Natural History of Residual Stone Fragments Following PCNL

  • Mohammad A. Alomar
  • Alaa A. Mokhtar


Since the introduction of minimally invasive procedures for managing renal stones, the presence of small residual fragments became an issue with debatable approaches.

Recently increasing body of literature uses the term clinically insignificant fragments to describe stones less than 4 mm that are not causing any obstruction nor infection.

We did a literature review of this subject and described our approach in managing residual stones after PCNL.


Renal stones PCNL Residual fragments Staghorn stones Management of clinical insignificant fragments Second-look nephroscopy 


  1. 1.
    Türk C, Knoll T, Petrik A, Sarica K, Straub M, Seitz C. Guidelines on urolithiasis. European Association of Urology, 2016.
  2. 2.
    Preminger GM, Tiselius HG, Assimos DG, et al. 2007 guideline for the management of ureteral calculi. J Urol. 2007;178:2418–34.PubMedCrossRefGoogle Scholar
  3. 3.
    Kallidonis P, Panagopoulos V, Kyriazis I, et al. Complications of percutaneous nephrolithotomy: classification, management, and prevention. Curr Opin Urol. 2016;26:88.PubMedCrossRefGoogle Scholar
  4. 4.
    Ghani KR, Sammon JD, Bhojani N, et al. Trends in percutaneous nephrolithotomy use and outcomes in the United States. J Urol. 2013;190:558–64.PubMedCrossRefGoogle Scholar
  5. 5.
    Borofsky MS, Tayeb MM, El Paonessa JE, et al. Initial experience and comparative intracorporeal ultrasonic lithotriptor. Urology. 2015;85:1279–83.PubMedCrossRefGoogle Scholar
  6. 6.
    Mishra S, Jagtap J, Sabnis RB, et al. Training in percutaneous nephrolithotomy. Curr Opin Urol. 2013;23:147–51.PubMedCrossRefGoogle Scholar
  7. 7.
    Ganpule AP, Bhattu AS, Desai M. PCNL in the twenty-first century: role of Microperc, Miniperc, and Ultraminiperc. World J Urol. 2015;33:235–40.PubMedCrossRefGoogle Scholar
  8. 8.
    Olvera-Posada D, Tailly T, Alenezi H, et al. Risk factors for postoperative complications of percutaneous nephrolithotomy at a tertiary referral center. J Urol. 2015;194:1646–51.PubMedCrossRefGoogle Scholar
  9. 9.
    de la Rosette J, Assimos D, Desai M, et al. The Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study: indications, complications, and outcomes in 5803 patients. J Endourol. 2011;25:11–7.PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    Khaitan A, Gupta NP, Hemal AK, et al. Post-ESWL, clinically insignificant residual stones: reality or myth? Urology. 2002;59:20–4.PubMedCrossRefGoogle Scholar
  11. 11.
    Osman Y, Harraz AM, El-Nahas AR, et al. Clinically insignificant residual fragments: an acceptable term in the computed tomography era? Urology. 2013;81:723–6.PubMedCrossRefGoogle Scholar
  12. 12.
    Afshar K, McLorie G, Papanikolaou F, et al. Outcome of small residual stone fragments following shock wave lithotripsy in children. J Urol. 2004;172:1600–3.PubMedCrossRefGoogle Scholar
  13. 13.
    Dincel N, Resorlu B, Unsal A, Tepeler A, Silay MS, Armağan A, Diri A, Sancaktutar AA, Ziypak T, Mir S. Are small residual stone fragments really insignificant in children? J Pediatr Surg. 2013;48(4):840–4.PubMedCrossRefGoogle Scholar
  14. 14.
    Streem SB, Yost A, Mascha E. Clinical implications of clinically insignificant store fragments after extracorporeal shock wave lithotripsy. J Urol. 1996;155:1186–90.PubMedCrossRefGoogle Scholar
  15. 15.
    Altunrende F, Tefekli A, Stein RJ, et al. Clinically insignificant residual fragments after percutaneous nephrolithotomy: medium term follow-up. J Endourol. 2011;25:941–5.PubMedCrossRefGoogle Scholar
  16. 16.
    Chew BH, Brotherhood HL, Sur RL, et al. Natural history, complications and re-intervention rates of asymptomatic residual stone fragments after ureteroscopy: a report from the EDGE research consortium. J Urol. 2016;95(4 Pt 1):982–6.CrossRefGoogle Scholar
  17. 17.
    Raman JD, Bagrodia A, Gupta A, et al. Natural history of residual fragments following percutaneous nephrostolithotomy. J Urol. 2009;181:1163–8.PubMedCrossRefGoogle Scholar
  18. 18.
    Assimos DG. Re: clinically insignificant residual fragments: is it an appropriate term in children? J Urol. 2016;195:170.PubMedCrossRefGoogle Scholar
  19. 19.
    Ganpule A, Desai M. Fate of residual stones after percutaneous nephrolithotomy: a critical analysis. J Endourol. 2009;23(3):399–403.PubMedCrossRefGoogle Scholar
  20. 20.
    Olvera-Posada D, Ali S, Marie Dion M, Alenezi H, Denstedt J, Razv H. Natural history of residual fragments after percutaneous nephrolithotomy: evaluation of factors related to clinical events and intervention. J Urol. 2016;97:46–50.CrossRefGoogle Scholar
  21. 21.
    Anthony S, Emmott A, Brotherhood H, Paterson R, Lange D, Ben H. Chew complications, re-intervention rates, and natural history of residual stone fragments after percutaneous nephrolithotomy. J Endourol. 2018;32(1):33.CrossRefGoogle Scholar
  22. 22.
    Turk C, Knoll T, Petrik A, Sarica K, Straub M, Seitz C. Guidelines on urolithiasis. Eur Urol. 2014;14:1102–6.Google Scholar
  23. 23.
    Fulgham PF, Assimos DG, Pearle MS, Preminger GM. Clinical effectiveness protocols for imaging in the management of ureteral calculous disease: AUA technology assessment. J Urol. 2013;189:1203–13.PubMedCrossRefGoogle Scholar
  24. 24.
    Pearle MS, Goldfarb DS, Assimos DG, et al. Medical management of kidney stones: AUA guideline. J Urol. 2014;192:316–24.PubMedCrossRefGoogle Scholar
  25. 25.
    Delvecchio FC, Preminger GM. Management of residual stones. Urol Clin North Am. 2000;27:347–54.PubMedCrossRefGoogle Scholar
  26. 26.
    Denstedt JD, Clayman RV, Picus DD. Comparison of endoscopic and radiological residual fragment rate following percutaneous nephrolithotripsy. J Urol. 1991;145:703–5.PubMedCrossRefGoogle Scholar
  27. 27.
    Lehtoranta K, Mankinen P, Taari K, Rannikko S, Lehtonen T, Salo J. Residual stones after percutaneous nephrolithotomy; sensitivities of different imaging methods in renal stone detection. Ann Chir Gynaecol. 1995;84:43–9.PubMedGoogle Scholar
  28. 28.
    Ray AA, Ghiculete PKT, Honey RJ. Limitations to ultrasound in the detection and measurement of urinary tract calculi. Urology. 2010;76:295–300.PubMedCrossRefGoogle Scholar
  29. 29.
    Dundee P, Bouchier-Hayes D, Haxhimolla H, Dowling R, Costello A. Renal tract calculi: comparison of stone size on plain radiography and non-contrast spiral CT scan. J Endourol. 2006;20:1005–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Van Appledorn S, Ball AJ, Patel VR, Kim S, Leveillee RJ. Limitations of noncontrast CT for measuring ureteral stones. J Endourol. 2003;17:851–4.PubMedCrossRefGoogle Scholar
  31. 31.
    Sacks E, Fajardo L, Hillman B, Drach G, Gaines J, Claypool H, et al. Prospective comparison of plain abdominal radiography with conventional and digital renal tomography in assessing renal extracorporeal shock wave lithotripsy patients. J Urol. 1990;144:1341–6.PubMedCrossRefGoogle Scholar
  32. 32.
    Jewett M, Bombardier C, Caron D, Ryan M, Gray R, St. Louis E, et al. Potential for inter-observer and intra-observer variability in x-ray review to establish stone-free rates after lithotripsy. J Urol. 1992;147:559–62.PubMedCrossRefGoogle Scholar
  33. 33.
    Palmer J, Donaher E, O’Riordan M, Dell K. Diagnosis of pediatric urolithiasis: role of ultrasound and computerized tomography. J Urol. 2005;174:1413–6.PubMedCrossRefGoogle Scholar
  34. 34.
    Osman Y, El-Tabey N, Refai H, Elnahas A, Shoma A, Eraky I, et al. Detection of residual stones after percutaneous nephrolithotomy: role of non-enhanced spiral computerized tomography. J Urol. 2008;179:198–200.PubMedCrossRefGoogle Scholar
  35. 35.
    Rassweiler JJ, Renner C, Chaussy C, Thuroff S. Treatment of renal stones by extracorporeal shockwave lithotripsy: an update. EurUrol. 2001;39:187–99.Google Scholar
  36. 36.
    Carr LK, D’A Honey J, Jewett MA, Ibanez D, Ryan M, Bombardier C. New stone formation: a comparison of extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy. J Urol. 1996;155:1565–7.PubMedCrossRefPubMedCentralGoogle Scholar
  37. 37.
    Candau C, Saussine C, Lang H, Roy C, Faure F, Jacqmin D. Natural history of residual renal stone fragments after ESWL. Eur Urol. 2000;37:18–22.PubMedCrossRefPubMedCentralGoogle Scholar
  38. 38.
    Olcott EW, Sommer FG, Napel S. Accuracy of detection and measurement of renal calculi: in vitro comparison of three-dimensional spiral CT, radiography and nephrotomography. Radiology. 1997;204:19–25.PubMedCrossRefPubMedCentralGoogle Scholar
  39. 39.
    Park J, Hong B, Park T, Park HK. Effectiveness of non- contrast computed tomography in evaluation of residual stones after percutaneous nephrolithotomy. J Endourol. 2007;21:684–7.PubMedCrossRefPubMedCentralGoogle Scholar
  40. 40.
    Kanno T, Kubota M, Funada S, Okada T, Higashi Y, Yamada H. The utility of the kidneys-ureters-bladder radiograph as the sole imaging modality and its combination with ultrasonography for the detection of renal stones. Urology. 2017;104:40–4.PubMedCrossRefGoogle Scholar
  41. 41.
    Jackman SV, Potter SR, Regan F, Jarrett TW. Plain abdominal x ray versus computerized tomography screening: sensitivity for stone localization after nonenhanced spiral computerized tomography. J Urol. 2000;164:308–10.PubMedCrossRefGoogle Scholar
  42. 42.
    Eisner BH, McQuaid JW, Hyams E, Matlaga BR. Nephrolithiasis: what surgeons need to know. AJR. 2011;196:1274–8.PubMedCrossRefGoogle Scholar
  43. 43.
    Pearle MS, Watamull LM, Mullican MA. Sensitivity of noncontrast helical computerized tomography and plain film radiography compared to flexible nephroscopy for detecting residual fragments after percutaneous nephrostolithotomy. J Urol. 1999;162:23–6.PubMedCrossRefGoogle Scholar
  44. 44.
    Portis AJ, Laliberte MA, Holtz C, Ma W, Rosenberg MS, Bretzke CA. Confident intra- operative decision making during percutaneous nephrolithotomy: does this patient need a second look? Urology. 2008;71:218–22.PubMedCrossRefGoogle Scholar
  45. 45.
    Tanrikut C, Sahani D, Dretler SP. Distinguishing stent from stone: use of bone windows. Urology. 2004;63:823–7.PubMedCrossRefGoogle Scholar
  46. 46.
    Assimos D, Krambeck A, Miller N, Monga M, Murad H, Nelson C, Pace KT, Pais VM Jr, Pearle M, Preminger G, Razvi H, Shah O, Matlaga B. Surgical Management of Stones: American Urological Association/Endourological Society Guideline, PART II. J Urol. 2016;196(4):1161–9.PubMedCrossRefGoogle Scholar
  47. 47.
    Assimos D, Krambeck A, Miller N, Monga M, Murad H, Nelson C, Pace KT, Pais VM Jr, Pearle M, Preminger G, Razvi H, Shah O, Matlaga B. Surgical Management of Stones: American Urological Association/Endourological Society Guideline, PART I. J Urol. 2016;196(4):1153–60. Published online 2016 May 27.CrossRefPubMedGoogle Scholar
  48. 48.
    Portis AJ, Laliberte MA, Drake S, Holtz C, Rosenberg MS, Bretzke CA. Intraoperative fragment detection during percutaneous nephrolithotomy: evaluation of high magnification rotational fluoroscopy combined with aggressive nephroscopy. J Urol. 2006;175:162–6.PubMedCrossRefGoogle Scholar
  49. 49.
    Gücük A, Kemahli E, Uyeturk U, et al. Routine flexible nephroscopy for percutaneous nephrolithotomy for renal stones with low density: a prospective randomized study. J Urol. 2013;190:144.PubMedCrossRefGoogle Scholar
  50. 50.
    Raman JDA, Bagrodia A, Bensalah K, Pearle MS, Lotan Y. Residual fragments after percutaneous nephrolithotomy: cost comparison of immediate second look flexible nephroscopy versus expectant management. J Urol. 2010;183(1):188–93.PubMedCrossRefGoogle Scholar
  51. 51.
    Preminger GM, Assimos DG, Lingeman JE, Nakada SY, Pearle MS, Wolf JS Jr, AUA Nephrolithiasis Guideline Panel. Chapter 1: AUA guideline on management of staghorn calculi: diagnosis and treatment recommendations. J Urol. 2005;173:1991–2000.PubMedCrossRefGoogle Scholar
  52. 52.
    Roth CC, Donovan BO, Adams JM, Kibar Y, Frimberger D, Kropp BP. Use of second look nephroscopy in children undergoing percutaneous nephrolithotomy. J Urol. 2009;181:796–800.PubMedCrossRefGoogle Scholar
  53. 53.
    Knudsen BE. Second-look nephroscopy after percutaneous nephrolithotomy. Ther Adv Urol. 2009;1:27–31.PubMedCrossRefGoogle Scholar
  54. 54.
    Borofsky MS, Wollin DA, Reddy T, Shah O, Assimos DG, Lingeman JE. Salvage percutaneous nephrolithotomy: analysis of outcomes following initial treatment failure. J Urol. 2016;195:977–81.PubMedCrossRefGoogle Scholar
  55. 55.
    Kumar S, Karthikeyan V, Mallya A, Keshavamurthy R. Outcomes of second-look percutaneous nephrolithotomy in renal calculi-a single Centre experience. Turk J Urol. 2018;44(5):406–10.PubMedCrossRefGoogle Scholar
  56. 56.
    Andonian S, Okeke Z, Smith AD. Digital ureteroscopy: the next step. J Endourol. 2008;22:603–6.PubMedCrossRefGoogle Scholar
  57. 57.
    Mitchell S, Havranek E, Patel A. First digital flexible ureterorenoscope: initial experience. J Endourol. 2008;22:47–50.PubMedCrossRefGoogle Scholar
  58. 58.
    Menezes P, Dickinson A, Timoney AG. Flexible ureterorenoscopy for the treatment of refractory upper urinary tract stones. BJU Int. 1999;84:257–60.PubMedCrossRefGoogle Scholar
  59. 59.
    Xu G, Wen J, Li Z, et al. A comparative study to analyze the efficacy and safety of flexible ureteroscopy combined with holmium laser lithotripsy for residual calculi after percutaneous nephrolithotripsy. Int J Clin Exp Med. 2015;8(3):4501–7.PubMedGoogle Scholar
  60. 60.
    Chen L, Sha ML, Li D, Zhuo J, Jiang CY, Zhu YP, et al. Treatment for residual stones using flexible ureteroscopy and holmium laser lithotripsy after the management of complex calculi with single-tract percutaneous nephrolithotomy. Lasers Med Sci. 2017;32:649–54.PubMedCrossRefGoogle Scholar
  61. 61.
    Hamamoto S, Yasui T, Okada A, Taguchi K, Kawai N, Ando R, et al. Endoscopic combined intrarenal surgery for large calculi: simultaneous use of flexible ureteroscopy and mini-percutaneous nephrolithotomy overcomes the disadvantageous of percutaneous nephrolithotomy monotherapy. J Endourol. 2014;28:28–33.PubMedPubMedCentralCrossRefGoogle Scholar
  62. 62.
    Scarpa RM, Scoffone CM, Cracco CM. Letter about: treatment for residual stones using flexible ureteroscopy and holmium laser lithotripsy after the management of complex calculi with single-tract percutaneous nephrolithotomy. Lasers Med Sci. 2018;33:451.PubMedCrossRefGoogle Scholar
  63. 63.
    Aminsharifi A, Irani D, Amirzargar H. Shock wave lithotripsy is more effective for residual fragments after percutaneous nephrolithotomy than for primary stones of the same size: a matched pair cohort study. Curr Urol. 2018;12(1):27–32.PubMedPubMedCentralCrossRefGoogle Scholar
  64. 64.
    Kang DE, Maloney MM, Haleblian GE. Effect of medical management on recurrent stone formation following percutaneous nephrolithotomy. J Urol. 2007;177:1785–9.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2020

Authors and Affiliations

  • Mohammad A. Alomar
    • 1
  • Alaa A. Mokhtar
    • 2
  1. 1.Department of Surgery, Division of Urology, Faculty of MedicineKing Saud UniversityRiyadhSaudi Arabia
  2. 2.King Faisal Specialist Hospital and Research CenterRiyadhSaudi Arabia

Personalised recommendations