The ideal puncture approach for PCNL: Fluoroscopy, ultrasound or endoscopy?

Percutaneous renal access is a common procedure in urologic practice. The main indications are drainage of an obstructed and hydronephrotic kidney and antegrade renal access prior to percutaneous renal surgeries such as percutaneous nephrolithotomy (PCNL) and percutaneous endopyelotomy (EP). The contraindications for this technique are patients with history of allergy to topical or local anesthesia and patients with coagulopathy. The creation of a percutaneous tract into the renal collecting system is one of the important steps for percutaneous renal access. This step usually requires imaging. The advantages and disadvantages of each modality of image guidance are controversial. We performed a structured review using the terms: Percutaneous nephrostomy, guidance, fluoroscopy, ultrasonography, computed tomography (CT) scan, and magnetic resonance imaging (MRI). The outcomes are discussed.