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Free-flank modified supine vs. prone position in percutaneous nephrolithotomy: A prospective randomised trial

Free-flank modified supine vs. prone position in percutaneous nephrolithotomy: A prospective... Arab Journal of Urology (2013) 11,74–78 Arab Journal of Urology (Official Journal of the Arab Association of Urology) www.sciencedirect.com STONES/ENDOUROLOGY ORIGINAL ARTICLE Free-flank modified supine vs. prone position in percutaneous nephrolithotomy: A prospective randomised trial 1, Essam Abdel-Mohsen, Mostafa Kamel, Abdel-Latif Zayed, Emad A. Salem , Ehab Ebrahim, Khalid Abdel Wahab, Ahmed Elaymen, Ashraf Shaheen, Hussien M. Kamel Department of Urology, Zagazig University, Zagazig, Egypt Received 8 August 2012, Received in revised form 30 October 2012, Accepted 1 November 2012 Available online 8 December 2012 KEYWORDS Abstract Objective: To compare the technical aspects, operative time, safety and effectiveness of percutaneous nephrolithotomy (PCNL) in the free-flank modified Stones; supine position (FFMSP) vs. the standard prone position (SPP). Percutaneous nephro- Patients and methods: Seventy-seven patients (47 men and 30 women) with renal lithotomy; stones were enrolled and systematically randomised into two groups, A (39 patients) Prone; treated using the FFMSP, and B (38 patients) in the SPP. The outcome was consid- Supine; ered as a cure (successful procedure) if the patient became stone-free or had residual Position fragments of <4 mm in diameter. The operative time (from the induction of anaes- thesia to the removal of the endotracheal tube) was measured and any operative ABBREVIATIONS complications or conflicts were recorded. The different variables were compared FFMSP, free-flank and analysed between the groups. modified supine posi- Corresponding author. Address: 42 Mostafa Foad St., Manshiet Abaza, Zagazig, Sharkia, Egypt. Tel.: +20 55 2317595; fax: +20 55 E-mail address: Dr_emadsalem@yahoo.com (E.A. Salem). Mobile: +20 10 1228091. Peer review under responsibility of Arab Association of Urology. Production and hosting by Elsevier 2090-598X ª 2012 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.aju.2012.11.002 Free-flank modified supine vs. prone position in percutaneous nephrolithotomy 75 tion; SPP, standard Results: Patients in both groups had comparable preoperative clinical data and prone position; PCNL, there were no significant differences in the preoperative clinical characteristics. percutaneous nephro- The procedure was successful in 84.6% and 84% of group A and B, respectively. lithotomy; BMI, body The operative time was significantly longer in group B (SPP) than A (FFMSP). mass index There was no significant difference between the groups in fluoroscopy time and patients’ outcome. Conclusions: The FFMSP (with a cushion under the ipsilateral shoulder) has sim- ilar efficacy and safety as the SPP for PCNL and is associated with a significantly quicker operation. ª 2012 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. Introduction confidence of 95%, power of 80%, and odds ratio 4.5, using the data from De Sio et al. [6]. The sample size analysis showed that at least 36 patients were required The treatment of renal stones has changed dramatically for each group; thus 77 patients (47 men and 30 women) over the past few years. In 1981, Alken et al. [1] popular- with renal stones were enrolled and systematically ran- ised percutaneous nephrolithotomy (PCNL), which has domised into two groups (one patient was allocated to a high success rate, and since then PCNL has been one treatment arm and the next to the other, the patients widely accepted. PCNL is usually done with the patient being unaware of the selection). lying prone [2]. Many drawbacks of this position have Group A (FFMSP) included 39 patients and group B been described by several authors [3–6], including a pro- (SPP) included 38. Included were patients with an indica- longed operative time due to positional changes, adverse tion for PCNL and who had no contraindications for an effects on ventilation and blood circulation, especially in operation in the prone position. Excluded were patients obese patients, and exposure of the surgical team to with intrarenal anomalies, uncorrectable bleeding disor- radiation. These difficulties encouraged many urologists ders, a body mass index (BMI) of >40 kg/m , and preg- to try other positions for PCNL [7–10]. The supine posi- nancy. The preoperative evaluation included a thorough tion was popularised in 1998 by Valdivia Uria et al. [9]. medical history, physical examination, laboratory investi- They found that the colon tends to rise away from the gations (urine analysis, urine culture/sensitivity, complete kidney when the patient is supine, which makes the co- blood count, coagulation profile, blood urea nitrogen and lon less likely to be injured. They described many merits serum creatinine) and radiological investigations (plain of the supine position, including ease of patient position- abdominal film, abdominal ultrasonography, IVU and ing, being more comfortable for the patient, a depen- non-contrast spiral CT for radiolucent stones). If the ur- dant Amplatz sheath, and easy control of the airways. ine culture was positive an appropriate antibiotic was pre- The supine position has mechanical limitations. Desoky scribed for 1 week and the urine culture repeated to verify et al. [11] described the free-flank modified supine posi- urinary sterility before the intervention. Informed con- tion (FFMSP) and assumed that this position over- sent was signed by all enrolled patients. comes the mechanical limitation by providing ample space for PCNL. In the present study we compared Operative technique PCNL in both the FFMSP and the standard prone po- sition (SPP) for the technical aspects, safety, stone-free With the patient supine, cystoscopy was performed and rate, operative time, X-ray exposure, complications, a 6 F open-tip ureteric catheter was introduced and fixed and the need for a second PCNL and/or ESWL. with plaster tape to the indwelling Foley catheter. In group A the patients were placed in the FFMSP by putt- Patients and methods ing a suitable cushion (a 3-L water bag, or less according to body mass) under the ipsilateral shoulder, having the This prospective randomised comparative study was ipsilateral arm bent over the thorax, and extending and conducted in the Urology Department of Zagazig Uni- crossing the patient’s ipsilateral leg over the flexed con- versity hospitals, from October 2008 to March 2010. tralateral leg (Fig. 1). This modification increased the An informed consent was obtained from all patients distance between the last rib and iliac crest, and moving who participated. The study design was approved by the cushion from under the flank (as in the original Val- the ethics committee of our hospital. divia position) to under the shoulder provided ample The sample size for the study was calculated using free flank space for the puncture, dilatation and manip- Epi Info 6 version 6.04d software (WHO, Geneva) and ulation of the stone. This manoeuvre also allowed easy a difference in operative time of 25% between the access to the posterior calyx. In group B, the patients groups was considered as clinical equivalence, with a 76 Abdel-Mohsen et al. Table 1 The patients’ demographics and clinical characteris- tics, operative data, outcome and complications. Variable Group A Group B P N patients 39 38 Male/female 24/15 23/15 0.92 Mean (SD) Age (years) 40.8 (10.5) 44.2 (10.4) 0.16 BMI (kg/m ) 28.8 (4.7) 29.2 (3.8) 0.73 History of ipsilateral renal surgery (n) 19 15 0.29 ESWL for renal stone (n) 5 6 0.75 Stone side, R/L (n) 17/22 20/18 0.43 Stone location (n) 0.79 Pelvis 15 12 Calyces 7 10 Both 17 16 Mean (SD) Figure 1 (A, B) A patient in the FFMSP, with a water bag under Stone diameter (cm) 3.4 (0.7) 3.4 (0.8) 0.9 his ipsilateral shoulder and his arm over the thorax. Stone opacity (n) Radio-opaque/radiolucent 29/10 31/7 0.71 were turned prone (SPP) and renal access was achieved Operative data and outcome under fluoroscopic guidance through the posterior axil- Mean (SD) lary line. Fluoroscopy time (min) 6.5 (1.7) 6.5 (2) 0.88 Coaxial dilators of the Alken type were used for tract Operative time (min) 88 (16) 104 (25) 0.001 dilatation. A 30 F Amplatz sheath was positioned, Successful, n (%) 33 (84.6) 32(84) 0.74 allowing the introduction of a 26 F nephroscope. A Second PCNL (n) 4 5 Postoperative ESWL (n) 2 1 pneumatic lithotripsy device was used to fragment the stone. Fragments were retrieved through the Amplatz Complications sheath. At the end of the procedure, an 18–22 F Blood transfusion 1 1 0.67 Urine leakage 1 2 0.98 nephrostomy catheter was inserted. Fever (>38 C) 5 4 0.59 Colonic injury None None Outcome At 2 days after surgery the patients were assessed with ultrasonography, a plain abdominal film and antegrade PCNL was needed in four patients in group A and five pyelography, to evaluate residual fragments and ureteric in group B. After surgery ESWL was applied to two pa- patency. The nephrostomy tube was removed 2–3 days tients in group A and one in group B. The operative time after PCNL. Prophylactic parenteral broad-spectrum was significantly longer in group B than group A antibiotics were continued until all tubes were removed. (P = 0.001). There was no significant difference The patients were considered ‘cured’ (a successful proce- between the groups in fluoroscopy time and patient dure) if they became stone-free or had asymptomatic outcome (Table 1). One patient had a urine leakage residual fragments of <4 mm in diameter. Patients with (>1 week) in group A that necessitated a JJ stent, as residual stones were scheduled for either a second PCNL did two in group B; Table 1 also summarises the postop- (7 days after the initial procedure) or ESWL. The erative complications in both groups. operative time (from the induction of anaesthesia to the removal of endotracheal tube) was measured and Discussion any operative complications or conflicts were recorded. Data were analysed using Student’s t-test to compare For decades endourologists had placed patients prone means, with P < 0.05 considered to indicate a signifi- during PCNL because they tried to avoid colonic injury, cant difference. until Valdivia Uria et al. [9], in their study of 557 pa- tients, popularised PCNL with the patient supine. They Results showed that there was no damage to colon, as it moves away from the kidney when the patient is supine rather Patients in both groups had comparable preoperative than prone. The supine position has several advantages, clinical data and there was no significant difference in i.e. free ventilation and less time needed to turn the pa- clinical characteristics between the groups for patient tient after inducing anaesthesia. Our modification gender, age, BMI, history of previous ipsilateral renal (FFMSP) of the position has the same advantages of surgery, ESWL for ipsilateral renal stones, stone loca- decreasing the operative time and avoiding the mechan- tion, and stone burden (Table 1). The procedure was ical limitations of the supine position. successful for all patients in both groups. A second Free-flank modified supine vs. prone position in percutaneous nephrolithotomy 77 Several authors [6,9,11,12] favour the supine posi- findings of many urologists [6,9,11,12,17], and it reflects tion as far as recommending that it replaces the SPP. the time lost when turning the patient at the beginning Despite these reports, the supine position has not be- and the end of the procedure in group B. This position come popular, which might be attributed to the limited also does not allow simultaneous antegrade and retro- freedom in manipulating the access and the stone with grade endourological access [18]. a 3-L water bag under the flank, as described by Valdi- In conclusion, the FFMSP, with a suitable cushion via Uria et al. [9]. However, we modified the position under the ipsilateral shoulder, has a similar efficacy by putting a suitable cushion (a 3-L water bag or less, and safety to the SPP for PCNL and offers a signifi- according to body mass) under the ipsilateral shoulder cantly quicker operation. Further studies are needed to instead of under the flank, and extending the ipsilateral confirm the anaesthesiological advantages of the leg over the flexed contralateral leg. This modification FMMSP. increases the distance between the last rib and iliac Conflict of interest crest, which together with having no cushion under the flank provides ample space for puncture, dilatation No conflict of interest. and stone manipulation. We became accustomed to doing PCNL using the SPP Source of funding for several years, then started to use the FFMSP over the last few years, and then planned the present randomised comparative study. We accessed the kidney through the None. posterior axillary line, as described by Valdivia Uria References et al. [9]. This is in contrast to Ng et al. [12], who accessed the kidney through the anterior axillary line, and in that [1] Alken P, Hutschenreiter G, Marberger M. Percutaneous stone study the nephrostomy tract was created by radiologists. manipulation. J Urol 1981;125:463–6. In both positions we preferred to access the kidney [2] Segura JW, Patterson DE, LeRoy AJ, May GR, Smith LH. through the posterior calyx, while Valdivia Uria et al. Percutaneous lithotripsy. J Urol 1983;130:1051–4. [3] Clayman RV, Bub P, Haaff E, Drenser S. Prone flexible [9] gained access through the anterior calyx. We assume cystoscopy: an adjunct to percutaneous stone removal. J Urol that the cushion under the flank, as described by Valdivia 1987;137:65–7. Uria et al. [9], makes it technically difficult to access the [4] Kerbl K, Clayman RV, Chandhoke PS, Urban DA, De Leo BC, posterior calyx. Placing the cushion under the shoulder et al. Percutaneous stone removal with the patient in a flank provides ample free space under the flank, so the poster- position. J Urol 1994;151:686–8. [5] Rana AM, Bhojwani JP, Junejo NN, Das Bhagia S. Tubeless ior calyx is accessed easily. Also, we preferred to access PCNL with patient in supine position: procedure for all the kidney through the lower calyx in both the SPP seasons? – with comprehensive technique. Urology and FMMSP because it is safer in terms of thoracic com- 2008;71:581–5. plications, and we could reach the upper calyx easily. [6] De Sio M, Autorino R, Quarto G, Calabro F, Damiano R, Nevertheless, the middle and upper calyces could be ac- Giugliano F, et al. Modified supine versus prone position in percutaneous nephrolithotomy for renal stones treatable with a cessed when necessary. In the series of Neto et al. [13], the single percutaneous access: a prospective randomized trial. Eur upper calyx was accessed in 5.7% of their patients. One Urol 2008;54:196–202. of the disadvantages of the FMMSP is that it does not [7] Lehman T, Bagley DH. Reverse lithotomy, modified prone allow simultaneous retrograde access to the urinary position for simultaneous nephroscopic and ureteroscopic proce- tract, by contrast with the modified supine position of dures in women. Urology 1988;32:529–31. [8] Grasso M, Nord R, Bagley DH. Prone split leg and flank roll Ibarluzea et al. [10]. positioning: simultaneous anterograde and retrograde access to In the present study the success rate for PCNL was the upper urinary tract. J Endourol 1993;7:307–10. high in both groups (84.6% and 84% for group A and [9] Valdivia Uri’a JG, Valle GJ, Lopez Lopez JA, Villarroya B, respectively, P = 0.74). De Sio et al. [6] and Shoma Rodriguez S, Ambroj Navarro C, Ramirez Fabian M, et al. et al. [14] reported a stone-free rate close to 90%, with Technique and complications of percutaneous nephroscopy: experience with 557 patients in the supine position.. J Urol no statistically significant difference between the prone 1998;160:1975–8. and supine positions. Manohar et al. [15] reported a [10] Ibarluzea G, Scoffone CM, Cracco CM, Poggio M, Porpiglia F, stone-free rate of 95% by initial PCNL with or without Terrone C, et al. Supine Valdivia and modified lithotomy ureteroscopy. Neto et al. [13] reported a stone-free rate position for simultaneous anterograde and retrograde endouro- of 70.5% in their series of 88 patients. Thus in the pres- logical access. BJU Int 2007;100:233–6. [11] Desoky EA, Allam MN, Ammar MK, Abdelwahab KM, Elssaid ent study the stone-free rate is similar to those reported AM, Fawzi AM, et al. Flank-free modified supine position: a new by others, and there was no significant difference be- modification for supine percutaneous nephrolithotomy. Arab J tween the groups in patient outcome, complications Urol 2012;10:143–8. and stone-free rate [15,16]. [12] Ng MT, Sun WH, Cheng CW, Chan ES. Supine position is safe Only the operative time was statistically significantly and effective for percutaneous nephrolithotomy. J Endourol 2004;18:469–74. different (P < 0.001). This is in accordance with the 78 Abdel-Mohsen et al. [13] Neto EA, Mitre AI, Gomes CM, Arap MA, Srougi M. Percu- [16] Daels F, Gozales MS, Freire FG, Jurado A, Damia O. Percuta- taneous nephrolithotripsy with the patient in a modified supine neous lithotripsy in Valdivia–Galdakao decubitus position: our position. J Urol 2007;178:165–8. experience. J Endourol 2009;23:1615–20. [14] Shoma AM, Eraky I, El-Kenawy MR, El Kappany HA. [17] Kumar P, Bach C, Kachrillas S, Papatsoris AG, Buchholz N, Percutaneous nephrolithotomy in the supine position. Technical Masood J. Supine percutaneous nephrolithotomy (PCNL): ‘in aspects and functional outcome compared with the prone vogue’ but in which position? BJU Int 2012; [Epub ahead of technique. Urology 2002;60:388–92. print]. [15] Manohar T, Jain P, Desai M. Supine percutaneous nephrolithot- [18] Papatsoris AG, Zaman F, Panah A, Masood J, El-Husseiny T, omy. Effective approach to high-risk and morbidly obese patients. Buchholz N. Simultaneous anterograde and retrograde endouro- J Endourol 2007;21:44–9. logic access: ‘the Barts technique’. J Endourol 2008;22:2665–6. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Arab Journal of Urology Taylor & Francis

Free-flank modified supine vs. prone position in percutaneous nephrolithotomy: A prospective randomised trial

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© 2012 Arab Association of Urology
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Arab Journal of Urology (2013) 11,74–78 Arab Journal of Urology (Official Journal of the Arab Association of Urology) www.sciencedirect.com STONES/ENDOUROLOGY ORIGINAL ARTICLE Free-flank modified supine vs. prone position in percutaneous nephrolithotomy: A prospective randomised trial 1, Essam Abdel-Mohsen, Mostafa Kamel, Abdel-Latif Zayed, Emad A. Salem , Ehab Ebrahim, Khalid Abdel Wahab, Ahmed Elaymen, Ashraf Shaheen, Hussien M. Kamel Department of Urology, Zagazig University, Zagazig, Egypt Received 8 August 2012, Received in revised form 30 October 2012, Accepted 1 November 2012 Available online 8 December 2012 KEYWORDS Abstract Objective: To compare the technical aspects, operative time, safety and effectiveness of percutaneous nephrolithotomy (PCNL) in the free-flank modified Stones; supine position (FFMSP) vs. the standard prone position (SPP). Percutaneous nephro- Patients and methods: Seventy-seven patients (47 men and 30 women) with renal lithotomy; stones were enrolled and systematically randomised into two groups, A (39 patients) Prone; treated using the FFMSP, and B (38 patients) in the SPP. The outcome was consid- Supine; ered as a cure (successful procedure) if the patient became stone-free or had residual Position fragments of <4 mm in diameter. The operative time (from the induction of anaes- thesia to the removal of the endotracheal tube) was measured and any operative ABBREVIATIONS complications or conflicts were recorded. The different variables were compared FFMSP, free-flank and analysed between the groups. modified supine posi- Corresponding author. Address: 42 Mostafa Foad St., Manshiet Abaza, Zagazig, Sharkia, Egypt. Tel.: +20 55 2317595; fax: +20 55 E-mail address: Dr_emadsalem@yahoo.com (E.A. Salem). Mobile: +20 10 1228091. Peer review under responsibility of Arab Association of Urology. Production and hosting by Elsevier 2090-598X ª 2012 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.aju.2012.11.002 Free-flank modified supine vs. prone position in percutaneous nephrolithotomy 75 tion; SPP, standard Results: Patients in both groups had comparable preoperative clinical data and prone position; PCNL, there were no significant differences in the preoperative clinical characteristics. percutaneous nephro- The procedure was successful in 84.6% and 84% of group A and B, respectively. lithotomy; BMI, body The operative time was significantly longer in group B (SPP) than A (FFMSP). mass index There was no significant difference between the groups in fluoroscopy time and patients’ outcome. Conclusions: The FFMSP (with a cushion under the ipsilateral shoulder) has sim- ilar efficacy and safety as the SPP for PCNL and is associated with a significantly quicker operation. ª 2012 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. Introduction confidence of 95%, power of 80%, and odds ratio 4.5, using the data from De Sio et al. [6]. The sample size analysis showed that at least 36 patients were required The treatment of renal stones has changed dramatically for each group; thus 77 patients (47 men and 30 women) over the past few years. In 1981, Alken et al. [1] popular- with renal stones were enrolled and systematically ran- ised percutaneous nephrolithotomy (PCNL), which has domised into two groups (one patient was allocated to a high success rate, and since then PCNL has been one treatment arm and the next to the other, the patients widely accepted. PCNL is usually done with the patient being unaware of the selection). lying prone [2]. Many drawbacks of this position have Group A (FFMSP) included 39 patients and group B been described by several authors [3–6], including a pro- (SPP) included 38. Included were patients with an indica- longed operative time due to positional changes, adverse tion for PCNL and who had no contraindications for an effects on ventilation and blood circulation, especially in operation in the prone position. Excluded were patients obese patients, and exposure of the surgical team to with intrarenal anomalies, uncorrectable bleeding disor- radiation. These difficulties encouraged many urologists ders, a body mass index (BMI) of >40 kg/m , and preg- to try other positions for PCNL [7–10]. The supine posi- nancy. The preoperative evaluation included a thorough tion was popularised in 1998 by Valdivia Uria et al. [9]. medical history, physical examination, laboratory investi- They found that the colon tends to rise away from the gations (urine analysis, urine culture/sensitivity, complete kidney when the patient is supine, which makes the co- blood count, coagulation profile, blood urea nitrogen and lon less likely to be injured. They described many merits serum creatinine) and radiological investigations (plain of the supine position, including ease of patient position- abdominal film, abdominal ultrasonography, IVU and ing, being more comfortable for the patient, a depen- non-contrast spiral CT for radiolucent stones). If the ur- dant Amplatz sheath, and easy control of the airways. ine culture was positive an appropriate antibiotic was pre- The supine position has mechanical limitations. Desoky scribed for 1 week and the urine culture repeated to verify et al. [11] described the free-flank modified supine posi- urinary sterility before the intervention. Informed con- tion (FFMSP) and assumed that this position over- sent was signed by all enrolled patients. comes the mechanical limitation by providing ample space for PCNL. In the present study we compared Operative technique PCNL in both the FFMSP and the standard prone po- sition (SPP) for the technical aspects, safety, stone-free With the patient supine, cystoscopy was performed and rate, operative time, X-ray exposure, complications, a 6 F open-tip ureteric catheter was introduced and fixed and the need for a second PCNL and/or ESWL. with plaster tape to the indwelling Foley catheter. In group A the patients were placed in the FFMSP by putt- Patients and methods ing a suitable cushion (a 3-L water bag, or less according to body mass) under the ipsilateral shoulder, having the This prospective randomised comparative study was ipsilateral arm bent over the thorax, and extending and conducted in the Urology Department of Zagazig Uni- crossing the patient’s ipsilateral leg over the flexed con- versity hospitals, from October 2008 to March 2010. tralateral leg (Fig. 1). This modification increased the An informed consent was obtained from all patients distance between the last rib and iliac crest, and moving who participated. The study design was approved by the cushion from under the flank (as in the original Val- the ethics committee of our hospital. divia position) to under the shoulder provided ample The sample size for the study was calculated using free flank space for the puncture, dilatation and manip- Epi Info 6 version 6.04d software (WHO, Geneva) and ulation of the stone. This manoeuvre also allowed easy a difference in operative time of 25% between the access to the posterior calyx. In group B, the patients groups was considered as clinical equivalence, with a 76 Abdel-Mohsen et al. Table 1 The patients’ demographics and clinical characteris- tics, operative data, outcome and complications. Variable Group A Group B P N patients 39 38 Male/female 24/15 23/15 0.92 Mean (SD) Age (years) 40.8 (10.5) 44.2 (10.4) 0.16 BMI (kg/m ) 28.8 (4.7) 29.2 (3.8) 0.73 History of ipsilateral renal surgery (n) 19 15 0.29 ESWL for renal stone (n) 5 6 0.75 Stone side, R/L (n) 17/22 20/18 0.43 Stone location (n) 0.79 Pelvis 15 12 Calyces 7 10 Both 17 16 Mean (SD) Figure 1 (A, B) A patient in the FFMSP, with a water bag under Stone diameter (cm) 3.4 (0.7) 3.4 (0.8) 0.9 his ipsilateral shoulder and his arm over the thorax. Stone opacity (n) Radio-opaque/radiolucent 29/10 31/7 0.71 were turned prone (SPP) and renal access was achieved Operative data and outcome under fluoroscopic guidance through the posterior axil- Mean (SD) lary line. Fluoroscopy time (min) 6.5 (1.7) 6.5 (2) 0.88 Coaxial dilators of the Alken type were used for tract Operative time (min) 88 (16) 104 (25) 0.001 dilatation. A 30 F Amplatz sheath was positioned, Successful, n (%) 33 (84.6) 32(84) 0.74 allowing the introduction of a 26 F nephroscope. A Second PCNL (n) 4 5 Postoperative ESWL (n) 2 1 pneumatic lithotripsy device was used to fragment the stone. Fragments were retrieved through the Amplatz Complications sheath. At the end of the procedure, an 18–22 F Blood transfusion 1 1 0.67 Urine leakage 1 2 0.98 nephrostomy catheter was inserted. Fever (>38 C) 5 4 0.59 Colonic injury None None Outcome At 2 days after surgery the patients were assessed with ultrasonography, a plain abdominal film and antegrade PCNL was needed in four patients in group A and five pyelography, to evaluate residual fragments and ureteric in group B. After surgery ESWL was applied to two pa- patency. The nephrostomy tube was removed 2–3 days tients in group A and one in group B. The operative time after PCNL. Prophylactic parenteral broad-spectrum was significantly longer in group B than group A antibiotics were continued until all tubes were removed. (P = 0.001). There was no significant difference The patients were considered ‘cured’ (a successful proce- between the groups in fluoroscopy time and patient dure) if they became stone-free or had asymptomatic outcome (Table 1). One patient had a urine leakage residual fragments of <4 mm in diameter. Patients with (>1 week) in group A that necessitated a JJ stent, as residual stones were scheduled for either a second PCNL did two in group B; Table 1 also summarises the postop- (7 days after the initial procedure) or ESWL. The erative complications in both groups. operative time (from the induction of anaesthesia to the removal of endotracheal tube) was measured and Discussion any operative complications or conflicts were recorded. Data were analysed using Student’s t-test to compare For decades endourologists had placed patients prone means, with P < 0.05 considered to indicate a signifi- during PCNL because they tried to avoid colonic injury, cant difference. until Valdivia Uria et al. [9], in their study of 557 pa- tients, popularised PCNL with the patient supine. They Results showed that there was no damage to colon, as it moves away from the kidney when the patient is supine rather Patients in both groups had comparable preoperative than prone. The supine position has several advantages, clinical data and there was no significant difference in i.e. free ventilation and less time needed to turn the pa- clinical characteristics between the groups for patient tient after inducing anaesthesia. Our modification gender, age, BMI, history of previous ipsilateral renal (FFMSP) of the position has the same advantages of surgery, ESWL for ipsilateral renal stones, stone loca- decreasing the operative time and avoiding the mechan- tion, and stone burden (Table 1). The procedure was ical limitations of the supine position. successful for all patients in both groups. A second Free-flank modified supine vs. prone position in percutaneous nephrolithotomy 77 Several authors [6,9,11,12] favour the supine posi- findings of many urologists [6,9,11,12,17], and it reflects tion as far as recommending that it replaces the SPP. the time lost when turning the patient at the beginning Despite these reports, the supine position has not be- and the end of the procedure in group B. This position come popular, which might be attributed to the limited also does not allow simultaneous antegrade and retro- freedom in manipulating the access and the stone with grade endourological access [18]. a 3-L water bag under the flank, as described by Valdi- In conclusion, the FFMSP, with a suitable cushion via Uria et al. [9]. However, we modified the position under the ipsilateral shoulder, has a similar efficacy by putting a suitable cushion (a 3-L water bag or less, and safety to the SPP for PCNL and offers a signifi- according to body mass) under the ipsilateral shoulder cantly quicker operation. Further studies are needed to instead of under the flank, and extending the ipsilateral confirm the anaesthesiological advantages of the leg over the flexed contralateral leg. This modification FMMSP. increases the distance between the last rib and iliac Conflict of interest crest, which together with having no cushion under the flank provides ample space for puncture, dilatation No conflict of interest. and stone manipulation. We became accustomed to doing PCNL using the SPP Source of funding for several years, then started to use the FFMSP over the last few years, and then planned the present randomised comparative study. We accessed the kidney through the None. posterior axillary line, as described by Valdivia Uria References et al. [9]. This is in contrast to Ng et al. [12], who accessed the kidney through the anterior axillary line, and in that [1] Alken P, Hutschenreiter G, Marberger M. Percutaneous stone study the nephrostomy tract was created by radiologists. manipulation. J Urol 1981;125:463–6. In both positions we preferred to access the kidney [2] Segura JW, Patterson DE, LeRoy AJ, May GR, Smith LH. through the posterior calyx, while Valdivia Uria et al. Percutaneous lithotripsy. J Urol 1983;130:1051–4. [3] Clayman RV, Bub P, Haaff E, Drenser S. Prone flexible [9] gained access through the anterior calyx. We assume cystoscopy: an adjunct to percutaneous stone removal. J Urol that the cushion under the flank, as described by Valdivia 1987;137:65–7. Uria et al. [9], makes it technically difficult to access the [4] Kerbl K, Clayman RV, Chandhoke PS, Urban DA, De Leo BC, posterior calyx. Placing the cushion under the shoulder et al. Percutaneous stone removal with the patient in a flank provides ample free space under the flank, so the poster- position. J Urol 1994;151:686–8. [5] Rana AM, Bhojwani JP, Junejo NN, Das Bhagia S. Tubeless ior calyx is accessed easily. Also, we preferred to access PCNL with patient in supine position: procedure for all the kidney through the lower calyx in both the SPP seasons? – with comprehensive technique. Urology and FMMSP because it is safer in terms of thoracic com- 2008;71:581–5. plications, and we could reach the upper calyx easily. [6] De Sio M, Autorino R, Quarto G, Calabro F, Damiano R, Nevertheless, the middle and upper calyces could be ac- Giugliano F, et al. Modified supine versus prone position in percutaneous nephrolithotomy for renal stones treatable with a cessed when necessary. In the series of Neto et al. [13], the single percutaneous access: a prospective randomized trial. Eur upper calyx was accessed in 5.7% of their patients. One Urol 2008;54:196–202. of the disadvantages of the FMMSP is that it does not [7] Lehman T, Bagley DH. Reverse lithotomy, modified prone allow simultaneous retrograde access to the urinary position for simultaneous nephroscopic and ureteroscopic proce- tract, by contrast with the modified supine position of dures in women. Urology 1988;32:529–31. [8] Grasso M, Nord R, Bagley DH. Prone split leg and flank roll Ibarluzea et al. [10]. positioning: simultaneous anterograde and retrograde access to In the present study the success rate for PCNL was the upper urinary tract. J Endourol 1993;7:307–10. high in both groups (84.6% and 84% for group A and [9] Valdivia Uri’a JG, Valle GJ, Lopez Lopez JA, Villarroya B, respectively, P = 0.74). De Sio et al. [6] and Shoma Rodriguez S, Ambroj Navarro C, Ramirez Fabian M, et al. et al. [14] reported a stone-free rate close to 90%, with Technique and complications of percutaneous nephroscopy: experience with 557 patients in the supine position.. J Urol no statistically significant difference between the prone 1998;160:1975–8. and supine positions. Manohar et al. [15] reported a [10] Ibarluzea G, Scoffone CM, Cracco CM, Poggio M, Porpiglia F, stone-free rate of 95% by initial PCNL with or without Terrone C, et al. Supine Valdivia and modified lithotomy ureteroscopy. Neto et al. [13] reported a stone-free rate position for simultaneous anterograde and retrograde endouro- of 70.5% in their series of 88 patients. Thus in the pres- logical access. BJU Int 2007;100:233–6. [11] Desoky EA, Allam MN, Ammar MK, Abdelwahab KM, Elssaid ent study the stone-free rate is similar to those reported AM, Fawzi AM, et al. Flank-free modified supine position: a new by others, and there was no significant difference be- modification for supine percutaneous nephrolithotomy. Arab J tween the groups in patient outcome, complications Urol 2012;10:143–8. and stone-free rate [15,16]. [12] Ng MT, Sun WH, Cheng CW, Chan ES. Supine position is safe Only the operative time was statistically significantly and effective for percutaneous nephrolithotomy. J Endourol 2004;18:469–74. different (P < 0.001). This is in accordance with the 78 Abdel-Mohsen et al. [13] Neto EA, Mitre AI, Gomes CM, Arap MA, Srougi M. Percu- [16] Daels F, Gozales MS, Freire FG, Jurado A, Damia O. Percuta- taneous nephrolithotripsy with the patient in a modified supine neous lithotripsy in Valdivia–Galdakao decubitus position: our position. J Urol 2007;178:165–8. experience. J Endourol 2009;23:1615–20. [14] Shoma AM, Eraky I, El-Kenawy MR, El Kappany HA. [17] Kumar P, Bach C, Kachrillas S, Papatsoris AG, Buchholz N, Percutaneous nephrolithotomy in the supine position. Technical Masood J. Supine percutaneous nephrolithotomy (PCNL): ‘in aspects and functional outcome compared with the prone vogue’ but in which position? BJU Int 2012; [Epub ahead of technique. Urology 2002;60:388–92. print]. [15] Manohar T, Jain P, Desai M. Supine percutaneous nephrolithot- [18] Papatsoris AG, Zaman F, Panah A, Masood J, El-Husseiny T, omy. Effective approach to high-risk and morbidly obese patients. Buchholz N. Simultaneous anterograde and retrograde endouro- J Endourol 2007;21:44–9. logic access: ‘the Barts technique’. J Endourol 2008;22:2665–6.

Journal

Arab Journal of Urology – Taylor & Francis

Published: Mar 1, 2013

Keywords: Stones; Percutaneous nephrolithotomy; Prone; Supine; Position; FFMSP, free-flank modified supine position; SPP, standard prone position; PCNL, percutaneous nephrolithotomy; BMI, body mass index

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