Background and Objectives: Because of its consistently high stone-free rates (SFRs), percutaneous nephrolithotomy (PCNL) continues to be the first-line treatment for renal stones larger than 20 mm. Standard 24 to 30 Fr access tracts, however, are linked to access-related morbidity, such as bleeding, pain, and extended hospital stays. These restrictions have led to progressive tract miniaturization and the development of mini-PCNL, ultra-mini PCNL, and micro-PCN techniques. Materials and Methods: We performed a narrative review of studies published through January 2026 using PubMed and Google Scholar. Search terms included percutaneous nephrolithotomy, mini-PCNL, ultra-mini PCNL, micro-PCNL, and vacuum-assisted PCNL. Original studies, systematic reviews, and meta-analyses reporting clinical outcomes, complications, and advancements were selected, whereas conference abstracts, non-English papers, and articles without accessible full text were excluded. Results: Across randomized trials, miniaturized PCNL generally preserves efficacy when patients are selected appropriately. Across randomized trials and meta-analyses, miniaturized PCNL achieved stone-free rates comparable to standard PCNL (typically ~80-90% for stones ≤20 mm and similar rates in selected stones >2 cm), while demonstrating lower hemoglobin decrease (mean difference approximately -0.6 to -1.0 g/dL), reduced transfusion rates, and shorter hospital stays, at the cost of longer operative time (mean difference ~8-12 min). On the other hand, operative time may increase, and smaller working channels can make visualization and fragment evacuation more demanding as stone burden rises. Raised intrarenal pressure is a recurring safety issue because it may increase infectious risk unless drainage is actively managed. Recent innovations aim to address these limitations, including vacuum-assisted access sheaths, pressure-controlled irrigation, improved laser and lithotripsy platforms, image-fusion guidance, navigation systems, and robotic assistance. Conclusions: PCNL now spans a spectrum of tract sizes rather than a single standard approach. When chosen appropriately and performed with attention to pressure control and fragment evacuation, miniaturized PCNL can reduce morbidity without sacrificing stone clearance. Future advancements in percutaneous stone surgery are more likely to rely on integrated technological solutions that improve accuracy, safety, and repeatability than on additional tract size reduction.
Medicina (Kaunas, Lithuania). 2026 Mar 04*** epublish ***
Mladen Doykov, Jasmin Gurung, Usman Khalid, Gancho Kostov, Bozhidar Hristov, Petar Uchikov, Krasimir Kraev, Lyubomir Chervenkov, Elizabet Karen Dzhambazova
Department of Urology and General Medicine, Medical Faculty, Medical University of Plovdiv, 4002 Plovdiv, Bulgaria., Medical Faculty, Medical University of Plovdiv, 4002 Plovdiv, Bulgaria., Second Department of Internal Diseases, Section "Gastroenterology", Medical Faculty, Medical University of Plovdiv, 4002 Plovdiv, Bulgaria., Department of Special Surgery, Faculty of Medicine, Medical University of Plovdiv, 4002 Plovdiv, Bulgaria., Department of Propedeutics of Internal Diseases, Medical Faculty, Medical University of Plovdiv, 4002 Plovdiv, Bulgaria., Department of Diagnostic Imaging, Medical Faculty, Medical University of Plovdiv, 4002 Plovdiv, Bulgaria., Department of Social Medicine and Public Health, Public Health Faculty, Medical University of Plovdiv, 4002 Plovdiv, Bulgaria.