Re: Kallidonis,et al .,Papillary vs Nonpapillary Puncture in Percutaneous Nephrolithotomy: A Prospective Randomized Trial (From: Kallidonis P,Kyriazis I,Kotsiris D,et al . J Endourol 2017;31:S-2–S-7;DOI: 10.1089/end.2016.0571)

Dear Editor:

I have read the article entitled “Papillary vs Nonpapillary Puncture in Percutaneous Nephrolithotomy: A Prospective Randomized Trial” by Kallidonis, et al. that was published in Journal of Endourology Vol. 31, No. S1. I want to congratulate the authors for this article, and respectfully submit these comments.

In the article, it has been indicated that the infundibular approach for percutaneous nephrolithotomy to the posterior middle renal calices is not associated with higher blood loss or transfusion rate in comparison with the respective approach to the fornix of the papilla.

I think that the title of the article is not compatible with the conclusion aforementioned; therefore, the authors may consider modifying the title, to limit their conclusion to “safe infundibular puncture to the posterior middle calices” and not to generalize such results to the upper or lower calices.

My second concern is regarding the choice of the middle caliceal puncture, as the desired entrance site, in 15 patients with lower caliceal stones in the second group, as typically an upper or lower caliceal puncture would be recommended in this situation.

Lastly, a technique utilizing a direct middle posterior infudibular puncture may lead the needle to transfix and traverse the calix in its way to the infudibulum, which may lead to missing some caliceal stones if present or to increase the incidence of infundibular vessel puncture according to Sampaio and colleagues. ¹