# Pure Ultrasound with Two-Step Dilation vs. Combined Ultrasound-Fluoroscopy in Percutaneous Nephrolithotomy: Is Fluoroscopy Still Needed?

## TL;DR

This study compares using only ultrasound versus combining ultrasound and fluoroscopy for kidney stone removal, finding that pure ultrasound is safe and avoids radiation.

## Contribution

Demonstrates that pure-ultrasound PCNL with two-step dilation is a viable alternative to fluoroscopy.

## Key findings

- Pure-ultrasound PCNL achieved a 78.3% stone-free rate, similar to the 80% in the combined method.
- Fluoroscopy time was completely avoided in the pure-ultrasound group.
- Complication rates were lower in the pure-ultrasound group, though not statistically significant.

## Abstract

Fluoroscopy has been the most widely used guidance method for percutaneous nephrolithotomy (PCNL); however, radiation exposure is a significant concern. Recently, ultrasound has gained popularity, offering several advantages. The objective was to evaluate the safety and outcomes of the pure-ultrasound PCNL with a two-step tract dilation.

The authors retrospectively analyzed the data of patients from March 2019 to October 2023. In all patients, percutaneous renal access was ultrasound guided, and they were divided into 2 groups: Group 1, all steps of PCNL were performed under ultrasound guidance, and Group 2, tract dilation, confirmation of stone clearance, and exit strategy were done with fluoroscopy.

The authors included 100 patients, 60 in Group 1 and 40 in Group 2, with a mean body mass index of 30.8 kg/m2. Mean stone burden was 4,162 mm3, 53% were complex stones and 59% of the cases were without hydronephrosis in the targeted calyx. Fluoroscopy was absent in Group 1 and 20 (11.3-31.5) seconds in Group 2 (P < .001). Complications were present in 13% of the cases. Group 1 patients had a lower complication rate than those in Group 2 (10% and 17%, respectively, P = .27). The authors had a global stone-free rate of 79%, Group 1: 78.3% and Group 2: 80% (P = 1.0). Multivariate analysis revealed that the stone-free rate is associated with the total operative time (P = .002) and the number of tracts (P = .031).

Pure ultrasound PCNL is a safe and effective technique, offering a similar stone-free rate compared to fluoroscopy and providing an alternative method to avoid radiation exposure during PCNL.