The Evolution of Percutaneous Nephrolithotripsy – An Overview from European Association of Urology Endourology Section

Introduction: While reviews and book chapters focus on certain aspects of evolution and perhaps key milestones, a comprehensive overview of the history and evolution of percutaneous nephrolithotomy (PCNL) is lacking. This review looks at different aspects of PCNL evolution with procedural and technological advancements, with specific aspects of history, positioning, imaging and puncture, tract dilation, miniaturization, and lithotripsy devices. Material and Methods: We conducted a thorough search in October 2024 across multiple databases, social media platforms, and Google with specific terms and Boolean operators to determine the main dates for the development of individual PCNL stages. To be more specific, the main focus was on identifying chronological events that led to the evolution of PCNL with respect to these six categories: (1) history of PCNL; (2) patient positioning; (3) imaging and puncture; (4) tract dilation; (5) nephroscope size; and (6) lithotripsy devices. Results: All six aspects that have been investigated have undergone significant changes, leading to the modernization of PCNL in the 21st century. There is a trend toward supine position, miniaturization of instruments, an increase in image quality, the active development of various imaging modalities, and the integration of various digital and prototyping technologies. There are tools to help with puncture and needle guidance, as well as the emergence of navigation and robotic systems. Tract dilation seems to move toward single-step approach rather than serial dilatation. Major discoveries in energy sources such as lasers have now been incorporated into lithotripsy for PCNL. Conclusion: The modernization of PCNL has been a result of multiple evolutions along its journey, from imaging advancements, lithotripsy devices, miniaturization, learning from cross-disciplinary techniques, and digital integration with the use of virtual and augmented reality. While the journey continues to evolve, we summarize the key milestones that have led to the current clinical standard of practice.