European Section of Urotechnology educational video on fluoroscopic-guided puncture in percutaneous nephrolithotomy: all techniques step by step.

OBJECTIVE: To describe the most common fluoroscopic-guided access techniques during percutaneous nephrolithotomy (PCNL) in a step-by-step manner and to assist in the standardisation of their technique and terminology.

METHODS: A high-quality animation video was created for each of the respective fluoroscopic techniques, focusing into the parallel projection of external surgical manoeuvres and their effect in the three-dimensional space of the kidney.

RESULTS: Four predominant fluoroscopic-guided percutaneous access techniques are available, each with different advantages and limitations. Monoplanar access is used when a stable single-axis fluoroscopic generator is available and is mostly based on surgeons' experience. Biplanar access uses a second fluoroscopy axis to assess puncture depth. The 'bull's eye' technique follows a coaxial to fluoroscopy puncture path and is associated with a shorter learning curve at the cost of increased hand radiation exposure. Hybrid and conventional triangulate techniques use target projection by two fluoroscopic planes to define the exact localisation of the target in space and access it through a third puncture site.

CONCLUSIONS: Fluoroscopic guidance during PCNL puncture is a very efficient method for access establishment. The percutaneous surgeon should be familiar with all available variations of fluoroscopic approach in order to be prepared to adapt puncture technique for any given scenario.