Radiation Free Percutaneous Nephrolithotomy (PCNL) is Not Always Feasible comparative prospective trial

Introduction and ObjectivePercutaneous nephrolithotomy (PCNL) is a minimally invasive procedure for kidney stone removal traditionally guided by fluoroscopy. This study aimed to evaluate the feasibility and outcomes of radiation-free PCNL using ultrasound alone compared to standard fluoroscopy-guided PCNL. MethodsA total of 63 PCNL cases were eligible for radiation-free PCNL, but 27 were excluded (intra-operatively aborted, ureteroscopy performed instead, pre-operative complex anatomy). Of the remaining 36 cases eligible for radiation-free PCNL, 11 were converted intra-operatively to fluoroscopic based PCNL. Post-operative CT imaging was available for only 16 of the 25 radiation-free PCNL cases and 4 of the 11 converted cases. We designated these 16 prospective radiation-free PCNL cases (2024-2025) as Group A. For comparison purposes we identified a historical case-matched cohort of 150 PCNLs. Of these 67 were excluded (similar reasons) leaving 83 retrospective fluoroscopy-guided PCNL cases (2022-2024) called Group B. The primary outcome was stone-free rate (SFR), assessed post-operatively by non-contrast CT (2-3 mm slices). Secondary outcomes included estimated blood loss (EBL), complication rates (Clavien-Dindo), and post-operative stone events. ResultsThe median pre-operative stone burden was 35 mm in Group A and 27 mm in Group B and C [p=0.3]. SFR (Grade A) was comparable across Groups A, B, and C [38%, 30%, 25% respectively (p = 0.8)]. No differences were observed in complications or secondary outcomes. ConclusionsRadiation-free PCNL is feasible and yields comparable outcomes to standard fluoroscopy-guided PCNL, offering a promising method to reduce radiation exposure without compromising surgical success. However, we identified a consistent theme of poor visualization that led to large proportion of cases requiring conversion to fluoroscopy. Innovation directed towards improving tool echogenicity is key to diffusing this technique.