10:225.

Wenzler DL, Abbott JE, Su JJ et al. Predictors of radiation exposure to providers during percutaneous nephrolithotomy. Urol Ann 2017;9:55–60.

Mancini JG, Raymundo EM, Lipkin M et al. Factors Affecting Patient Radiation Exposure During Percutaneous Nephrolithotomy. J Urol 2010;184:2373–2377.

Demirci A, Raif Karabacak O,Yalçınkaya F, Yiğitbaşı O, Aktaş C. Radiation exposure of patient and surgeon in minimally invasive kidney stone surgery. Prog Urol 2016;26:353-359.

Safak M, Olgar T, Bor D, Berkmen G, GogusC. Radiation doses of patients and urologists during percutaneous nephrolithotomy. J Radiol Prot 2009;29:409–415.

Usawachintachit M, Masic S, Chang HC, Allen IE, Chi T. Ultrasound Guidance to Assist Percutaneous Nephrolithotomy Reduces Radiation Exposure in Obese Patients. Urology 2016;98:32–38.

Ng FC, Yam WL, Lim TYB, Teo JK, Ng KK, Lim SK. Ultrasound-guided percutaneous nephrolithotomy: Advantages and limitations. Investig Clin Urol 2017;58:346-352.

Desai M, Ridhorkar V, Patel S, Bapat S. Pediatric percutaneous nephrolithotomy: assessing impact of technical innovations on safety and efficacy. J Endourol 1999, doi: 10.1089/end.1999.13.359.

Dietrich CF, Goudie A, Chiorean L et al. Point of Care Ultrasound: A WFUMB Position Paper. Ultrasound Med Biol 2017;43:49–58.

Lojanapiwat B. The ideal puncture approach for PCNL: Fluoroscopy, ultrasound or endoscopy?. Indian J Urol 2013;29:208-213.

Chu C, Masic S, Usawachintachit M et al. Ultrasound-Guided Renal Access for Percutaneous Nephrolithotomy: A Description of Three Novel Ultrasound-Guided Needle Techniques. J Endourol 2016;30:153–159.

Basiri A, Ziaee AM, Kianian HR, Mehrabi S, Karami H, Moghaddam SMH. Ultrasonographic versus Fluoroscopic Access for Percutaneous Nephrolithotomy: A Randomized Clinical Trial. J Endourol 2008;22:281–284.

Agarwal M, Agrawal M, Jaiswal A, Kumar D, Yadav H, Lavania P. Safety and efficacy of ultrasonography as an adjunct to fluoroscopy for renal access in percutaneous nephrolithotomy (PCNL). BJU Int 2011;108:1346–1349.

Andonian S, Scoffone CM, Louie MK et al. Does Imaging Modality Used for Percutaneous Renal Access Make a Difference? A Matched Case Analysis. J Endourol 2013;27:24–28.

Wang K, Zhang P, Xu X, Fan M. Ultrasonographic versus Fluoroscopic Access for Percutaneous Nephrolithotomy: A Meta-Analysis. Urol Int 2015;95:15–25.

Jagtap J, Mishra S, Bhattu A, Ganpule A, Sabnis R, Desai MR. Which Is the Preferred Modality of Renal Access for a Trainee Urologist: Ultrasonography or Fluoroscopy? Results of a Prospective Randomized Trial. J Endourol 2014;28:1464–1469.

Clavien PA, Barkun J, de Oliveira ML et al. The clavien-dindo classification of surgical complications: Five-year experience. Ann Surg 2009;250:187–196.

Kamphuis GM, Baard J, Westendarp M, de la Rosette JJ. Lessons learned from the CROES percutaneous nephrolithotomy global study. World J Urol 2015;33:223–233.

Ingimarsson J, Bechis S, Moses R, Johnson E, Eisner B, Pais V.Comparsion of access related complications: radiologist vs urologist obtained percutaneous renal access. J Urol 2014;191:e280.

Wang Y, Lu Z, Hu J et al. Renal access by sonographer versus urologist during percutaneous nephrolithotomy. Urol J 2014;10:1035–1039.

Watterson JD, Soon S, Jana K. Access Related Complications During Percutaneous Nephrolithotomy: Urology Versus Radiology at a Single Academic Institution. J Urol 2006;176:142–145.

Osman M, Wendt-Nordahl G, Heger K, Michel MS, Alken P, Knoll T. Percutaneous nephrolithotomy with ultrasonography-guided renal access: Experience from over 300 cases. BJU Int 2005;96:875–878.

Hudnall M, Usawachintachit M, Metzler I et al. Ultrasound Guidance Reduces Percutaneous Nephrolithotomy Cost Compared to Fluoroscopy. Urology 2017;103:52–58.

Zhao Z, Fan J, Liu Y, de la Rosette J, Zeng G. Percutaneous nephrolithotomy: position, position, position!. Urolithiasis 2018;46:79–86.

Usawachintachit M, Tzou DT, Mongan J, Taguchi K, Weinstein S, Chi T. Feasibility of Retrograde Ureteral Contrast Injection to Guide Ultrasonographic Percutaneous Renal Access in the Nondilated Collecting System. J Endourol 2017;31:129–134.

Tzeng BC, Wang CJ, Huang SW, Chang CH. Doppler Ultrasound-guided Percutaneous Nephrolithotomy: A Prospective Randomized Study. Urology 2011;78:535–539.

Li J, Xiao B, Hu W, Yang B, Chen L, Hu H, Wang X. Complication and safety of ultrasound guided percutaneous nephrolithotomy in 8,025 cases in China. Chin Med J (Engl) 2014;127:4184–4189.

Allen D, O’Brien T, Tiptaft R, Glass J. Defining the learning curve for percutaneous nephrolithotomy. J Endourol 2005;19:279–282.

Tanriverdi O, Boylu U, Kendirci M, Kadihasanoglu M, Horasanli K, Miroglu C. The Learning Curve in the Training of Percutaneous Nephrolithotomy. Eur Urol 2007;52:206–211.

Negrete-Pulido O, Molina-Torres M, Castaño-Tostado E, Loske AM, Gutiérrez-Aceves J. Percutaneous Renal Access: The Learning Curve of a Simplified Approach. J Endourol 2010;24:457–460.

Song Y, Ma Y, Song Y, Fei X. Evaluating the Learning Curve for Percutaneous Nephrolithotomy under Total Ultrasound Guidance. PLoS One 2015;10:e0132986.

Yu W, Rao T, Li X et al. The learning curve for access creation in solo ultrasonography-guided percutaneous nephrolithotomy and the associated skills. Int Urol Nephrol 2017;49:419–424.

Usawachintachit M, Masic S, Allen IE, Li J, Chi T. Adopting Ultrasound Guidance for Prone Percutaneous Nephrolithotomy: Evaluating the Learning Curve for the Experienced Surgeon. J Endourol 2016;30:856–863.

DOI: http://dx.doi.org/10.11152/mu-1618


  • There are currently no refbacks.