Stone fragmentation in percutaneous surgery: is there a paradigm shift?

PURPOSE OF REVIEW: Percutaneous nephrolithotomy (PCNL) remains the gold standard for the treatment of large and complex renal calculi. Traditionally, stone fragmentation during PCNL has relied on mechanical lithotripsy combined with manual or passive fragment extraction. This review examines whether recent advances in stone fragmentation and evacuation technologies represent a true paradigm shift in percutaneous stone surgery or rather a progressive refinement of established principles. RECENT FINDINGS: Recent literature highlights a progressive transition from conventional mechanical lithotripsy - based on ultrasonic, pneumatic, or dual-energy devices - towards laser-based fragmentation strategies, particularly in miniaturized PCNL. While mechanical systems remain highly effective in standard-tract PCNL, their efficiency and applicability may be limited as access calibre decreases. In this setting, holmium:YAG and thulium fibre lasers, supported by advanced pulse modulation technologies, enable efficient dust-oriented fragmentation through small-calibre tracts. The parallel introduction of suction-enabled access sheaths has further modified clearance dynamics, allowing simultaneous fragmentation and active evacuation. Comparative studies consistently report comparable stone-free rates (SFRs) between traditional and contemporary approaches, with improvements in operative efficiency, intrarenal pressure control, and procedural workflow favouring laser-based and suction-assisted systems. SUMMARY: Overall, current evidence supports a shift in PCNL from mechanical fragmentation and fragment extraction towards laser-driven dusting combined with active aspiration. This evolution appears to prioritize efficiency and physiological safety rather than absolute gains in stone-free rates. However, its broader adoption remains dependent on cost, equipment availability, and training, underscoring the need for further comparative and implementation-focused research.