Diagnosis and management of postpercutaneous nephrolithotomy residual stone fragments

Residual stone fragments can occur in up to 8% of patients who are treated with percutaneous nephrolithotomy (PCNL). When left untreated, approximately half of these patients will experience a stone-related event, for which more than half will need a secondary surgical intervention. Predictors of adverse events are a residual fragment larger than 2 mm that is located in the pelvis or ureter. Preventive measures for the creation of residual fragments include a carefully selected access giving exposure to the bulk of the stone, the creation of multiple tracts, the use of single pulse pneumatic lithotripsy, the prevention of stone migration with ureteral balloons or stone cones, and careful flushing of the stones from the collecting system. Plain radiography of the kidneys, ureters, and bladder, linear tomography, and ultrasonography have all been used to judge the result of PCNL and to detect the presence of residual fragments. Thin-slice, unenhanced helical CT, however, is more sensitive and should be performed at 1 month after surgery. While medical therapy and shockwave lithotripsy possess a minor role, second-look flexible nephroscopy and/or flexible ureterorenoscopy seem to be the treatments of choice for residual stone fragments after PCNL.