Small tools, big impact and redefining endourology: the paradigm shift of ureteroscopy for large stones and percutaneous nephrolithotomy for small stones – a literature review

Purpose of review We aim to review the evolving paradigm in endourology, where technology has led us to manage small stones with ureteroscopy (URS) and large stones with miniaturized percutaneous nephrolithotomy (mPCNL) techniques. We analyse recent literature, their findings, emerging trends and newer technologies that are helping redefine modern day endourology in pushing these boundaries. Recent findings A significant trend is the use of smaller devices to treat larger stones via ureteroscopy, and to treat smaller stones via percutaneous nephrolithotomy (PCNL). Improved laser technologies, smaller single use ureteroscopes and nephroscopes, suction access sheaths, all play a key role in this. The use of suction sheaths and vacuum assisted devices allows to control intrarenal pressure and help in reducing infectious and other complications whilst improving the stone-free rate (SFR). The treatment choice often depends on surgical expertise and available resources, guided by anatomical factors, stone composition and patient-specific considerations. Summary The management of kidney stone disease has undergone a paradigm shift. While ureteroscopy is being done for larger renal stones, miniaturised PCNL is being done for small stones. This has been driven by a surge in technology, but a tailored and patient-centred approach is needed, and must be helped by guidelines and a multidisciplinary approach.