Theoretically a papillary puncture should be performed to decrease the risk of bleeding (although this approach does not avoid completely this complication). For this technique the fluoroscopic renal puncture has been widely used to define the renal anatomy. A combined fluoroscopic-ultrasound renal puncture has also many advantages as seeing retro-renal organs and reduce radiation exposure. This paper analyses another interesting advantage which is the reduction of bleeding by using the color doppler flow image during the puncture instead of the traditional type-B. A multicentric trial was done comparing color doppler to type-B imaging. When using the Doppler, the blood flow velocity mas measured (set at 15–17 cm/s) and the puncture was done only with a low or moderate vascular density.

The new technique showed a significant reduction in the incidence of tract bleeding (10.8% vs 24.8%) and a novel way to perform the puncture. This remind us that the kidney has accessory renal vessels and a variable blood supply anatomy and that new techniques have to be employed in order to avoid them.

As bleeding is one of the most common complications during PCNL we need to use all the necessary tools to control it. Tranexamic acid (TXA), a antifibrinolytic agent, has been recently used in PCNL preoperatively as an drug that stabilizes formed clots and reduce active bleeding (and transfusion).

This authors have done a systematic review and meta-analysis to evaluate the efficacy and safety of TXA in PCNL. As always only few studies have been included in the study (11 studies of which 8 were RCTs) evaluating the use of 1g of TXA given preoperatively in patients of high stone burden.

The patients that received TXA had significant reduction of transfusion rates (from a range of 10% to 35% to a range of 2% to 6.25%). Also it was associated with a slight decreased operative time, minor and mayor complications and hospital stay.

Based on the evidence it could be wise to start using TXA in patients with high stone burdens (especially staghorn stones). I believe is a matter of time that TXA appears in the guidelines as a proper recommendation.

It has been estimated that the prevalence of urolithiasis can rise up to 10% with a higher rate among men. Meaning 1 out of 10 people you know may have kidney stones. But this study tried to evaluate the incidence of urolithiasis in the United Sates over the course of 12 months. Overall, the yearly incidence of asymptomatic urolithiasis was estimated to be 2.1% and the incidence of suffering a symptomatic episode from a previous stone was 11% (which is huge). The implications of this number goes along the fact that with increasing BMI, hypertension and cholesterol levels was associated to an increased prevalence of stone disease. White race also tends to have a higher risk compared to Black, Hispanic and Asian races. Such high incidence is of course a burden for patients and health systems. Again, as urologists we can keep recommending metabolic evaluations and a proper follow up with medical treatment to decrease the incidence of such patients and reduce this burden.