Percutaneous nephrolithotomy (PCNL) is the American Urological Association's recommended first‐line treatment for kidney stones > 20 mm[
1]. However, only 8% of urolithiasis procedures in the United States involve PCNL, largely due to access difficulties, with > 68% of urologists relying on interventional radiology[
2,
3]. This dependence increases costs and may result in suboptimal access points, affecting stone clearance[
4]. This video demonstrates a step‐by‐step approach to the endoscopic retrograde renal access technique (Supporting Information S1: Video 1), an innovative method using flexible ureteroscopy and retrograde pyelography, potentially enabling more urologists to perform their own PCNL access. A 31‐year‐old female with a 3‐cm left partial staghorn calculus (Guy score 4) underwent the procedure in a supine position. Flexible ureteroscopy was used to identify the target calyx, and RetroPerc
® facilitated antegrade access under fluoroscopy. The nephrostomy tract was dilated to 24 Fr. The procedure lasted 105 min with 23 s of fluoroscopy. The patient was discharged within 24 h without complications.
Preoperative CT is essential to identify the ideal puncture calyx. Patient positioning in a modified Galdakao setup and ureteral stent placement were performed. A retrograde pyelogram confirmed access to the target calyx, followed by ureteral access sheath insertion. The flexible ureteroscope was advanced into the chosen posterior calyx and confirmed with retrograde pyelography. While the surgeon stabilized the ureteroscope, the assistant advanced the RetroPerc® puncture apparatus under fluoroscopy. Once it tinted the skin, gentle pressure was applied to puncture through (Figure 1). The wire was clamped, and the tract was confirmed by correlating the exit site with palpation. The wire was then drawn from the flank to allow smooth coaxial catheter advancement under fluoroscopy. After confirming the catheter inside the collecting system endoscopically, the ureteroscope was retracted, and the catheter advanced. The clamp was removed, and both the ureteroscope and puncture wire were withdrawn. After anterograde placement of a new working wire, the catheter was removed, creating a through‐and‐through access for renal dilation and stone removal. If the wire exits suboptimally, repositioning it or adjusting the incision can create a perpendicular pathway to the calyx, especially helpful in obese patients.
The endoscopic retrograde access technique offers a practical alternative to antegrade access in PCNL, utilizing urologists' expertise in retrograde procedures, particularly flexible ureteroscopy[
5]. By enabling renal access without interventional radiology, it expands the potential for self‐sufficient PCNL, especially in routine cases. This approach allows targeted calyx access in complex cases, potentially improving stone clearance rates and shortening hospital stays[
6]. Despite its advantages, this technique has contraindications, including non‐patent ureters, retrorenal colon, bleeding disorders, or the absence of a safe percutaneous window for access. Identifying these conditions preoperatively is crucial to minimize complications and ensure safety. Additionally, eliminating the need for interventional radiology streamlines procedures, enabling PCNL access and stone removal in a single session, thus reducing patient burden, anesthesia exposure, and procedural costs[
5,
7]. This method is intuitive and reproducible, allowing urologists without extensive endourology experience to perform it effectively[
8]. As the technique gains wider adoption, the overall number of PCNL procedures could increase, enhancing patient access to care, especially in regions where interventional radiology is limited[
9]. Finally, current data on the endoscopic retrograde access approach is scarce. However, a prospective trial is underway[
10].
The endoscopic retrograde renal access technique offers a valuable alternative for achieving renal access during PCNL, enabling urologists to obtain precise access independently. This technique has the potential to lower costs, improve outcomes, and expand the number of urologists capable of performing PCNL. Further studies are needed to confirm the long‐term effectiveness and safety of this promising approach.
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