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.
PORCSE studygroup: Anneline Cremer (Erasme University Hospital Department of Gastroenterology Brussels Belgium) João A. Cunha Neves (ULS-Algarve Department of Gastroenterology Portimão Portugal) Andreas Kapsoritakis (University Hospital of Larissa IBD unit- Department of Gastroenterology Larissa Greece) Mircea Diculescu (Faculty of Medicine- Carol Davila University of Medicine and Pharmacy- Fundeni Clinical Institute Department of Gastroenterology Bucharest Romania) Lieven Pouillon (Imelda Hospital Bonheiden Department of Gastroenterology and Hepatology Bonheiden Belgium) Ioannis E. Koutroubakis (University Hospital Heraklion Department of Gastroenterology Heraklion- Crete Greece) Laura Nieto (Hospital Clinico Universitario de Santiago de Compostela- Health Research Institute of Santiago de Compostela IDIS Gastroenterology Compostela Spain) Sophie Claeys (AZ Sint-Lucas Department of Gastroenterology Ghent Belgium) Iago Rodríguez-Lago (Hospital Universitario de Galdakao- Biobizkaia Health Research Institute Department of Gastroenterology Galdakao Spain) Pauline Rivière (Bordeaux University Hospitals Department of Gastroenterology Bordeaux France) Serkan Dumanli (Gazi University Department of Gastroenterology Ankara Turkey) Francisco Portela (ULS de Coimbra Department of Gastroenterology Coimbra Portugal) Ian Arnott (Western General Hospital IBD unit Edinburgh United Kingdom) Pinelopi Nikolaou (Venizeleio General Hospital Department of Gastroenterology Heraklion Greece) Joana Revés (Hospital Beatriz Ângelo Division of Gastroenterology- ULS Loures-Odivelas Loures Portugal) Inês Botto (Unidade local de saúde de santa maria- Clinica Universitária de Gastroenterologia- Faculdade de Medicina de Lisboa Servico Gastroenterologia e Hpatologia Lisbon Portugal) Margalida Calafat (Hospital Universitari Germans Trias i Pujol and CIBEREHD Gastroenterology Badalona Spain) The retrospective, multicentric, observational PORCSE study evaluated postoperative recurrence of Crohn’s disease after ileocaecal resection. Early medical prophylaxis (proactive strategy, cohort1) was found to have lower rates of endoscopic (Rutgeerts >i1) and clinical postoperative recurrence compared to expectant management (reactive strategy, cohort2) at first endoscopic evaluation. In this analysis from a subgroup of the PORCSE population, long term outcomes of these 2 strategies are explored. A subgroup analysis was performed in patients with extended follow-up beyond the timeframe of the original PORCSE study (Fig1). Primary endpoints were surgical (sPOR) and clinical (cPOR) recurrence. Endoscopic disease activity and progression were evaluated as secondary endpoints. Progression was defined as an increase in Rutgeerts score (>i1) and/or development of colon inflammation from first to consecutive postoperative endoscopies. Logistic regression models with propensity score matching were fitted to adjust for confounding factors in comparing the proactive and reactive strategy. For 92.2% of the 346 originally included patients, a mean additional follow-up duration of 38.5months (SD24.5) was available (mean total follow-up 110.9months, SD44.8). sPOR and cPOR rate was numerically higher with the reactive strategy. However these differences were not statistically significant (sPOR: cohort1:13.2%, cohort2:18.2%; OR1.78, 95%CI 0.73-4.34, P = 0.202 - cPOR: cohort1: 39.3%, cohort2:49.7%; OR1.73, 95%CI 0.92-3.24, P = 0.089). No difference was found in IBD-related hospitalisation rate (cohort1: 10.8%, cohort2: 10.1%; OR 1.48, 95%CI 0.53-4.18, P = 0.457). Survival analysis did not show a significant difference for time to sPOR (HR1.34, 95% CI 0.59-3.06, P = 0.485) nor in time to cPOR (HR1.28, 95%CI 0.35-4.66, P = 0.713). Rates of endoscopic disease activity (Rutgeerts>i1 and/or colonic inflammation) at consecutive endoscopies after initial postoperative endoscopy did not differ (cohort1:59.2%, cohort2:57.8%, OR0.70, 95%CI 0.31-1.57, P = 0.381). Univariate analysis revealed a higher rate of endoscopic progression with a proactive strategy (cohort1: 20.6%, cohort2: 10.6%, P = 0.041). However, after correction for confounders this difference was no longer significant (OR2.44, 95%CI 0.92-6.48, P = 0.073). In this large subgroup of patients with extended follow-up from the original PORCSE study, proactive medical prophylaxis after ileocaecal resection showed no statistically significant differences compared with a reactive approach in reducing the rate of surgical and clinical posoperative recurrence, despite a numerical trend. Further prospective studies and larger cohorts are required to confirm these findings. References: Geldof, J., Truyens, M., Hanssens, M., Van Gucht, E., Holvoet, T., Elorza, A., Bouillon, V., Barros, S., Martins, V., Argyriou, K., Potamianos, S., Diculescu, M., Stroie, T., Bossuyt, P., Moens, A., Theodoraki, E., Koutroubakis, I. E., Pedro, J., Fernandes, S., … Lobaton, T. (2024). Prophylactic Versus Endoscopy-driven Treatment of Crohn’s Postoperative Recurrence: A Retrospective, Multicentric, European Study [PORCSE Study]. Journal of Crohn’s and Colitis, 18(8), 1202–1214. https://doi.org/10.1093/ecco-jcc/jjae011 Conflict of interest: Dr. Geldof, Jeroen: JG received honoraria as speaker or advisory board member from Galapagos, Viatris, Abbvie, Pfizer, Janssen, Celltrion and Arena Pharmaceuticals. Truyens, Marie: No conflict of interest Van Gucht, Emily: No conflict of interest Argyriou, Konstantinos: No conflict of interest Bouchard, Isaure: No conflict of interest Abrantes, Daniela: No conflict of interest Roseira, Joana Selas: Advisory board fees from Abbvie and Janssen presenter fees from dr. Falk Nicholls, Jack: No conflict of interest. Elorza, Ainara: No conflict of interest Ferreiro Iglesias, Rocio: RF-I has served as a speaker, or has received research or education funding from AbbVie, Takeda, MSD, Pfizer, Janssen, Adacyte, Ferring, Casen Recordati, Palex, Tillotts Pharma, Dr. Falk, Chiesi, Faes Farma, Alphasigma. Eder, Piotr Michał: Travel and educational grants: Takeda, Ferring, Abbvie, Janssen (J & J), Eli Lilly. Lecture and/or consultancy fees: Takeda, Abbvie, Ferring, Janssen (J & J), Eli Lilly, Bristol Myers Squibb, Pfizer, Recordati, Ibsen, Sandoz. Karakan, Tarkan: None Bossuyt, Peter: Grant support for research from AbbVie, EG Consulting fee from AbbVie, Bristol Meyers Squibb, CIRC, Galapagos, Janssen, Jeito capital, Lilly, Pentax, Pfizer, PSI-CRO, Roche, Takeda, Tetrameros Speakers fee from AbbVie, AMC ICP, Amgen, Bristol Myers Squibb, Celltrion, Dr Falk Benelux, EG, Galapagos, Globalport, Lilly, Medtalks, Materia Prima, Pentax, Springer Media Bouillon, Vincent: No conflict of interest Holvoet, Tom: No conflict of interest Peeters, Harald: Disclosures – conflicts of interest Financial support for research: Abbvie, Mylan, Amgen, Sandoz, Takeda Speaker fees: Janssen, Takeda, Abbvie Consultancy fees: Janssen, Fresenius-Kabi, Abbvie, Galapagos Baert, Filip J.: Grants: Abbvie, Amgen, Eurogenerics, J&J, Takeda Lecture fees/Speakers Bureau: AbbVie, Arena Pharmaceuticals, Celltrion, Ferring, Galapagos, J&J, Lilly, Merck Sharp & Dohme, Pfizer, and Takeda Consultancy: AbbVie, Abivax, Amgen, Arena Pharmaceuticals, Celgene, Celltrion, Ferring, Fresenius Kabi, J&J, Merck Sharp & Dohme, Pfizer, Sandoz Desmedt, Valérie: Speakers fee: AbbVie Jauregui-Amezaga, Aranzazu: I declare that I have no personal financial conflicts of interest related to my scientific activities. Any research funding received from Takeda, Johnson & Johnson, and AbbVie has been allocated to the research group to which I belong and has been used exclusively to support institutional or group-based research initiatives, with no personal financial benefit. Van Dyck, Evi: No conflict of interest Stroie, Tudor Gheorghe: No conflict of interest Theodoraki, Eirini: No conflict of interest Casanova, María José: María José Casanova, has received education funding from Pfizer, Takeda, Janssen, MSD, Dr. Falk, Shire, Ferring, Galápagos and Abbvie, and research funding from Lilly. Mañosa Ciria, Miriam: Personal Fees: Abbvie, FAES Pharma, Ferring, Jannsen, MSD, Pfizer, Tillots and Lilly Cristiano, Margarida: No conflict of interest Karmiris, Konstantinos: Personal Fees: Speaker fees from Abbvie, BMS, Eli-Lilly, Genesis, Innovis, Johnson & Johnson, Pfizer and consultancy or advisory board member fees from Abbvie, BMS, Faran, Ferring, Genesis, Johnson & Johnson, Pfizer, Roche and Takeda Fernandes, Samuel Raimundo: None to declare Márquez Mosquera, Lucía: None Mesonero Gismero, Francisco: I ve served as a speaker for and received consulting fees from MSD, AbbVie, Takeda, Janssen, Pfizer, Ferring Pharmaceuticals, Kern Pharma, Dr. Falk Pharma, Galapagos, Lilly, Chiesi Farmaceutici, and Faes Farma. Lobatón Ortega, Triana: No conflict of interest
