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Objectives: Clinical T1 (cT1) renal mass treated surgically has a good prognosis, but there is an upstaging risk that potentially threatens oncological outcomes after partial nephrectomy (PN). We aim to analyze and study the incidence, predictors, perioperative morbidity, and oncological outcomes of pT3a upstaging. Methodology: A retrospective study of 313 patients who underwent PN for cT1 renal mass at a single center from a single tertiary referral center between 2000 and 2021 was done. Demographic, perioperative, pathological, and outcome variables were reviewed. We compared these parameters between upstaged and non‐upstaged groups. Multivariate logistic regression analysis was used to study preoperative variables associated with upstaging. Results: Nineteen patients were upstaged to pT3a. Making an incidence of 6.1%. Upstaged tumors were bigger (5.02 cm vs. 4.08 cm, p = 0.004), had higher clinical stage T1b (84.2 vs. 40.5%, p < 0.001), had more tumors which were central location (21 vs. 3.4%, p < 0.001), had more endophytic and mesophytic tumors (15.8 vs. 5.8% and 52.6 vs. 9.5%, p < 0.001), and had higher R.E.N.A.L Nephrometry score (8.05 vs. 6, p < 0.001). Upstaged tumors had more operative times (227 vs. 203 min, p = 0.01), more postoperative complications (68.4 vs. 13.1%, p < 0.001), more major complications of Clavien Dindo Grade 3 and above (15.8 vs. 4.4%, p < 0.001). Age (OR 1.035, p = 0.034), Radiological tumor dimension (OR 1.578, p = 0.003), Radiological or Clinical stage (T1b) (9.19, p = 0.008), Higher Nephrometry score (Intermediate and High) (OR 6.184, p = 0.004) were preoperative predictors of upstaging. Oncological outcomes were comparable. Conclusion: Tumor upstaging was uncommon with more perioperative morbidity. Higher age, larger tumor size, higher tumor stage, and higher nephrometry scores were preoperative predictors of upstaging. [ABSTRACT FROM AUTHOR]

Objective: To compare and analyze the results of laparoscopic ureteric reimplantation and robotic‐assisted ureteric reimplantation at our tertiary institute. Materials and methods: We retrospectively reviewed data of adult patients who underwent laparoscopic ureteric reimplantation and robotic‐assisted ureteric reimplantation between January 2000 and December 2020. Data were analyzed for 19 patients in the laparoscopic group and 47 patients in the robotic group. The data were compared in both the groups. Results: The most common presentation was flank pain (67.89%) followed by recurrent UTI (21.05%) in both the groups. The baseline characteristics and demographic data including age, gender, laterality, Charlson comorbidity index, and BMI were comparable in both the groups. The time range from previous surgeries to presentation varied from 7 days to 5 years. There is statistically significant difference between the operative time in the laparoscopic (224.23 ± 76.61 min) and robotic groups (187.06 ± 52.81 min) (p = 0.027). There is statistically significant difference between the hospital stay also between the two groups (9.07 ± 2.75 vs. 6 ± 1.65 days p‐0.001). There were no differences in the complication rate and postoperative outcomes in both the groups. Mean length of follow‐up was 28 ± 25.5 (2–108) months and 20.57 ± 19.91 (2–96) months in both the groups, respectively. The success rates in terms of symptomatic improvement, decrease in hydronephrosis, and improved drainage in the laparoscopic and robotic groups were 94.73% and 95.45%, respectively, which were statistically not significant. Conclusions: Robotic ureteric reimplantation and laparoscopic ureteric reimplantation are comparable in clinical outcomes. Robotic‐assisted laparoscopic ureteric reimplantation is feasible, safe, and faster with excellent outcomes, decreased hospital stay, and minimal complications. [ABSTRACT FROM AUTHOR]

Objective: To evaluate which among the three scoring systems used to predict stone‐free status (SFS) after percutaneous nephrolithotomy (PCNL), namely Guy's stone score (GSS), STONE nephrolithometry score and Clinical Research Office of the Endourological Society (CROES) nephrolithometry nomogram, is the most accurate predictor of SFS. Method and Materials: We prospectively included all patients who underwent PCNL (tract size >24 F) at our hospital between July 2017 and January 2019. All demographic and peri‐operative data were tabulated including calculation of GSS, STONE score and CROES nomogram score using preoperative computed tomography. Comparison of the 'stone‐free' group and 'residual‐stone' group was carried out using standard statistical methods. Results: A total of 252 patients were enrolled. The mean GSS, STONE score and CROES score in the stone‐free group was 1.60, 6.98 and 212.27, respectively, and in the residual stone group group it was 2.93, 8.98 and 129.89, respectively (P < 0.001 in each). Receiver‐operating characteristic (ROC) curves showed that all three scoring systems had similar predictive accuracy for post‐PCNL SFS, with STONE score having the highest area under the ROC curve value (0.852). GSS was significantly associated with operating time, estimated blood loss (EBL) and length of hospital stay (LOS; P < 0.001 in each). STONE score and CROES score were both significantly associated with EBL (P = 0.029 and 0.001, respectively). Conclusion: All three scoring systems are equally predictive of post‐PCNL SFS. EBL is significantly associated with all three scoring systems, while GSS is also associated with operating time and LOS. [ABSTRACT FROM AUTHOR]

Objectives: To measure and analyse various factors affecting radiation exposure (RE) to surgeons during percutaneous nephrolithotomy (PCNL). Patients and Methods: A total of 212 patients who underwent PCNL were analysed. Informed consent was obtained from all enrolled patients. Ultrasonography/fluoroscopy guided punctures were done. The tract was dilatated and sheath placement done after which the procedure was completed in a routine fashion. A JJ or ureteric catheter or percutaneous nephrostomy (PCN) tube was placed as per the merit of the case. A digitalised mobile surgical C‐arm image‐intensifier system was used in all cases. RE was determined using a pen dosimeter worn outside the lead apron of the surgeon at the level of the chest for uniformity and was recorded on a per case basis at the end of the procedure. Data were recorded for analysis with respect to relevant parameters. Multivariate regression analysis was used to identify various parameters which affect RE (mSv). Results: The parameters analysed included: age, number and size of stones, body mass index (BMI) of patients, Hounsfield unit of stone (HU), degree of hydronephrosis, number of tracts, mode of access to pelvicalyceal system (PCS), sheath size (F), operative time (min), placement of a JJ or ureteric catheter or PCN tube, and kV used for exposure. There was a significant statistical relationship between stone volume (P < 0.001), number of tracts (P < 0.001), mode of access to PCS (P = 0.001), and sheath size (P = 0.002), with RE. The HU had a negative relationship, with a decrease in HU causing increased RE (P = 0.002). BMI, number of stones, degree of hydronephrosis, operative time and placement of a JJ or ureteric catheter or PCN tube did not have any correlation with RE in our study. Conclusion: The mean (SD) RE per procedure was 0.21 (0.11) mSv. Increasing size and low HU of stone, increasing number of tracts, fluoroscopic access to PCS, increasing sheath size and kV were found to increase RE. Although the exposure levels are within safety limits, serial monitoring and constant vigilance are mandatory to inform surgeons. [ABSTRACT FROM AUTHOR]

Objectives: To present our single‐centre experience of urolithiasis management in anomalous kidneys, highlighting the need for an algorithm‐based approach in deciding the appropriate treatment method for each type. Patients and Methods: We retrospectively reviewed the data of all the patients who presented to our renal unit with urolithiasis in an anomalous kidney between January 1990 and July 2014. The peri‐operative characteristics of all the patients, along with management approach, were studied. Results: Percutaneous nephrolithotomy (PCNL) was the most common surgical technique used, followed by flexible ureterorenoscopy (URS). Pain was the most common presentation in these patients. The overall stone clearance rate associated with PCNL and flexible URS was 85.8% in cases of anomalous kidneys in this series. The stone clearance rates in ectopic kidneys, horseshoe kidneys, malrotated kidneys and autosomal dominant polycystic kidneys associated with PCNL and flexible URS were similar: 86%, 88%, 76% and 83%, respectively, and 81.2%, 80%, 92% and 100%, respectively. Based on our results, we developed a stone management algorithm. Conclusion: The management of renal calculi in patients with renal anomalies may vary based on the stone size, location, density, pelvicalyceal system anatomy and drainage. An algorithm‐based approach could help surgeons decide the appropriate treatment in this population. [ABSTRACT FROM AUTHOR]

Objective: To report procedure process improvements and confirm the preserved safety and short-term effectiveness of a secondgeneration Aquablation device for the treatment of lower urinary tract symptoms (LUTS) attributable to benign prostatic hyperplasia (BPH) in 47 consecutive patients at a single institution. Patients and Methods: Aquablation was performed in 47 patients with symptomatic BPH at a single institution. Baseline, peri-operative and 3-month urinary function data were collected. Results: The mean (range) patient age was 66 (50-79) years, and transrectal ultrasonography-measured prostate volume was 48 (20-118) mL. A median lobe was present in 25 patients (53%) and eight patients had catheter-dependent urinary retention. The mean (range) total procedure time was 35 (13-128) min and the tissue resection time was 4 (1-10) min. Five Clavien-Dindo grade I/II and five Clavien-Dindo grade III complications were recorded in eight patients. The mean (range) hospital stay was 3.1 (1-8) days and the mean (range) duration of urethral catheterization was 1.9 (1-11) days. The mean International Prostate Symptom Score (IPSS) decreased from 24.4 at baseline to 5 at 3 months; IPSS quality-of-life score decreased from 4.5 to 0.3 points; peak urinary flow rate increased from 7.1 to 16.5 mL/s and post-void residual urine volume decreased from 119 to 43 mL (all P < 0.01). Conclusions: This study confirmed procedure process improvements resulting from system enhancements, with preservation of safety and effectiveness during use of a second-generation device for the treatment of LUTS attibutable to BPH in the largest single-institution study conducted to date. [ABSTRACT FROM AUTHOR]

Objectives To present our single-centre experience of the micropercutaneous nephrolithotomy (microperc) technique and define its role in the management of renal calculi as well as to analyse the factors predicting outcome. Patients and Methods We retrospectively analysed data from 139 patients who underwent microperc for renal calculi between June 2010 and November 2014 at our institution. The factors analysed were demographic variables, which included age, sex, stone volume, stone density (Hounsfield units [ HU]) and stone location, and intra- and peri-operative variables, such as operating time, drop in haemoglobin level, stone clearance and complications. Results The mean ± sd (range) patient age was 38.99 ± 17 years (9 months to 73 years), stone volume was 1 095 ± 1 035 (105-6 650) mm3 and stone density was 1 298 ± 263 HU. The mean ± sd (range) operation duration was 50.15 ± 9.8 (35-85) min, hospital stay was 2.36 ± 0.85 (2-5) days and drop in haemoglobin level was 0.63 ± 0.84 (0-3.7) mg/dl. Eight patients had renal colic that was managed by antispasmodic medication, four patients had renal colic severe enough to warrant JJ stenting and three patients had urinary tract infections which were managed with appropriate antibiotics. We were able to complete microperc in 130 patients, with 119 (91.53%) patients being rendered completely stone-free, while in 11 patients (8.46%) there were some residual fragments seen on imaging. On multivariate analysis, stone number, volume and density were found to be significant predictors of clearance. Conversion to mini- or standard percutaneous nephrolithotomy was required in nine patients (6.47%), with intra-operative complications and stone number being the significant factors warranting conversion on a multivariate basis. Conclusion The outcomes in the present study suggest that microperc is a promising treatment method for solitary renal stones with volumes <1 000 mm3 and stones with low density ( HU), regardless of stone location. In the present series we achieved a high success rate with low morbidity; however larger, prospective and comparative studies from multiple centres are required to further establish the role of microperc in the management of renal calculi. [ABSTRACT FROM AUTHOR]

Objective To assess the impact of various treatment optimisation strategies in shockwave lithotripsy ( SWL) used at a single centre over the last 25 years. Patients and Methods In all, 5017 patients treated between 1989 and 2013 were reviewed and divided into groups A, B, C and D for the treatment periods of 1989-1994 (1561 patients), 1995-2000 (1741), 2001-2006 (1039) and 2007-2013 (676), respectively. The Sonolith 3000 ( A and B) and Dornier compact delta lithotripters ( C and D) were used. Refinements included frequent re-localisation, limiting maximum shocks and booster therapy in group B and Hounsfield unit estimation, power ramping and improved coupling in group D. Parameters reviewed were annual SWL utilisation, stone and treatment data, retreatment, auxiliary procedures, complications and stone-free rate ( SFR). Results The SFR with Dornier compact delta was significantly higher than that of the Sonolith 3000 ( P < 0.001). The SFR improved significantly from 77.58%, 81.28%, 82.58% to 88.02% in groups A, B, C, and D, respectively ( P < 0.001). There was a concomitant decrease in repeat SWL (re-treatment rate: A, 48.7%; B, 33.4%; C, 15.8%; and D, 10.1%; P < 0.001) and complication rates ( A, 8%; B, 6.4%; C, 4.9%; and D, 1.6%; P < 0.001). This led to a rise in the efficiency quotient ( EQ) in groups A-D from 50.41, 58.94, 68.78 to 77.06 ( P < 0.001).The auxiliary procedure rates were similar in all groups ( P = 0.62). Conclusion In conclusion, improvement in the EQ together with a concomitant decrease in complication rate can be achieved with optimum patient selection and use of various treatment optimising strategies. [ABSTRACT FROM AUTHOR]

Objective To compare micropercutaneous nephrolithotomy (microperc) and retrograde intrarenal surgery ( RIRS) for the management of renal calculi <1.5 cm with regard to stone clearance rates and surgical characteristics, complications and postoperative recovery., Patients and Methods Seventy patients presenting with renal calculi <1.5 cm were equally randomized to a microperc or a RIRS group between February 2011 and August 2012 in this randomized controlled trial. Randomization was based on centralized computer-generated numbers. Patients and authors assessing the outcomes were not blinded to the procedure., Microperc was performed using a 4.85- F (16-gauge) needle with a 272-μm laser fibre. RIRS was performed using a uretero-renoscope., Variables studied were stone clearance rates, operating time, need for JJ stenting, intra-operative and postoperative complications (according to the Clavien- Dindo classification system), surgeon discomfort score, postoperative pain score, analgesic requirement and hospital stay., Stone clearance was assessed using ultrasonography and X-ray plain abdominal film of kidney, ureter and bladder at 3 months., Results There were 35 patients in each group. All the patients were included in the final analysis., The stone clearance rates in the microperc and RIRS groups were similar (97.1 vs 94.1%, P = 1.0)., The mean [ sd] operating time was similar between the groups (51.6 [18.5] vs 47.1 [17.5], P = 0.295). JJ stenting was required in a lower proportion of patients in the microperc group (20 vs 62.8%, P < 0.001). Intra-operative complications were a minor pelvic perforation in one patient and transient haematuria in two patients, all in the microperc group. One patient in each group required conversion to miniperc., One patient in the microperc group needed RIRS for small residual calculi 1 day after surgery. The decrease in haemoglobin was greater in the microperc group (0.96 vs 0.56 g/dL, P < 0.001). The incidence of postoperative fever ( Clavien I) was similar in the two groups (8.6 vs 11.4%, P = 1.0). None of the patients in the study required blood transfusion., The mean [ sd] postoperative pain score at 24 h was slightly higher in the microperc group (1.9 [1.2] vs 1.6 [0.8], P = 0.045). The mean [ sd] analgesic requirement was higher in the microperc group (90 [72] vs 40 [41] mg tramadol, P < 0.001). The mean [ sd] hospital stay was similar in the two groups (57 [22] vs 48 [18] h, P = 0.08)., Conclusions Microperc is a safe and effective alternative to RIRS for the management of small renal calculi and has similar stone clearance and complication rates when compared to RIRS., Microperc is associated with higher haemoglobin loss, increased pain and higher analgesic requirements, while RIRS is associated with a higher requirement for JJ stenting. [ABSTRACT FROM AUTHOR]

Study Type - Therapy (pattern of practice survey) Level of Evidence 2b What's known on the subject? and What does the study add? Miniperc and RIRS are commonly used modality for treating non-bulky renal urolithiasis. Both the treatment options are invasive and are associated with inherent complications. There are only a few studies that compare these two treatment modalities. Both the modalities are effective to render patient stone free with minimal complications. Immediate stone free rate is higher with miniperc but comparable in both the modalities at 1 month. RIRS is associated with favourable pain scores and lower hemoglobin drop. OBJECTIVE To plan a prospective comparative case-control designed study aiming to compare minipercutaneous (miniperc) and retrograde intrarenal surgery (RIRS) for a renal calculus of size 1-2 cm., PATIENTS AND METHODS A total of 64 cases (32 in each arm) underwent miniperc and RIRS during the study period from March 2009 to April 2011., The primary and secondary outcome objective was stone-free rate and retreatment rate, complications, operation duration, patient visual pain scores, analgesic requirement, haemoglobin drop and hospital stay, respectively., RESULTS Miniperc and RIRS had stone clearance rates of 100% and 96.88%, respectively., In the RIRS group, one patient required retreatment at 1 month., Hospital stay (0.24) and intra-operative (0.99) and postoperative complications (0.60) were similar in both groups., Operation duration ( P= 0.003) was lower in the miniperc group., Haemoglobin drop ( P < 0.001), patient pain and visual analogue scale score (each P < 0.001) at 6, 24 and 48 h, as well as analgesic requirement ( P < 0.003), were all lower in the RIRS group., CONCLUSIONS The stone clearances in both modalities are high and complications are low., RIRS requires a larger operation duration, although it is associated with favourable pain scores and a lower haemoglobin drop. [ABSTRACT FROM AUTHOR]

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Standard PNL is known to have higher clearance rates for stones 1-2 cm. However, it is not promoted because of its associated morbidity, especially bleeding. Minitiarization of the PNL has spawned a new interest in this modality for treating small bulk urolithiasis. The study adds to a growing body of evidence in a prospective manner that smaller tract PNL 'miniperc' is associated with a similiar efficacy of achieving stone-clearance rates while decreasing the invasiveness of the procedure and associated morbidity. OBJECTIVE • To evaluate the results of miniperc vis-à-vis standard PNL in the treatment of stones of 1-2 cm in size. Miniperc may represent a reasonable procedure in patients with nonbulky urolithiasis offering a similar outcome as standard percutaneous nephrolithotomy (PNL) with advantage of reduced morbidity. PATIENTS AND METHODS • 55 procedures including 27 miniperc and 28 standard PNL were performed for renal stones 1-2 cm in size. Pediatric patient, active urinary tract infection, renal malformation, uncorrected coagulopathy and morbid obesity patients were excluded from the study. • The parameters studied were demography, operative time, postoperative analgesic requirement, hemoglobin drop, complications and stone clearance. RESULTS • Mean tract size was 18.2 ± 2 F (15-20) and 26.8 ± 2 F (24-30), P value <0.0001 in the miniperc and standard PNL, respectively. Holmium LASER and pneumatic lithotripter were the main energy sources used in miniperc and standard PNL, respectively. • Miniperc operative time was longer than that of standard PNL (45.2 ± 12.6 vs 31 ± 16.6 min, P= 0.0008 respectively). • Conversely, there was an advantage of miniperc over standard PNL in terms of a significantly reduced hemoglobin drop (0.8 ± 0.9 vs 1.3 ± 0.4 gram%, P= 0.01), analgesic requirement (55.4 ± 50 vs 70.2 ± 52 mg tramadol, P= 0.29) and hospital stay (3.2 ± 0.8 vs 4.8 ± 0.6 days, P≤ 0.001), respectively. • Intra- operative conversion of the procedure into a tubeless PNL was significantly more in the miniperc group ( P≤ 0.001). The miniperc and standard PNL group had clearance rates of 96% and 100%, respectively at 1 month follow up. CONCLUSIONS • This study demonstrated significant advantages of the miniperc procedure in terms of reduced bleeding leading to a tubeless procedure and reduced hospital stay. • The stone free rates and the complications were similar in either group. [ABSTRACT FROM AUTHOR]

OBJECTIVE • To compare the content validity (realism and usefulness) of percutaneous renal access (PRA) obtained on a live porcine model and a high-fidelity computer-based surgical simulator (PERC Mentor, Simbionix; Lod, Israel) in our skills laboratory for trainees interested in PRA training, so as to determine which of the two is a more appropriate and effective training model. MATERIALS AND METHODS • In all, 24 'experts' performed PRA in a live porcine model and using the PERC Mentor. • The porcine model access required a live anaesthetized pig with a pre-placed ureteric catheter. The access was done with flouroscopic guidance using a 22-G 'skinny' needle (Cook Medical, Bloomington, IN, USA). • Then the specific task of PRA using a similar case scenario was done using the PERC Mentor. • The experts rated the models using a questionnaire based on a 5-point Likert scale, consisting of 10- and three-items of realism and usefulness, respectively. RESULTS • Of the 10 items of realism assessed, the porcine model was rated as better than the PERC Mentor for 'overall realism', 'movement of the kidney', 'tactile feedback of perinephric space', 'fluoroscopic realism' and 'complications encountered' (All P < 0.001). • It was inferior to the PERC Mentor for 'orientation to the flank', 'aspiration', 'repetitive performance' and 'organisational feasibility' (All P < 0.001). • 'Tactile feedback of successful access' was similar in both models (mean [ SD ] points, 4.24 [0.7] vs 4.6 [0.5]). • Of the three items of usefulness, 'overall usefulness' (4.6 [0.6] vs 4.65 [0.5]) and 'use as a training tool' (4.32 [0.5] vs 4.75 [0.4]) was similar; however, the porcine model was a much better assessment tool ( P < 0.001). CONCLUSIONS • Both models have relative advantages and disadvantages. The live porcine model is a more realistic assessment tool for PRA. The specific advantage of the PERC Mentor is of repetitive tasking and easier set up feasibility. • The overall usefulness was same for both the models. [ABSTRACT FROM AUTHOR]

Study Type - Therapy (RCT) Level of Evidence 1b OBJECTIVE To establish the efficacy of early removal of a nephrostomy tube after percutaneous nephrolithotomy (PCNL), to challenge the wisdom of tubeless PCNL, as we hypothesized that it would result in a shorter hospital stay, comparable benefit and safety, while maintaining the option of check nephroscopy ensuring far superior stone clearance. PATIENTS AND METHODS In all, 22 patients were prospectively randomized equally into two groups, group 1 (early nephrostomy removal) or group 2 (tubeless) during a 1-month study period. Inclusion criteria for the study were: a simple stone of <3 cm, no significant bleeding, no perforation, single-tract access and 'on-table' complete stone clearance. In group 1, a 20 F nephrostomy, 6 F retrograde ureteric catheter and a Foley catheter were used, while in group 2 only a 6 F retrograde ureteric catheter and Foley catheter were placed at the end of the procedure. Computed tomography (CT) with no contrast medium was done on the first morning after surgery before removing all catheters/tubes, and patients discharged subsequently. The variables assessed were stone clearance, hospital stay, analgesic requirement, postoperative complications and auxiliary procedures. RESULTS The mean (sd) stone bulk was similar between the groups, at 2737 (946.9) and 2934.2 (2090.7) µL, respectively. Despite an on-table complete clearance, clearance assessed by CT was nine of 11 vs eight of 11 in groups 1 and 2, respectively. CT showed a 6 mm stone in one patient in group 1, while the remaining patients had stones of <4 mm. The mean (sd) analgesic requirement, haemoglobin decrease, urine leak and hospital stay in the two groups were 72.7 (51.8) vs 68.2 (46.2) mg of tramadol ( P= 0.25), 1.6 (0.7) vs 1.6 (0.9) g/dL ( P= 0.39), 13.9 (6.3) vs 7.1 (14.2) h ( P= 0.018) and 72.8 (2.1) vs 70.2 (18.5) h ( P= 0.09), respectively. Complications noted were early haematuria in none vs three ( P= 0.21), urinoma none vs one, and fever in two vs one, respectively; one patient in group 1 required a check nephroscopy for a residual fragment. Overall clearance including re-treatment was 10/11 vs eight of 11 ( P= 0.009), respectively. CONCLUSION Early tube removal after PCNL results in an equivalent analgesic requirement, decrease in haemoglobin and hospital stay as tubeless PCNL. It has a significantly lower incidence of early haematuria, better clearance rates and preserves the option of check nephroscopy. It can be considered as an accepted standard of care, with the preserved advantages of tubeless PCNL. [ABSTRACT FROM AUTHOR]

OBJECTIVE To review the development of the technique of percutaneous nephrolithotomy (PCNL), for ease of learning and development of instrumentation for staghorn calculi at our centre since 1991, and to assess the results and outcomes. PATIENTS AND METHODS We retrospectively analysed the hospital records of 773 patients (632 males and 141 females, 834 renal units) who underwent PCNL for staghorn calculi at our centre from January 1991 to August 2008. We divided the patients into three groups depending on the changes in treatment policy, global trends and advances in equipment as follows: the first 200 cases (group I) from January 1991 to December 1996 (216 renal units); the next 200 (group II) from January 1997 to December 2001 (212 renal units); and the last 373 (group III) from January 2002 to August 2008 (406 renal units). RESULTS The mean (sd, range) operative duration in groups I, II and III, respectively, were 138.2 (52.7, 60–310), 121.4 (42.8, 70–250) and 112.5 (51.5, 55–310) min; the decrease in haemoglobin level was 3.2, 2.6 and 1.6 g/dL, respectively, and continued to decrease with improvements in technique. With increasing experience, the number of stages required for stone clearance and the number of tracts required decreased exponentially. Most of the severe complications occurred early in our experience. The stone clearance rate in groups I, II and III was 81%, 86% and 93%, respectively, after completing the procedure; the overall clearance rate with observation/auxiliary procedures was 86%, 89% and 96%, respectively. The mean hospital stay for groups I, II and III was 11.1 (3.9, 7–25), 9.5 (3.4, 5–22) and 7.1 (3.6, 4–28) days, respectively. CONCLUSION The percutaneous management of staghorn calculi requires considerable expertise. Our data suggest that ‘multiperc’ PCNL is difficult to learn and requires experience. Although over the years our results improved, complete clearance remains a challenge. A constant review and application of newer techniques and results will improve the overall clearance rates further. [ABSTRACT FROM AUTHOR]