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Percutaneous nephrolithotomy (PCNL) is the current gold standard for the treatment of large and complex renal stone disease. It is a complex procedure that requires skill and experience. The most challenging step and key requisite of a successful PCNL is establishing optimal access to the renal collecting system with imaging modalities. To increase safety and efficacy in this crucial step, and with ongoing advancements in current technology, several aids have been developed to assist the urologist and help accurately guide the needle to the target. The goal of this systematic review was to identify and discuss these innovations.