A non-transpapillary technique appears to ease access to the kidney – the most critical step in percutaneous nephrolithotomy (PNL) – when compared to the classic transpapillary approach. Remarkably, the earliest descriptions of percutaneous access by Goodwin et al. in 1955 described a pyelostomy, not a nephrostomy, thus avoiding the papilla. More recently, non-calyceal puncture methods have gained attention, yet a persistent belief, reinforced by Lotfi et al. and many others, is that our anatomical understanding of access is primarily based on Sampaio’s extensive work. However, Sampaio’s publications came 15 years after the widespread adoption of transpapillary PNL in the 1970s. By then, thousands of PNLs had already been performed using the principle of entering through the least vascular parenchyma without injuring the collecting system. This marked a reversal of the logic from open surgery, where access was often gained through a preformed transpapillary route. Wickham’s later contributions, including transpapillary multiple nephrotomies for staghorn stones, further shaped this approach and were refined by the Mainz group, who operated without clamping the renal artery. In practice, achieving access is often a greater priority than ideal papillary puncture. As Wickham noted, “large venous anastomoses… around calyceal necks” may explain the venous oozing observed with non-papillary access. Though manageable, this remains a concern. Ultimately, many surgeons, including Tahra et al., pragmatically “puncture wherever we can” to maximise stone clearance. Cracco and Scoffone also acknowledged that not all papillary punctures are anatomically perfect. The non-papillary approach, while imperfect, remains a viable alternative when standard access is difficult. Yet, caution is warranted; targeting larger areas may raise the risk of complications. As Sampaio rightly observed in 1988, anatomical understanding remains one of the most overlooked aspects of endourology and continues to warrant deeper exploration.
Percutaneous nephrolithotomy: wisdom, dogma, paradigm and myths
Reviewed by Asif H Ansari
Percutaneous nephrolithotomy: wisdom, dogma, paradigm and myths surrounding puncture.
