Who still needs multiple access sites in the era of ECIRS and US-guided supine PCNL?

Multiaccess PCNL, typically performed for large complex renal stones, is associated with higher complication rates. Newer techniques like ECIRS and US-guided supine PCNL may reduce the need for multiple tracts and related morbidity. This study aims to identify contemporary preoperative predictors for multiple access tracts during ECIRS and US-guided supine PCNL.

We analyzed our most recent 250 patients undergoing US-guided supine PCNL (and ECIRS when indicated) with at least one year follow-up using logistic regression models and sensitivity analyses to find preoperative factors associated with the likelihood of requiring multiple access tracts.

Seventeen patients (7%) had a multiaccess procedure, with the lower pole as the most common first access site (59%), followed by upper pole (35%) and interpolar (6%). Fourteen patients had two access sites, two had three, and just one had four. On univariable analysis, multiple stones, higher stone burden, upper pole stones, interpolar stones, and a higher Guy's Stone Score were associated with likelihood of requiring multiple accesses. On multivariable analysis, stone burden remained the only significant predictor (OR = 1.038, 95% CI: 1.010-1.066, p = 0.007). A burden > 34.5 mm was found to be the optimal size cutoff. Among 36 full staghorn cases, 6 (17%) required multiple accesses. In non-staghorn patients, upper pole stones were the strongest predictor (OR = 5.056, 95% CI: 1.272-20.099, p = 0.021).

In the era of ECIRS, US-guidance, and supine position, only 7% of patients require multiaccess PCNL. Total linear stone burden, upper pole stones and number of calyces are key risk factors, highlighting the value of preoperative identification for optimized surgical planning and outcomes.