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Percutaneous Nephrolithotomy (PCNL) has evolved over the decades from Standard to Mini to Ultramini PCNL to Micro-perc, with miniaturisation being the dominant theme and supine approach gaining momentum world over.Aim: In literature, miniaturised PCNL with microperc needle access system has raised concerns of intrarenal pressure and has some limitations with its success for larger stones. Our tips and tricks explain how to overcome these pitfalls by utilising the full construct of the needle system to its maximum potential. These will in turn help make the procedure versatile, precise, ergonomical, and enhance a surgeon's experience with improved outcomes for patients especially in large renal stones.Materials and Methods: We describe the limitations of microperc needle access as stated in literature and proposals by the co-authors using microperc for miniaturised access on how to overcome the same.Results: A simplified table describing the limitations and tips and tricks on overcoming these is provided for quick reference.Conclusion: As Technological advancements and techniques for miniaturised access in urolithiasis improve, we believe our suggestions will help surgeons overcome the quoted limitations of microperc needle access for miniaturised PCNL, making this a versatile, safe and efficacious technique even in large and complex stones. A multi centre trial will be the best way to validate the suggestions proposed in this article.

Background Renal stones are conventionally treated with percutaneous lithotomy (PCNL), with miniPCNL and endoscopic combined intrarenal surgery (ECIRS) as preferred choices to reduce morbidity associated with bigger tracts. MicroPCNL is not recommended for larger stones as fragments obscure intraoperative vision and high intrarenal pressure with prolonged operative time increases the risk of sepsis. MicroECIRS overcomes these disadvantages with simultaneous antegrade and retrograde lithotripsy and drainage. Objectives To provide a step-by-step illustration on how to perform microECIRS. Materials and methods 1. Patient in supine Barts flank-free with French split leg or Galdakao-modified supine Valdivia (GMSV) position. 2. MicroPCNL with 4.8Fr “All Seeing Optical Needle” (Polydiagnost, Germany). 3. Placement of access sheath with/without suction. 4. Retrograde intrarenal surgery (RIRS) with Boston Scientific Lithovue or Olympus URF-V ureteroscope. 5. Lithotripsy using Lumenis 120-watt high-power 200-micron laser with/without Moses fibre. Results MicroECIRS has multiple advantages. Direct ureteroscope-guided puncture, antegrade visualisation of the tract via the "all seeing needle", and miniaturization, ensures safe and accurate percutaneous access even in challenging renal anatomy, hence reducing the risk of bleeding and need for post-operative nephrostomy. Low intrarenal pressure with good active and passive drainage bidirectionally prevents pyelovenous reflux and sepsis, and maintains clear vision to allow precision laser lithotripsy. MicroECIRS is also ergonomic for both antegrade and retrograde surgeons as they can remain seated throughout the operation, avoiding muscle fatigue. Additionally, as the camera head of the microPCNL set is mounted on a separate rod, weight is taken off the handheld part such that the surgeon only maneuvers the lightweight needle. Conclusion MicroECIRS is a safe, easy, and ergonomic option for larger stone volumes. Achieving single-stage stone clearance with no morbidity translates into shorter hospital stays and a faster return to daily activities, hence making this economically viable.