Year : 2013 | Volume
: 29 | Issue : 1 | Page : 83--84
Supine percutaneous nephrolithotomy for renal calculus disease: An underutilized yet useful surgical procedure
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Kumar A. Supine percutaneous nephrolithotomy for renal calculus disease: An underutilized yet useful surgical procedure.Indian J Urol 2013;29:83-84
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Kumar A. Supine percutaneous nephrolithotomy for renal calculus disease: An underutilized yet useful surgical procedure. Indian J Urol [serial online] 2013 [cited 2020 Jan 21 ];29:83-84
Available from: http://www.indianjurol.com/text.asp?2013/29/1/83/109999
Percutaneous nephrolithotomy (PCNL) in prone position (pPCNL) has been the standard of care for >20 mm renal calculus for the past 30 years. Recently Hoznek et al. have prospectively evaluated 47 patients who underwent PCNL in the supine position (sPCNL) from September 2009 to August 2010.  Besides patient demographic details, stone size and surface area were recorded by a noncontrast CT and plain X-ray. The patient position was modified by the authors placing the ipsilateral limb in extension and contralateral in flexion with a lumbar elevation to 20° by an inflatable device (Galdakao modified supine Valdivia position) to allow combined antegrade and retrograde approach by independent surgeons. The puncture was done using ultrasound or fluoroscopic assistance. There were three arms, 31 single, 9 multiple, and 7 staghorn stones. The mean body mass index was 26.1 ± 5 (range: 17.3-45.7), the mean stone size was 29.6 ± 15.3 mm (range: 10- 75). The preferred puncture site was the lower calyx as upper pole puncture was difficult and risked pleural injury. The rest of the procedure was similar to pPCNL. Postoperatively 8 Fr nephrostomy was placed. In case of venous bleeding, a 24F Foley catheter was inserted and the balloon inflated to 3 ml. In the majority of cases, the ureter was drained with a double-J stent or, occasionally, with a ureteral catheter. Treatment success was defined as patients stone free or with residual fragments <4 mm.
Postoperatively stone free rates (SFR) were assessed on first postoperative day by a plain X-ray KUB or a CT scan. Patients were routinely discharged on the second postoperative day. If the patient had no residual stones, the ureteral catheter was removed before the patient left the hospital and double-J stent was removed 1 week after surgery in the outpatient department. For patients with residual fragments, double-J stent was left in situ and the patient underwent adjuvant treatment by a flexible ureterorenoscope or by extracorporeal shock wave lithotripsy (SWL) 2-3 weeks after PCNL.
The mean operation room occupation time was 123.5 ± 51.2 min (50-245min) and 24 patients required adjuvant flexible/semirigid nephroscopy/ureterorenoscopy for achieving stone free status. For 39 patients an 8Fr nephrostomy was placed and 37 required double-J stent placement. The results in terms of full success (stone free + residual fragments <4 mm) were 90%, 78%, and 43% in the single-stone, multiple-stone, and staghorn stone groups, respectively. The hospital stay was 3.4 days (range: 2-12). Nine patients (19%) had further treatment with ESWL or flexible URS. The SFR at 3 months increased to 97%, 100%, and 100% in the single-stone, multiple-stone, and staghorn stone groups, respectively.
Since its description 13 years back by Valdivia-Uria, sPCNL has been performed by various surgeons but has not attained the popularity pPCNL. A meta-analysis by Wu et al. comparing pPCNL to sPCNL revealed no statistically significant difference in terms of stone burden, SFR, complications and mean hospital stay but a significant difference was found in the mean operative time which was 65 ± 15 min in sPCNL and 90 ± 15 min in pPCNL. Only 0.5% patients had a colonic injury in sPCNL group. Falahatkar et al. performed an extensive literature search and reviewed results of 1914 patients who underwent sPCNL and concluded that SFR was 70.5-95% and that the lower calyx was the most common puncture site. They noted that transfusion was needed in 0-20% of the patients; extravasation occurred in 1.09% of the patients. The most common complication was fever (seen in 10.25% of the patients). The advantages of sPCNL highlighted included absence of need to change position, ability to perform ureteroscopy during PCNL, easier air way control, easier approach to upper caliceal stones from the lower calyx, greater ease of stone fragment evacuation, reduced operating time, reduction in wetting of the patient's skin thereby preventing hypothermia, less kidney displacement, less chance of injury to a retrorenal colon, and greater comfort for obese patients and for patients with respiratory or cardiac problems. The present authors have also highlighted similar advantages.
On the other hand Lashay et al. highlighted the technical difficulties faced by the urologist during sPCNL such as difficult approach to the anterior calyces requiring, sometimes, extreme torque by the rigid scopes or the use of flexible scopes, greater chance of pleural/lung injury in the case of upper pole punctures, shorter working space as the distance between the 12 th rib and superior margin of iliac crest is small and the greater mobility of the floating kidney being associated with a longer tract, which subsequently decreases nephroscope mobility. sPCNL was associated with a decreased filling of the pyelocaliceal system restricting the surgical field and so that even a moderate amount of bleeding obscured vision that sometimes lead to early termination of the surgery.
We conclude that urologists' lack of familiarity is the major reason for not performing sPCNL on a wider scale at present. The present study clearly indicates that sPCNL is a very viable option but more randomized studies are needed to accurately determine the correct status of the two positions in the surgical management of large renal stones.
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|2||Wu P, Wang L, Wang K. Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: A meta-analysis. Int Urol Nephrol 2011;43:67-77.|
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|4||Lashay A, Amini E, Ahanian A, Ozhand A, Nikkar M, Sharifi S. Supine percutaneous PCNL- Con. Urol J 2011;8:265-8.|