Editorial Comment on: Complications,Re-Intervention Rates,and Natural History of Residual Stone Fragments After Percutaneous Nephrolithotomy by Emmott et al.

Percutaneous nephrolithotomy (PCNL) is currently the treatment of choice for large and complex renal calculi. One of the main advantages of PCNL is gaining a real stone-free status in a single session. However, there are several major complications that necessitate careful patient selection for this surgery. ¹ In this well-written article, the authors deal with the true rates and importance of residual fragments (RFs) after PCNL surgeries done in a high-volume center. They reviewed 658 PCNL procedures from 2008 to 2013 that underwent a CT scan on postoperative day 1. The immediate and real stone-free rates were lower (55%) than previously published.

Moreover, the rate of spontaneous passage of very small RFs in this study is interestingly low (23.4%). The question is whether these are real RFs or just parenchymal calcifications such as Randall's plaques or even nephrocalcinosis. It is crucial to find a way to distinguish between these two options. Furthermore, when they compared the fate of RFs <4 mm and >4 mm, they found that there was no difference in the rate of spontaneous passage and growth of fragments based on size of RFs.

While keeping this in mind, we are currently facing an evolution of two major processes that have a safer complication profile and have the potential to challenge the role of standard PCNL. One is a continuous reduction of tract size of percutaneous surgery and the other is very effective dusting capabilities of larger renal stones using one of the new high-power laser machines through a flexible ureteroscope. Both gave very good results. ^{2 –5}

Facing and truly recognizing these issues are important to future surgical decisions in the era of the aforementioned surgical trends. We should be open-minded to future changes in surgical approaches and technological improvements in the field of endourology.