Is the supine position superior to the prone position for percutaneous nephrolithotomy (PCNL)?

Pre- and post-operative safety considerations for patients undergoing percutaneous nephrolithotomy

INTRODUCTION

Percutaneous nephrolithotomy (PCNL) is a widely used surgical procedure for treating large and complex kidney stones. Although effective, it carries risks of complications such as bleeding, infection, and injury to adjacent structures. Optimisation of procedural techniques and perioperative care can help minimize these risks.

AREAS COVERED

This review examines key pre- and post-operative safety considerations for PCNL patients. Topics include pre-operative imaging, patient positioning, puncture techniques, tract dilation, postoperative drainage, and complication management. The literature search involved analyzing recent studies and clinical guidelines to identify best practices. The search was conducted in several databases, including PubMed, Embase, the Cochrane Library and clinical guidelines. Training modalities for improving procedural skills are discussed.

EXPERT OPINION

Improving the safety of PCNL requires a combination of meticulous surgical technique, proper patient selection, and adherence to standardized protocols. Continuous skill development and technological advancements will further improve patient outcomes.

Supine or prone position in percutaneous nephrolithotomy: A systematic review and meta-analysis of 11,774 cases

INTRODUCTION

Percutaneous nephrolithotomy is the gold standard for large renal stones, with prone and supine positions offering distinct advantages and disadvantages. This meta-analysis compares the efficacy and safety of these two approaches.

METHODS

This meta-analysis registered in PROSPERO (CRD42024603670) followed PRISMA and AMSTAR guidelines, including RCTs, cohort, and case-control studies comparing SP and PP PCNL for renal stones. It assessed demographic data, stone-free rate, operative time, hospital stay, complications and hemoglobin drop, with bias risk evaluated using Cochrane and ROBINS-I tools and statistical analysis performed in Jamovi.

RESULTS

Forty-three studies with 11,774 patients were included. No significant differences were found in patient characteristics, SFR (RR=0.9945, P=0.7008), hemoglobin drop (P=0.0800), or hospital stay duration (P=0.1942). The SP group showed shorter OT (SMD=-0.3895, P=0.0084), fewer overall (RR=0.8692, P=0.0026) and major complications (RR=0.7461, P=0.0151). SP also had lower rates of visceral injury (RR=0.8485, P=0.1581), transfusion (RR=0.8514, P=0.1497), sepsis (RR=0.7880, P=0.1304), urinary leakage (RR=0.7699, P=0.2681), and pleural effusion (RR=0.5564, P=0.0898), but these were not statistically significant.

CONCLUSION

This meta-analysis found no significant differences between SP and PP in demographics, stone size, SFR, hospital stay, or hemoglobin drop. However, SP was associated with shorter OT, fewer complications and major complications, suggesting it is a viable alternative.

The Medial Mini-Open Supine Achilles Repair: Outcomes of a Medially Based Mini-Open Technique Compared With Prone Techniques

BACKGROUND

Achilles tendon rupture treatment has changed substantially in the past decade, with an evolution toward less-invasive techniques and more convenient patient positioning. This review aims to report on the 1-year clinical outcomes of a medially based, mini-open, supine, Achilles tendon repair technique.

METHODS

In this retrospective review, all patients who underwent surgical management of an Achilles tendon rupture were included and analyzed based on approach, including (1) standard open prone technique, (2) mini-open repair, prone, and (3) medial mini-open repair, supine. Primary outcomes were the Patient-Reported Outcome Measures Information Systems (PROMIS) Physical Function, PROMIS Pain Interference, and PROMIS Depression scores. Secondary outcomes of interest were surgical time and complications.

RESULTS

Seventy-eight patients were included in this study who underwent Achilles tendon repair and were seen in follow-up at least 1-year postoperatively. Demographics are displayed in Table 1. No statistical difference was observed regarding sex, laterality, age, and mechanism between those with 1-year follow-up data and those who were lost to follow-up before the 1-year mark. Primary outcomes were notable for statistically significant difference in the PROMIS Depression score between the mini-open repair, prone group, and the mini-open repair, supine group. The remainder of the primary outcomes of interest were not statistically significant. Secondary outcomes were notable for markedly shorter surgical time for the mini-open repair, supine group compared with both the standard open prone and mini-open repair, prone groups, with times being 89, 72, and 58 minutes, respectively. Surgical time was defined as starting from the time the patient was anesthetized in the room and included positioning and time up until extubation.

CONCLUSION

The medial mini-open repair, supine technique shows promise as a noninferior surgical option for acute Achilles tendon rupture repair with markedly decreased operating room time and 1-year outcomes with comparable results to both open and mini-open prone techniques.

An updated systematic review and meta-analysis on the efficacy of supine versus prone position for pediatric PCNL

BACKGROUND

The incidence of pediatric kidney stones is increasing with recurrence rates ranging from 35 to 50%. Supine percutaneous nephrolithotomy (PCNL) presents a viable alternative to the conventional prone position, offering specific benefits but also posing certain risks.

OBJECTIVE

To update a previously published systematic review and meta-analysis comparing the efficacy of PCNL in the supine versus prone positions in children.

METHODS

A systematic search of Web of Science, Cochrane Library, PubMed, and Embase was conducted to identify eligible studies. Two authors independently screened the literature and extracted data. The meta-analysis was performed using StataMP 17. The study was prospectively registered in PROSPERO (ID: CRD42024545145). The sensitivity and subgroup analyses explored sources of heterogeneity, and publication bias was assessed with a funnel plot. The study adhered to PRISMA guidelines and the Cochrane Handbook.

RESULTS

This study included a total of nine studies, comprising five randomized controlled trials and four case-control studies, with 614 patients in total. Compared with the prone position group, the supine position group demonstrated significant advantages in terms of operative time (WMD = - 15.43, 95% CI: - 22.18 to - 8.69, P = 0.0001), hospital stay (WMD = - 0.77, 95% CI: - 1.12 to - 0.42, P = 0.0001), overall complication rate (OR = 0.46, 95% CI: 0.42-0.99, P = 0.046), and hemoglobin decrease (WMD = - 0.22, 95% CI: - 0.40 to - 0.05, P = 0.013). However, no significant differences were observed between the two groups in stone clearance rate, high-grade complication rate, or radiation exposure time. Subgroup analysis revealed that in studies published after 2024, cases of small stones (< 2 cm), and older children (> 9 years), the supine position group had fewer low-grade complications. Additionally, in the supine PCNL group with ultrasound or endoscopy-assisted puncture, radiation exposure time was significantly reduced.

CONCLUSION

This study shows that supine position PCNL in children is superior to the prone position in terms of operative time, hospital stay, complication rate, and hemoglobin decrease, with no significant difference in stone clearance, high-grade complications, or radiation exposure. The subgroup analysis found that supine position resulted in fewer low-grade complications in studies published after 2024, small stones, and older children. It also significantly reduced radiation exposure with ultrasound or endoscopy-assisted puncture, suggesting that supine position is a safer and more effective option.

Analyzing learning curve for supine percutaneous nephrolithotomy in urology resident training programme: comparative analysis

INTRODUCTION

This article attempts to provide a comprehensive review of the learning objectives and importance of the supine percutaneous nephrolithotomy (PCNL) technique.

MATERIAL METHOD

We retrospectively reviewed the cases of Supine PCNL between January 2018 and January 2024. We divided the groups into 3: residents between 2 and 3 years (Group 1), residents between 4 and 5 years (Group 2), and endourologist (Group 3). The 2-3-year resident started to perform PCNL for the first time, while the 4-5-year resident started to perform Supine PCNL for the first time while previously performing prone PCNL.

RESULTS

Access, fluoroscopy, and operation time were higher in Group 1, shorter in Group 2, and shortest in Group 3 (p < 0.001). Postoperative length of stay and the need for additional treatment were found to be shorter (p < 0.001), and the stone-free rate (SFR) increased (p < 0.001) from Group 1 to Group 3. The highest complication rates were observed in Group 1 (p = 0.002). SFR rate increased as the number of cases increased in Group 1 patients. Success was stable after 46-60 cases in terms of SFR. In Group 2, the SFR rate was stable after 31-45.

CASES

The most complications were observed in Group 1 and the least in Group 3.

CONCLUSION

In 2-3-year residents, access time and fluoroscopy time decrease with experience. In 4-5-year residents, due to their expertise in prone PCNL, the operation time and fluoroscopy time decrease with the number of cases performed. SFR is higher after 46-60 cases for 2-3-year residents and 31-45 cases for 4-5-year residents.

Comparison of safety and efficacy of different positions in percutaneous nephrolithotomy: a network meta-analysis

OBJECTIVES

Various new positions for percutaneous nephrolithotomy (PCNL) were proposed to reduce the limitations of the traditional position. This study was aimed to evaluate the efficacy and safety of the different PCNL positions.

METHODS

PubMed, Embase, Web of Science, and the Cochrane Library were searched for relevant randomized controlled trials (RCTs) up to 18 April 2023. The authors collected five common surgical positions used for PCNL: oblique supine position (OSP), supine position (SP), flank position (FP), split-leg oblique supine/flank position (SLP), and prone position (PP). Paired and network meta-analysis were conducted to compare relevant outcomes, including complications, operative time, stone-free rates, hospital stay, and hemoglobin loss among these different positions.

RESULTS

The study included 17 RCTs with a total of 1841 patients. The result demonstrated that SLP significantly outperformed in terms of decreasing operation time (FP vs SLP MD- MD-41.65; OSP vs SLP MD 28.97; PP vs SLP MD 34.94), hospital stay, and hemoglobin loss. Ranking probabilities showed SLP had highest stone-free rate. Prone position was more likely to occur complications than others. Based on SMAA model, the benefit-risk analysis suggested the SLP was the optimal position in PCNL.

CONCLUSIONS

For PCNL, the split-leg, flank, supine, and OSPs are as secure as the prone position. Further RCTs are necessary to confirm the outstanding safety and efficacy of split-leg position. Besides, the position should be selected regard for the patient's demands, the surgeon's preference and learning curve.

Which position is more advantageous for percutaneous nephrolithotomy: supine or prone?

Percutaneous nephrolithotomy (PNL) can be performed in a number of different positions. Our aim was to evaluate the convenience and advantages of the supine position following the transition from the prone to the supine position. 94 patients undergoing supine PNL (Group-1) and 93 patients undergoing prone PNL (Group-2) were retrospectively reviewed and included in the study. Patients who underwent mini-PNL (mPNL) were selected from Group-1 and Group-2 and divided into Group-1A supine mPNL patients (77) and Group-2A prone mPNL patients (53). Demographic characteristics, operative data and post-operative parameters were compared between these groups. The operation time was 74.4 ± 21.9 min in Group-1A and 79.2 ± 19.8 min in Group-2A (p = 0.076). The median value of fluoroscopy time was 30 s in Group-1A and 40 s in Group-2A (p = 0.003). In Group-1A, 59 patients had no intraoperative double-J stent (DJS) insertion and 18 patients had DJS insertion, while in Group-2A, 24 patients had no DJS insertion and 29 patients had DJS insertion (p < 0.001). MPNL was performed in 81.9% of patients in the supine position and 57% in the prone position. This difference was statistically significant (p < 0.001). No significant difference was found with regard to the success rate and the complications of mPNL. Fluoroscopy time is shorter in the supine position. Moreover, the insertion rates of DJS are low. With increasing experience, we have found that our standard PNL (sPNL) rate is gradually decreasing and more mPNL is being performed.

Assessing the Variability of the Twelfth Rib as a Landmark for Percutaneous Nephrolithotomy Using Computed Tomography

BACKGROUND

The variability in length of the twelfth rib is mentioned in the literature but has never been formally studied. The highly variable rib length provides a challenge for urologists seeking a consistent landmark for Percutaneous Nephrolithotomy (PCNL). We set out to determine whether the twelfth rib is safe to use as a consistent landmark for surgery.

METHODS

Single centre, cross-sectional retrospective observational study and analysis of CT scans of 100 adults who had imaging between 23rd March and 12th April 2020. The distance from the mid-sagittal line to the twelfth rib tip in the axial plane was measured as was the distance from the twelfth rib tip to the kidney, spleen and liver.

RESULTS

Length from the mid-sagittal line to the right twelfth rib tip varied from 46 (percentile 95% CI 40 to 57) to 136mm (percentile 95% CI 133 to 138). On the left, the distances varied from 55 (percentile 95% CI 50 to 64) to 134mm (percentile 95% CI 131 to 135). Twenty-three percent of people had an organ lying between the tip of the twelfth rib and the kidney on the right and 11% on the left.

CONCLUSION

The twelfth rib is highly variable in length. Similar variability was recorded in the distance from the tip to intra-abdominal organs. Due to the frequency of organs lying between the tip of the rib and the kidney it should not be used as a landmark for accessing the kidney without prior knowledge of an individual patient's anatomy as seen on imaging.

Effect of patient positioning on anesthesiologic risk in endourological procedures

Objective

The objective is to compare supine and prone positions in terms of arterial blood gas during lithotripsy endourology procedures in different stages.

Material and Methods

Cases of during lithotripsy endourology procedures in our department from March to September 2020 were included prospectively. The variables registered were body mass index, age, the American Society of Anesthesiologists (ASA) score, diabetes mellitus, positive end-expiratory pressure (PEEP), FiO2, stone size, stone location, procedural type, position, procedure duration, PaO2, SaO2, PaCO2, pH, and dynamic compliance. PaO2, SaO2, PaCO2, pH, and dynamic compliance were recorded at the beginning of the procedure, 5 min later, 15 min later, and at the end of the procedure.

Results

Thirty patients in prone position and 30 in lithotomy position were included in this study. Patients in prone position underwent percutaneous nephrolithotomy, and patients in supine/lithotomy underwent retrograde intrarenal surgery or ureteroscopy. Statistically significant differences were found in PEEP, duration, PaO2 at the beginning, SaO2 at the beginning and at the end of the procedure, PaCO2 at the beginning and at minute 5 and pH at the beginning of the surgery. The saturation PaO2 increased significantly on prone position and was statistically significantly better at the end of the surgery.

Conclusions

Both prone and supine positions were safe regarding anesthesiologic risk and had no clinically relevant differences in terms of individual comparisons in arterial blood gas parameters in static moments of the procedure. Prone position was related to an increase in PaO2 and a drop in PaCO2 gradually from the beginning to the end of the surgery.

Comparative Study of Prone Position Variations for Percutaneous Nephrolithotomy

Objective

In this comparative study, we evaluated the results of flat prone and prone hip flexed percutaneous nephrolithotomy in terms of efficacy and safety to contribute to the optimal prone percutaneous nephrolithotomy position.

Materials and Methods

Data of the patients who underwent percutaneous nephrolithotomy operations in a flat-prone or prone hip flexed positions due to renal pelvis and/or ≥2 Calix filling stones between January 2016 and January 2022 were collected retrospectively. Demographic data of the patient groups in different prone positions as well as clinical findings, stone characteristics and operative data were analyzed. The groups were also compared in terms of post-operative findings and complications.

Results

The average age and CROES scores of patients included in the study were 47.15±15.6 years and 221.76±62.49, respectively. There was no statistically significant difference between the two groups in terms of patient demographic data, stone-free status and complication rates. Operation Room Time (ORT) (min) in flat prone PCNL group was shorter in average (100.57±32.74 min vs 92.32±28.75 min, p = 0.041) and duration with nephrostomy (days) and hospitalization (days) parameters were statistically significantly shorter in prone hip flexed PCNL (respectively, p < 0.001; p = 0.005).

Conclusion

Flat-prone PCNL provides significantly shorter ORT. However, the time with nephrostomy and hospitalization with the prone hip flexed PCNL were shorter than flat-prone position. The findings will guide the optimal prone PCNL position.

Percutaneous Nephrolithotripsy in Morbidly Obese Patient: A Case Report

A 50-year old male patient with morbid obesity was admitted for removal of large staghorn calculi and multiple small stones in the left kidney. The patient was managed by Percutaneous Nephrolithotomy (PCNL). Surgery was carried out in prone position and Alken's metal dilators were used for tract dilation. Alken dilators were inserted without any challenges, and the procedure was completed in a shorter span of time than anticipated with total operative time of 2 hours, including the change of positioning from lithotomy to prone. No intra-operative or post-operative complications were encountered. The patient has been followed up for 6 months post-operatively, without any complications or any evidence of stone recurrence.

Position-related anesthesiologic considerations and surgical outcomes of prone percutaneous nephrolithotomy: a review of the current literature

The aim of the current study was to perform a critical review of existing literature and report the potential morbidity of patient positioning during urological surgeries as well as evaluate the surgical outcomes and anesthesiologic benefits and risks of prone percutaneous nephrolithotomy (PCNL). A narrative review of the current literature has been performed. Articles related to position-related injuries and complications under general anesthesia in prone positions were selected, studied, and considered for the current review. We found that under general anesthesia, the prone position improved the oxygenation of patients and increased the elimination of carbon dioxide. A potential risk for position-related anesthesiologic side effects was reported for longer spine surgeries in a prone position. The injuries and position-related side effects were extremely rare following prone PCNL since the mean duration of the procedure was significantly shorter than that of spine surgery. In conclusion, the prone PCNL remains the most often utilized and preferred approach globally with well-established success and complication rates. Clinical outcomes of prone PCNL do not demonstrate an increased rate of anesthesiologic complications compared to the supine approach. Standardization of turnover of the position, and reduction of the operative time warrant a faster and complication-free recovery.

A prospective, randomized comparison of standard prone position versus flank-free modified supine position in percutaneous nephrolithotomy: A single-center initial experience

Background:

Percutaneous nephrolithotomy (PCNL) is the first choice for treatment of large renal stone >2 cm. The prone position is the classical position preferred by most surgeons. Aiming to improve patient anesthesia and surgery-related inconveniences of the prone position, Valdivia et al., 1987, described the performance of PCNL with the patient in the supine position. Hence, we aimed to study the safety and efficacy of flank-free modified supine position in PCNL compared to the standard prone position.

Patients and Methods:

This is a prospective randomized study for 60 patients with large renal stones planned for PCNL operation during the period from November 2017 to May 2019. Patients were divided into two groups (30 patients each group): Group A – patients underwent PCNL in the prone position and Group B – patients underwent PCNL in the modified flank supine position. Patients’ demographics, stone size, Hounsfield unit with intraoperative details as fluoroscopy time, operative time, and complications were recorded. Postoperatively, need for or not to blood transfusions, hospital stay, stone-free status, and postoperative complications were assessed.

Results:

There was no statistically significant difference between the prone and supine positions regarding stone size (4 cm vs. 4.5 cm, P = 0.16), Hounsfield unit (940 HU vs. 955 HU, P = 0.78), body mass index (31.2 kg/m² vs. 32.5 kg/m², P = 0.49), fluoroscopy time (6.9 min vs. 7.3 min, P = 0.5), operative time (89.5 min vs. 90.4 min, P = 0.9), residual stones (10% vs. 20%, P = 0.8), and hospital stay (45.6 h vs. 48.6 h, P = 0.5). Fever occurred in 3.3% of cases in each group and urine leakage observed in one patient with prone position. No blood transfusion was needed in both the groups.

Conclusions:

PCNL in the modified supine position proved to be a safe and effective choice compared to the prone position for adult patients with large renal calculi.

Prone versus Barts “flank-free” modified supine percutaneous nephrolithotomy: a match-pair analysis

Background/aim

In this study, we aimed to compare the results of prone and Barts “flank-free” modified supine percutaneous nephrolithotomy (PCNL) operations in our clinic.

Materials and methods

The data from patients that underwent Barts “flank-free” modified supine PCNL (BS-PCNL) (n = 52) between June 2018 and July 2020 and prone PCNL (P-PCNL) (n = 286) between April 2014 and June 2018 were retrospectively evaluated. Of those 286 patients, 104 patients whose sex, age, body mass index, American Society of Anesthesiology score, stone localization, stone size, and hydronephrosis matched the BS-PCNL group in a 1:2 ratio were included in the study. The groups were compared in terms of intraoperative outcome, complication rates, and stone-free rates.

Results

The mean age of all patients (58 females, 98 males) included in the study was 41.8 ± 15.2 years, and the mean body mass index (BMI) was 24.7 ± 2.9 kg/m2. The mean operation time was significantly shorter in the BS-PCNL group than in the P-PCNL group (80.2 ± 15.1 min vs. 92.4 ± 22.7 min and p = 0.01). There was no significant difference between the two groups in terms of fluoroscopy time, intraoperative complications, postoperative complications, and stone-free rates.

Conclusion

Our study shows that BS-PCNL is an effective and safe method that significantly reduces the operation time and should be considered as one of the primary treatment options for patients scheduled for PCNL.

Concomitant management of renal calculi and recurrent ureteropelvic junction obstruction with percutaneous nephrolithotomy and antegrade balloon dilation

Objective

This study aimed to present our experience of concomitant management of renal calculi and recurrent ureteropelvic junction obstruction (UPJO) with percutaneous nephrolithotomy (PCNL) and antegrade balloon dilation.

Methods

We retrospectively reviewed 31 patients who underwent PCNL and antegrade balloon dilation for treatment of renal calculi and recurrent UPJO. The inclusion criterion was the presence of UPJO after failed pyeloplasty with ipsilateral renal calculi. Success was defined as achievement of both symptomatic and radiographic resolution of any stones and obstruction.

Results

All operations were successful without grade III or higher postoperative complications. A stone-free status was observed in all patients and the overall success rate of the procedure was 87.1% (27/31). The success rate of the procedure was significantly higher in patients with mild or moderate preoperative hydronephrosis (96%) than in those with high-grade preoperative hydronephrosis (50%). Moreover, the success rate of the procedure was lower in patients with poor preoperative renal function (0%) than in those with good or moderate renal function (93.1%).

Conclusion

Combined PCNL and antegrade balloon dilation management represents a safe and effective approach for patients with renal calculi and recurrent UPJO after failed pyeloplasty.

Management of upper calyceal stone by percutaneous nephrolithotomy through lower calyx access: prone versus supine position

Background

The best way in the management of calyceal stone by percutaneous nephrolithotomy (PCNL) is to go directly into the desired calyx. However, in upper calyx, this direct entry may be associated with undesired complications, and through lower calyx is limited in prone PCNL. Recently, there is another option about reaching it through the lower calyx in supine position with more accessibility and better manipulation. This study aimed to evaluate the management of the upper calyceal stone by PCNL through lower calyx access in prone versus supine position.

Methods

A total of 38 patients with upper calyceal stone (≥ 2 cm) were randomly divided into two groups; the first group included 18 patients managed by PCNL in the prone position, and the second group included 20 patients managed in supine position. All data of both procedures were collected and statistically analyzed to compare between both groups.

Results

There is no statistically significant difference between groups as regards demographic and stone characters. The angle between the access to the lower calyx and access of the upper calyx was significantly wider in the supine group versus prone group (130.2° ± 23.46° vs. 89.67° ± 14.56°, respectively). The mean operative and fluoroscopy time was significantly longer in the prone group. There is no significant difference in intraoperative or postoperative morbidity. The stone-free rate was significantly higher in the supine group than the prone group (85% vs 38.9%, respectively). Also stone approachability was higher in the supine group than prone group (95% vs. 66.7%, respectively).

Conclusion

Management of upper calyceal stone by PCNL through the lower calyx is safe, but it is more effective in the supine position than in prone position.

Supine PCNL in patient with staghorn renal stone and severe degree kyphosis: A case report

Spinal deformity concomitantly with large renal stone has become a challenges for urologist since it needs different approach in performing percutaneous procedures. This case report highlight our success experience in treating a 53-years old female patients with severe degree of kyphosis and staghorn stone using supine PCNL. She underwent right PCNL and right Double-J stent insertion anterograde after stone were released. The duration of surgery was 2 hours and 45 minutes with no intra and post-operative complication reported. Supine position can be safely chosen if prone cannot be placed in complex situation such as staghorn stone in severe kyphosis patients.

Supine versus prone PCNL in lower calyceal stone: Comparative study in a tertiary care center

INTRODUCTION

Renal calculus disease is an age old disease of human being. PCNL (Percutaneous nephrolithotomy) stands as a gold standard treatment for large renal calculus which is traditionally being done in prone position.

OBJECTIVE

To evaluate the safety and efficacy of supine PCNL versus prone PCNL comparing intraoperative time, requirement of relook PCNL, post op hemoglobin drop, post operative hospital stay, post operative complication, SFR ( stone free rate).

METHODS AND MATERIALS

It is a prospective study done in Urology department in a tertiary care center in Eastern India between October 2017 and October 2018. A total of 84 patients with lower calyceal renal stones underwent PCNL, 42 of them in supine and 42 in prone position. Lower calyceal stone, size measuring 1 to 2 cm were included in the study.

RESULTS

The mean intra operative time was 91.76 min in supine group and 85.43 min in prone group with a p value of 0.115. The mean hemoglobin drop was 1.11 g/dl and 1.18 g/dl in supine and prone position, respectively (p value 0.75). The mean post operative hospital stay was 4.1 and 3.86 days in supine and prone group (p value 0.58), respectively. Two patients in each group require relook PCNL. Stone free rate at 1 month was 95.23% and 90.47% (p value 0.9), respectively in case of supine and prone group.

CONCLUSION

Supine PCNL is feasible, comparable to prone PCNL in respect to operative parameters with relatively higher stone free rate though statistically insignificant.

Supine versus prone position for percutaneous nephrolithotripsy: A meta-analysis of randomized controlled trials

OBJECTIVE

To compare the safety and efficacy of percutaneous nephrolithotripsy (PCNL) in supine versus prone position for patients with renal or upper ureteral calculi.

METHODS

A systematic search of Pubmed, Embase and Cochrane Central Register of Controlled Trials was performed to identify all eligible studies. All included randomized controlled trials (RCTs) were evaluated based on the inclusion and exclusion criteria. After quality assessment and date extraction, a meta-analysis was performed using RevMan 5.3 software.

RESULTS

A total of 15 RCTs with 1474 patients were included in our meta-analysis. Pooled data showed that PCNL in supine position could significantly reduce the operative time [weighted mean difference (WMD) -12.02, 95% confidence interval (CI) -20.49 to -3.54, p = 0.005] and rate of fever [risk ratio (RR) 0.67, 95% CI 0.46 to 0.97, p = 0.03] compared to prone position. In addition, no significant differences could be found between groups in stone-free rate (p = 0.31), hospital stay (p = 0.59) and rate of overall complications (p = 0.11), mainly including urinary leakage (p = 0.83), pleural effusion (p = 0.74) and blood transfusion (p = 0.58).

CONCLUSIONS

The current study found comparable stone-free rate and significant lower rate of postoperative fever in supine PCNL compared with prone PCNL. PCNL in supine position could be a safe and efficient choice for patients with renal or upper ureteral calculi.

Impact of patient position on the outcomes of percutaneous neprolithotomy for complex kidney stones

Purpose:

To evaluate the impact of the patient position on the outcomes of PCNL among patients with complex renal stones.

Material and Methods:

From July 2011 to July 2014, we collected prospective data of consecutive patients who underwent PCNL. We included all patients with complex stones (Guy's Stone Score 3 or 4 (GSS) based on a CT scan) and divided them based on the position used during PCNL (prone or supine). The variables analyzed were gender, age, body mass index, ASA score, stone diameter, GSS, number of punctures, calyx puncture site, intercostal access and patient positioning. Complications were graded according to the modified-Clavien Classification. Success was considered if fragments ≤ 4mm were observed on the first postoperative day CT scan.

Results:

We analyzed 240 (46.4%) of 517 PCNL performed during the study period that were classified as GGS 3-4. Regarding patient positions, 21.2% were prone and 79.8% were supine. Both groups were comparable, although intercostal access was more common in prone cases (25.5% vs 10.5%; p=0.01). The success rates, complications, blood transfusions and surgical times were similar for both groups; however, there were significantly more visceral injuries (10.3% vs 2.6%; p=0.046) and sepsis (7.8% vs 2.1%; p=0.042) in prone cases.

Conclusion:

Supine or prone position were equally suitable for PCNL with complex stones and did not impact the success rates. However, supine position was associated with fewer sepsis cases and visceral injuries.

Patient positioning during percutaneous nephrolithotomy: what is the current best practice?

Percutaneous nephrolithotomy (PCNL) is the gold standard procedure for treatment of large stones and complex kidney disorders, but its morbidity remains the highest among stone treatment procedures. In pursuit of minimizing complication rates, surgeons have developed different variations of the classic prone position in which PCNL is usually performed; one among them is supine position. In this study, we review the literature and present all available evidence on different variations in positioning during PCNL, in an effort to identify if there is a position that can minimize the morbidity of this procedure.

A retrospective, observational study of supine percutaneous nephrolithotomy

Objective:

The objective of this study is to assess stone clearance and perioperative complication rates of supine percutaneous nephrolithotomy (PCNL).

Methods:

This was a retrospective, observational study of supine PCNL performed in a surgical unit at a district general hospital by two surgeons in the United Kingdom. Data collected included patient demographics, comorbidities, complexity of renal calculi, perioperative complications and stone clearance rates.

Results:

A total of 112 supine PCNL procedures were observed in this study. The mean (SD) American Society of Anesthesiologists (ASA) grade and Guy’s Stone Score were 2.0 (0.75) and 2.3 (1.06) respectively. The median (interquartile range (IQR)) duration of in-patient admission was four (one) nights. Complete stone clearance was achieved in 74 (67.3%) of the procedures, while more than 90% clearance of the renal stone burden was achieved in a further eight (7.3%). The most common perioperative complications recorded were blood loss requiring blood transfusion (three (2.7%)) and postoperative fever (two (1.8%)).

Conclusion:

This case series shows that supine PCNL can lead to good stone clearance and low complication rates.

Percutaneous nephrolithotomy: complications and how to deal with them

Percutaneous nephrolithotomy is a common surgical treatment for large and complex stones within the intrarenal collecting system. A wide variety of complications can result from this procedure, including bleeding, injury to surrounding structures, infection, positioning-related injuries, thromboembolic disease, and even death. Knowledge of the different types of complications can be useful in order to prevent, diagnose, and treat these problems if they occur. This review describes the diversity of complications with the goal of improving their avoidance and treatment.

Modified supine percutaneous nephrolithotomy with combined fluoroscopy and ultrasound-guided renal puncture: Initial single-surgeon experience at a UK teaching hospital

Objective:

The purpose of this article is to report the outcomes of our initial experience of performing percutaneous nephrolithotomy in the supine position using ultrasound guidance in addition to fluoroscopy for renal access.

Patients and methods:

The first 34 consecutive modified supine percutaneous nephrolithotomy cases performed by a single consultant urologist inserting their own percutaneous tracts using ultrasound-guidance and fluoroscopy were evaluated. Operative data was collected prospectively over a 10-month period including any complications. The stone-free rate was evaluated three months post-operatively with a plain film or non-contrast computed tomography of the kidneys, ureters and bladder.

Results:

Renal access was achieved in all 34 cases. Mean age was 57 years (19–82) with 14 males and 20 females. Mean stone size 37.2 mm (20–72 mm). Overall stone-free rate was 85.3% at a mean follow up of 11.2 months. There was one Clavien Grade I, and three Clavien Grade II complications of post-operative fever requiring treatment with intravenous antibiotics. No patients developed urosepsis, required blood transfusion or sustained any visceral injury. Median in-patient stay was one night (1–4).

Conclusion:

Modified supine percutaneous nephrolithotomy with combined fluoroscopy and ultrasound-guided renal access has a low incidence of complications allowing for short hospital stay.

Complications after prone PCNL in pediatric, adult and geriatric patients - a single center experience over 7 years

Introduction

CROES-Clavien system (CCS) for grading complications in percutaneous nephrolithotomy (PCNL) is a step towards standardization of outcomes. We categorized complications based on CCS and predicted risk factors across the entire cohort and individually for pediatric (P: ≤18 years), adult (A: 19-65 years) and geriatric (G: ≥65 years) subgroups to assess the risk factors in each subset. We assessed association of complications with length of hospitalization (LOH) and operation time (OT).

Materials and Methods

Retrospective record review of unilateral PCNL performed between January 2009-September 2015 at a tertiary care center in India, performing around 150 PCNL per year.

Results

Out of 922 (P=61; A=794; G=67) PCNL, 259 (28.09%) complications occurred with CCS I, II, III and IV constituting 152 (16.49%), 72 (7.81%), 31 (3.36%) and 4 (0.43%) respectively and its distribution was similar across the subsets and majority (224; 24.3%) were minor (CCS-1, 2). Placement of a nephrostomy (47.4%; 18/38) in Group P, supracostal access, ≥2 punctures, higher GSS, nephrostomy, staghorn stones, ≥2 stones, stone size in Group A and hydronephrosis and prolonged OT in Group G were significantly associated with complications. On logistic regression, need of nephrostomy (adj. OR - 4.549), OT (adj. OR - 1.364) and supracostal access (adj. OR - 1.471) significantly contributed to complications in the study population. LOH was found to be significantly associated with complications (p<0.001).

Conclusions

Contrary to the belief that extremes of ages are associated with complications of prone PCNL, we found age does not alter the incidence or grade of complications and LOH.

[S2k guidelines on diagnostics, therapy and metaphylaxis of urolithiasis (AWMF 043/025) : Compendium]

Every tenth German citizen will suffer from at least one urinary calculus during the lifetime. The diagnostics, treatment and follow-up treatment of urolithiasis are, therefore, part of the daily routine practice for all urologists in hospitals and private practices as well as in many other disciplines, such as general practitioners, internists, nephrologists and pediatricians. Although the diagnostics and therapy have experienced substantial alterations over the last 10 years, the possibilities of metabolic diagnostics and secondary prevention for patients at risk are, unfortunately and unjustly, in many places very poorly represented. The present S2k guidelines, which for the first time were established in an interdisciplinary consensus process, represent the current practical recommendations and, whenever possible, use tables and algorithms in order to facilitate easy reference in the routine daily work. Last but not least, this greatly simplifies the measures for metaphylaxis.

What is better in percutaneous nephrolithotomy - Prone or supine? A systematic review

OBJECTIVE

To review the literature reporting the technique of percutaneous nephrolithotomy (PCNL) and outcomes for prone and supine PCNL, as PCNL is an established treatment for renal calculi and both prone and supine PCNL have been described, but there has been much debate as to the optimal position for renal access in PCNL.

METHODS

A review of the medical literature was conducted using the PubMed database to identify relevant studies reporting on prone and supine PCNL published up until July 2015. Only publications in English were considered. Search terms included 'supine', 'prone', 'percutaneous nephrolithotomy', 'PCNL' and 'randomised controlled trial'. Articles relevant to the particular aspect of PCNL discussed were selected.

RESULTS

In all, 30 articles were included in the literature review. Nine of these articles were of Level 1 Evidence as graded by the Oxford System of Evidence-based Medicine.

CONCLUSION

The present systematic review highlights the benefits and disadvantages of supine and prone PCNL. The published data on supine and prone PCNL have shown no significant superiority of either approach. Whether prone or supine PCNL is optimal, remains a debatable topic.