To systematically review the learning curve of percutaneous nephrolithotomy (PCNL) among urology trainees, focusing on the number of procedures required to achieve proficiency and key performance metrics.
A systematic review was conducted in accordance with the PRISMA and the EAU guidelines. PubMed/Medline, Scopus, and Embase were searched up to December 9, 2024, for studies on learning curves in urology trainees performing PCNL on adult humans. Outcomes included operative time, fluoroscopy time, stone-free rate, puncture time and success, complications, and safety indicators. The protocol was registered in PROSPERO (CRD42025633899).
17 studies (2,230 patients) were included from 807 records. Operative time plateaued after 40-50 cases. Fluoroscopy time improved with experience and plateaued after 30-115 cases, with faster learning in supine positioning. Puncture success neared 100% after 25-50 cases, and puncture time improved after 36 cases. Complication and retreatment rates declined over time, although plateau phases were rarely reported. Stone-free rates and patient safety indicators improvement inconsistently across studies. Considerable heterogeneity in outcome definitions and reporting methods precluded pooled analysis.
Performance plateaus in PCNL are generally observed after 30-60 procedures, depending on surgical approach and stone complexity. Operative and fluoroscopy times, puncture success, and complication rates improved with experience. Stone-free and retreatment rates showed greater variability, with no clear patterns or plateaus. However, heterogeneity in reporting and outcome definitions currently limits inter-study comparisons and precludes meta-analysis. Standardized training and uniform evaluation methods are needed to better define surgical proficiency.
Urology. 2025 Jun 02 [Epub ahead of print]
Nathan Wirtzfeld, Etienne-Xavier Keller, Jia-Lun Kwok, Nariman Gadzhiev, Arman Tsaturyan, Bhaskar Somani, Vincent De Coninck
Department of Urology, Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium. Electronic address: ., Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland; European Association of Urology Section of Endourology, Arnhem, the Netherlands; Progressive Endourological Association for Research and Leading Solutions (PEARLS), Paris, France; Young Academic Urologists (YAU), Endourology & Urolithiasis Working Group, Arnhem, the Netherlands., Department of Urology, Tan Tock Seng Hospital, Singapore, Singapore; European Association of Urology Section of Endourology, Arnhem, the Netherlands; Progressive Endourological Association for Research and Leading Solutions (PEARLS), Paris, France; Asian Urological Society of Endoluminal Surgery and Technology (AUSET), Seoul, South Korea; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore., Departement of Urology, Saint-Petersburg State University Hospital, Saint Petersburg, Russia., Department of Urology, Erebouni Medical Center, Yerevan, Armenia; Young Academic Urologists (YAU), Endourology & Urolithiasis Working Group, Arnhem, the Netherlands., Department of Urology, University Hospital Southampton, Southampton, UK; European Association of Urology Section of Endourology, Arnhem, the Netherlands., Urology Department, AZ Klina,Augustijnslei 100, 2930 Brasschaat, Belgium; Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium; European Association of Urology Section of Endourology, Arnhem, the Netherlands; Progressive Endourological Association for Research and Leading Solutions (PEARLS), Paris, France; Young Academic Urologists (YAU), Endourology & Urolithiasis Working Group, Arnhem, the Netherlands. Electronic address: .