title: Training the resident in percutaneous nephrolithotomy.
abstract: OBJECTIVE
  From the trainers' perspective percutaneous nephrolithotomy (PCNL) is one of the most challenging endourological procedures. In this review we examine the problems arising when training residents in PCNL, and how to facilitate this process.
  
  
  METHODS
  The recommendations are derived from discussions and consensus during the First European Urolithiasis Society (EULIS) meeting held in London in September 2011. In addition, we searched Medline for articles identified using the keywords 'training', 'percutaneous surgery', 'renal calculi', 'PCNL', 'virtual reality' and 'simulators'. We also assessed the effect of modern technology, including the availability of virtual reality models vs. operating room training, and how international organisations like EULIS and European Urological Association can help.
  
  
  RESULTS
  The difficulty of training residents in PCNL is partly due to the complexity of obtaining a safe access to the kidney for lithotripsy. The most common way of obtaining access is guided by imaging only, and usually only fluoroscopic imaging is available. This has the potential for injuring structures from the skin to the renal capsule. Minor vascular injuries are relatively common, although most are self-limiting. Visceral injuries that are particularly important are pleural and less commonly colonic injuries, but they are more complex and often require additional procedures.
  
  
  CONCLUSIONS
  Teaching the skills is more challenging than performing PCNL. In most urological training programmes it is difficult to incorporate teaching and training skills when performing PCNL. To train an academic stone doctor, proficiency in the safe conduct of PCNL is mandatory.
authors.affiliation: Urology Residency, Aga Khan University, Karachi, Pakistan.
authors.forename: M Hammad
authors.initials: MH
authors.lastname: Ather
authors.affiliation: Division of Urology, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China.
authors.forename: Chi-Fai
authors.initials: CF
authors.lastname: Ng
authors.affiliation: Urology Research Centre, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Gholamraza
authors.initials: G
authors.lastname: Pourmand
authors.affiliation: Clinical Urology, EAU Section on Urolithiasis (EULIS) Urological Research Centre, Department of Urology, Fredericia Hospital, University of Southern Denmark, Fredericia, Denmark.
authors.forename: Palle J
authors.initials: PJ
authors.lastname: Osther
keywords: EBM, evidence-based medicine; PCNL; PCNL, percutaneous nephrolithotomy; PCS, pelvicalyceal system; Residency; Training; US, ultrasonography; VR, virtual reality