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BJUI BJU INTERNATIONAL

Supine percutaneous nephrolithotomy (PCNL):


‘in vogue’ but in which position?
Priyadarshi Kumar, Christian Bach, Stephanos Kachrilas,
Athanasios G. Papatsoris, Noor Buchholz and Junaid Masood
Endourology and Stone Services, Barts and the London NHS Trust, London, UK
Accepted for publication 18 January 2012

Study Type – Therapy (case series) What’s known on the subject? and What does the study add?
Level of Evidence 4 Supine percutaneous nephrolithotomy (PCNL) has been described for over a decade
and has equivalent success rates when compared with the more widely used prone
position. The supine position offers a shorter operative duration with better access to
OBJECTIVE
the airway for the anaesthetist and also allows for simultaneous retrograde intra-renal
surgery (RIRS). Various supine positions have been described but there is little data
• To discuss the relative merits of the
regarding their differing benefits and disadvantages.
different described supine positions for
percutaneous nephrolithotomy (PCNL) and The present study looks at the different supine PCNL positions and compares the
highlight the new ‘Barts flank-free strengths and weaknesses of each. Each of the previously described supine PCNL
modified supine position’, as the last positions have some limitations, e.g. ease of puncture under image guidance, the
decade has seen the emergence of various ability and ease of making and dilating multiple tracts, and allowing simultaneous
supine positions for PCNL. RIRS. The new ‘Barts flank-free modified supine position’ is described, which seems to
offer a good compromise and addresses some of these issues. It is important to
highlight that one supine position does not fit all and the endourologist should
MATERIALS AND METHODS
familiarise themselves with these positions so the appropriate position can be used for
the right patient and stone burden.
• We reviewed English publications on
supine PCNL to look at the different
positions being used to carry out PCNL and
described Barts flank-free modified supine • However, one supine position does not
their relative merits.
position fit all and the right one must be chosen for
• We describe the new ‘Barts flank-free
• These positions all differ in regard to the right patient with the right stone
modified supine position’, which we think
ease of puncture under image guidance, burden. It is important for endourologists
will add significantly to the
operative field availability, ability to make of today to familiarise themselves with
armamentarium of the endourologist.
multiple tracts and the ease of combining these positions to be able to make these
retrograde intra-renal surgery. judgements.
RESULTS
CONCLUSIONS
• Five different supine positions are
discussed. • All of the supine positions decrease KEYWORDS
• These include the complete supine, the operative duration, as there is no need for
Valdivia, the Galdakao modified Valdivia, repositioning and allow quick access to the supine, percutaneous nephrolithotomy,
the Barts modified Valdivia and the herein airway for the anaesthetist. position

INTRODUCTION decade has seen the practise of various include direct and indirect pressure effects,
different positions for PCNL. These include, e.g. vascular, peripheral nerve and cervical
The last three decades has seen the prone flexed [2], lateral [3], split-leg [4], spine injuries, tracheal compression and
evolution of percutaneous nephrolithotomy supine [5,6] and modified supine positions ocular injury. Simultaneous anterograde and
(PCNL) as the ‘gold standard’ treatment of [7,8]. retrograde access is also not feasible in the
large renal stones. Initial experience with prone position.
PCNL was in the prone position [1] and it Prone PCNL has potential disadvantages, as
was done this way almost exclusively until it may cause circulatory and ventilatory Two recent meta-analyses have shown
the last decade. Although prone is still the compromise, especially in the obese patient. supine PCNL to be as effective as prone
most widely practised position, the last Additional difficulties of prone anaesthesia PCNL when comparing stone-free rates,

E1018 © 2 0 1 2 B J U I N T E R N A T I O N A L | 11 0 , E 1 0 1 8 – E 1 0 2 1 | doi:10.1111/j.1464-410X.2012.11188.x
SUPINE PERCUTANEOUS NEPHROLITHOTOMY

FIG. 1. ‘The Barts flank-free modified supine FIG. 2. The ipsilateral leg is relatively extended and chest to the contralateral side (Fig. 1). The
position’. Please note gel pad one under the the contralateral leg is relatively abducted. legs are placed in lithotomy, with the
ipsilateral pelvis and gel pad two under the rib ipsilateral side relatively extended and the
cage leaving the flank free, allowing around 15 ° contralateral side abducted (Fig. 2). There is
rotation of the patient. The ipsilateral arm is no support under the loin thus allowing
brought across the chest to the contralateral side. more space for ideal renal access and the
The ribs are marked. P.A.L, posterior axillary line; I.C, ability to use image-guided access with
iliac crest. relative ease. Fluoroscopy is easier and
conventional in this supine position, with
the surgeon’s hands being further from the
operative and radiological field. Additionally,
the kidney lies in a neutral position as
compared with the semi-supine positions,
e.g. the modified Valdivia and Barts
positions, and therefore it is less likely to
displace anteriorly. The kidney is therefore
ultrasound localisation. Simultaneous also less mobile and puncture and dilatation
retrograde intra-renal surgery (RIRS) is are consequently easier. This supine position
possible although ureteroscopy is performed also offers great flexibility in planning
from a position of relative unfamiliarity due surgery, in that primary ureteroscopy may
to the rotated position. be embarked upon in this position quite
readily and then if percutaneous access is
transfusion, complications and it was noted With the modified Valdivia position there is required then no further adjustment is
to be significantly quicker than the prone not quite the radical rotation of the torso, required. However, there is a smaller
position [9,10]. Today, the debate is not as with the Barts technique, and therefore operative field with the tract being fairly
merely whether prone or supine is the best puncture under fluoroscopic control is much horizontal, even more so than the modified
position. There are various supine positions easier. In this position the kidney is Valdivia, and again this facilitates lower
available and we would like to discuss the hypermobile. There is therefore the risk that intra-renal pressures and washout of
relative merits of each. puncture and guidewire manipulation is fragments. The more horizontal angle may
more difficult. In obese patients especially on occasion make the scope more difficult
The first described supine position was that this leads to longer tracts, which themselves to manoeuvre due to the low position of
of Valdivia [5] with a 3-L saline bag below lead to reduced nephroscope mobility. There the tract with the operating table getting
the flank. This original position does not is therefore a greater torque required to in the way.
allow for easy concurrent retrograde manipulate the scope, which can lead to
instrumentation and also provides limited damage to the renal parenchyma and risk The complete supine position [6] allows
space for choosing an access and hence has increased bleeding form the tract. The tract limited space for planning renal access, as
never been universally popularised. A is more lateral in the supine position thus the flank is relatively poorly exposed and
modification of this was the Galdakao- there is less radiation exposure for the may result in reduced ability to manoeuvre
modified Valdivia position [7] with again surgeon and also the surgeon is able to sit the nephroscope, especially for anterior
a saline bag below the flank with the legs during the procedure. The more horizontal calyceal calculi. There is also no readily
in lithotomy, the affected side extended access also leads to lower intra-renal available retrograde access to the urinary
with the contralateral leg abducted. This pressures and easier washout of fragments. tract and hence combined procedures are
allows access to the entire urinary tract However, there is an inability to distend the not possible.
without the need for repositioning and pelvi-calyceal system and it is more difficult
allows simultaneous retrograde access to employ multiple punctures. Although The traditionally used prone position offers
if required. there is not as much space as the Barts a wide operative field with ease of puncture
position for multiple punctures this is offset under image and indeed ultrasound
The Barts modified Valdivia position [8] by the relative ease of puncture under guidance, easy ability to make and dilate
offers a large surface area for access fluoroscopy. Ureteroscopy again is multiple tracts but has a significant
with easy manipulation of the nephroscope, performed in a much more familiar and disadvantage in that simultaneous RIRS in
as the trunk is placed at 90 ° to the conventional position. not practical if not impossible. The increased
operating table. However, renal access is operative time and anaesthetic concerns are
not always a straightforward and easy Recently, we have started using a supine well recognised and described in this
endeavour. The position results in rotation position that we have termed ‘the Barts position. Table 1 shows a comparison of the
of the kidney such that the calyces are flank-free modified supine position’, ease of puncture under image guidance,
viewed end on and also the spine lies in the involving a 15 ° tilt by using a 3-L saline ability to make and dilate multiple tracts
field of the collecting system. Therefore bag under the ipsilateral rib cage and a and to carry our simultaneous RIRS between
puncture is difficult to achieve under small gel pad under the ipsilateral pelvis, all the mentioned supine together with the
fluoroscopy alone and often requires with the ipsilateral arm brought across the prone positions.

© 2012 BJU INTERNATIONAL E1019


KUMAR ET AL.

TABLE 1 Comparison of the ease of puncture under image guidance, ability to make and dilate multiple tracts and to carry our simultaneous RIRS between
the supine and the prone positions

Position
Complete Galdakao modified Barts modified Barts flank-free modified
Method Prone supine Valdivia Valdivia Valdivia supine
Ease of A-P image, A-P image, 30° torso rotation 30° torso rotation Difficult and usually 15° torso rotation but a
puncture puncture puncture makes puncture makes puncture requires 5–10° rotation of c-arm
under image routine routine more difficult more difficult ultrasound- gives an A-P view and
guidance guided puncture hence easy puncture
Ease of tract Routine with Routine, but Kidney more mobile Kidney more mobile Kidney more mobile Kidney less mobile than
dilatation shorter tracts tract usually in this position in this position in this position with the Valdivia and
compared with longer than and hence tract and hence tract and hence tract modified Valdivia
supine with prone dilatation can be dilatation can be dilatation can be positions but more
positions position more difficult more difficult more difficult mobile than with prone
and complete supine
Multiple Large operative Difficult due More difficult than More difficult than Routine as flank Good exposure as flank is
punctures field, multiple to lack of prone due to prone due to well exposed free from support but
punctures exposure of support under support under still less exposure than
routine flank flank and hence flank and hence with prone and Barts
limited exposure limited exposure modified Valdivia
position
Combined Difficult even in Difficult as Difficult as legs not Routinely Routinely Routinely done and
RIRS split leg prone legs not in in lithotomy performed but performed but relatively little trunk
position lithotomy trunk rotation rotation makes rotation makes
makes position position of ureteroscopy easier
of ureteroscopy ureteroscopy than with Galdakao and
unfamiliar unfamiliar Barts modified Valdivia
positions

In summary, all of the supine positions CONFLICT OF INTEREST 5 Valdivia Uría JG, Valle Gerhold J,
decrease operative duration, as there is no López López JA et al. Technique and
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© 2012 BJU INTERNATIONAL E1021

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