PCNL Access Approaches and Calyceal Selection

Introduction to PCNL Approaches

The posterior approach is the standard for PCNL and should be used in the vast majority of cases, as it provides safer access through the relatively avascular Brödel's line and allows optimal stone clearance, according to the European Association of Urology 1
Both prone (posterior) and supine (anterior/anterolateral) positions are equally safe according to current evidence, though the supine position offers the advantage of simultaneous retrograde access if needed, as recommended by the European Association of Urology 1

Hemorrhage requiring transfusion occurs in 7% of PCNL cases overall, with rates of 4-15% considered acceptable by quality standards, as stated by the American College of Radiology and the European Association of Urology 1, 2
Sepsis occurs in approximately 0.5% of cases across all approaches, according to the European Association of Urology 1
Organ injury (bowel, spleen, liver) occurs in <1% of cases, though upper pole access requires careful preoperative imaging to identify interposed organs, as recommended by the American College of Radiology and the European Association of Urology 1, 2
Pleural complications occur in approximately 1% of cases with standard access but increase to 15% with supracostal puncture, as reported by the American College of Radiology 2

Ultrasound guidance for initial puncture reduces radiation exposure and has lower complication rates compared to fluoroscopy alone, according to the European Association of Urology 1
Flexible nephroscopy must be routinely performed regardless of access site to retrieve stone fragments that migrate to inaccessible areas, as recommended by the American Urological Association and the European Association of Urology 1, 3
Normal saline irrigation is mandatory to prevent hemolysis and electrolyte abnormalities, as stated by the American Urological Association and the European Association of Urology 1, 3
Single-step or balloon dilation may shorten operative time and reduce complications compared to serial dilation, according to the European Association of Urology 1