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Percutaneous nephrolithotomy in the supine position: Safety and outcomes in a single-centre experience

Percutaneous nephrolithotomy in the supine position: Safety and outcomes in a single-centre... Arab Journal of Urology (2013) 11,62–67 Arab Journal of Urology (Official Journal of the Arab Association of Urology) www.sciencedirect.com STONES/ENDOUROLOGY ORIGINAL ARTICLE Percutaneous nephrolithotomy in the supine position: Safety and outcomes in a single-centre experience Hani H. Nour , Ahmed M. Kamal, Samir E. Ghobashi, Ahmed S. Zayed, Mamdouh M. Rushdy, Ahmed G. El-Baz, Ahmed I. Kamel, Tarek El-Leithy Urology Department, Theodor Bilharz Research Institute, Giza, Egypt Received 2 November 2012, Received in revised form 8 December 2012, Accepted 9 December 2012 Available online 4 February 2013 KEYWORDS Abstract Objectives: To assess the feasibility of performing percutaneous nephro- lithotomy (PCNL) with the patient supine. Although PCNL with the patient prone is Percutaneous nephro- the standard technique for treating large (>2 cm) renal stones including staghorn lithotomy; stones, we evaluated the safety and efficacy of supine PCNL for managing large Supine; renal stones, with special attention to evaluating the complications. Renal stones; Patients and method: In a prospective study between January 2010 and December Outcome 2011, 54 patients with large and staghorn renal stones underwent cystoscopy with a ureteric catheter inserted, followed by puncture of the collecting system while they ABBREVIATIONS were supine. Tract dilatation to 30 F was followed by nephroscopy, stone disintegra- PCNL, percutaneous tion using pneumatic lithotripsy, and retrieval using a stone forceps. All patients had nephrolithotomy; a nephrostomy tube placed at the end of the procedure. The results were compared PCN, percutaneous with those from recent large series of supine PCNL. nephrostomy; Results: The median (range) operative duration was 130 (90–210) min, and the BMI, body mass index mean (SD) volume of irrigant was 22.2 (3.7) L. One puncture was used to enter the collecting system in 51 renal units (94%), while three units (6%) with a staghorn Abbreviations PCNL, percutaneous nephrolithotomy; PCN, percutaneous nephrostomy; BMI, body mass index Corresponding author. Address: Theodor Bilharz Research Insti- tute, Cornishe Elnile, El-Warak, Giza, Egypt. Tel.: +20 1111000 191. E-mail address: hani_nour@hotmail.com (H.H. Nour). Peer review under responsibility of Arab Association of Urology. Production and hosting by Elsevier 2090-598X ª 2013 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.aju.2012.12.007 Percutaneous nephrolithotomy in the supine position: Safety and outcomes 63 stone needed two punctures. The stone clearance rate was 91%, and five patients had an auxiliary procedure. There were complications in 15 patients (28%). All patients were stone-free at a 3-month follow-up. Conclusion: Supine PCNL is technically feasible; it has several advantages to patients, urologists and anaesthesiologists. It gives stone-free rates and a low inci- dence of organ injury comparable to those in standard prone PCNL. ª 2013 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. Introduction Patients and method The first documented percutaneous nephrostomy (PCN) At our centre, between January 2010 and December 2011, was by Thomas Hillier in 1865, but it was not until 1955 supine PCNL was used in 54 patients (median age when Goodwin et al. [1] reported their work on PCN for 39 years, range 19–62; 31 men and 23 women) with a med- the drainage of suppuration and urine in a hydrone- ian (range) body mass index (BMI) of 30 (17–42) kg/m . phrotic kidney that PCN gained widespread acceptance. The preoperative evaluation included history, clinical In 1976 Ferstrom and Johansson [2] reported the first examination and routine laboratory investigations. All percutaneous procedure for stone removal and since patients had IVU or noncontrast-enhanced spiral CT then percutaneous nephrolithotomy (PCNL) has been of the urinary tract to evaluate the stone location, bur- shown to be effective and safe for treating large renal den and radiolucency. The stone burden was determined stones (>2 cm), including staghorn stones. by measuring the longest diameter on the preoperative PCNL is usually done with the patient prone, as it radiological investigations; if there were multiple calculi is believed that for puncturing and dilatation of the the burden was defined as the sum of the longest diam- kidney, which is a retroperitoneal organ, the posterior eter of each stone. approach provides a large working space with a lower A preoperative sterile urine culture was mandatory incidence of splanchnic and vascular injury. However, and patients with a positive culture were treated for even in this position, major complications, including 48 h before PCNL, and the treatment continued for 7 haemorrhage and organ injury, have been reported days afterwards. A third-generation cephalosporin was in 0.9–4.7% of cases [3,4]. The prone position is asso- given as prophylaxis to patients with a sterile culture ciated with patient discomfort, a compromised circula- at the time of surgery, and was continued for 48 h after- tion and ventilation, especially in obese patients, and wards. Staghorn stones included in the study were either it is also time-consuming and increases the radiologi- one stone with branches from the renal pelvis into all cal hazards to the urologist [4]. major calyces, or a pelvic stone with multiple stones in Various modifications of patient positioning for at least two major calyceal groups. The median stone PCNL were tried as urologists understood more of size was 20 mm, 12 patients had a staghorn stone, 10 the surface anatomy of the kidney and related viscera. had a pelvic stone, and 32 had multiple stones, with a These included the reverse lithotomy [5], supine [6] mean stone burden of 29.7 mm (Table 1). and lateral decubitus [7] positions. These options were The procedure began with the patient in the lithot- shown to be safe and effective compared with the con- omy position, with insertion of an open-tip 7–8 F ure- ventional prone PCNL, yet were never popular. The teric catheter, using a 22 F cystoscope. The operative complete supine PCNL is a tempting substitute for duration was calculated from the time of ureteric cathe- prone PCNL, with the potential advantages of less pa- ter insertion until the nephrostomy tube was secured to tient handling, a quicker operation, better drainage the skin. through the Amplatz sheath, and the ability to per- After inserting the ureteric catheter, the patient was form simultaneous PCNL and ureteroscopic proce- placed supine with the ipsilateral arm secured to the dures [6–8]. Although severe complications of chest, and a 3-L fluid bag under the flank. Under fluoro- anaesthesia are infrequently reported with the patient scopic guidance an 18 G needle was used to puncture the prone, the supine position is more comfortable for collecting system. Unlike in the prone position, the nee- the anaesthetist, especially in obese patients at high- dle must remain almost horizontal or slightly inclined risk during anaesthesia [6]. upward towards the operating table. We marked the Thus we assessed supine PCNL to evaluate its safety puncture site, which lies at the level of the posterior ax- and efficacy in managing large renal stones, with special illary line under the level of the 12th rib, targeting the attention to evaluating the complications. lower posterior calyces (Figs. 1 and 2). 64 Nour et al. The increased mobility of the kidney, due to the ab- Table 1 The perioperative variables of the 54 patients. sence of support when supine, caused the guidewire to Variable Value buckle, hindering tract dilatation. This was managed Age (years) by an assistant supporting the patient’s abdomen, push- Median (range) 39 (19–62) ing it backward during dilatation. After tract dilatation Mean (SD) 38.8 (14) we used a 27 F nephroscope with a ballistic energy Sex, M/F (n) 31/23 source for stone disintegration. Stone site, R/L (n) 28/26 The volume of irrigant used and the duration of fluo- Stone location (n) roscopic exposure were recorded at the end of the proce- Pelvis 10 dure. Haemodynamic changes and any need for Pelvis + calyceal 32 transfusion were evaluated and recorded during the first Staghorn 12 24 h after surgery. BMI, kg/m A radiological examination was used to assess stone Median (range) 30 (17–42) clearance on the first day after surgery, with either a Mean (SD) 30.2 (6.9) plain film of the abdomen or CT of the urinary tract. Stone burden (mm) Perioperative complications were classified according Median (range) 30 (10–55) to the modified Clavien grading system [9]: Grade 1, Mean (SD) 29.9 (10.9) Stone radiolucency (n) any deviation from the normal postoperative course Radio-opaque 37 but with no need for pharmacological, surgical, endo- Radiolucent 11 scopic, or radiological intervention; Grade 2, complica- Mixed 6 tions requiring pharmacological treatments or blood transfusions; Grade 3, complications requiring surgical, endoscopic, or radiological intervention with no (grade 3a) or with (grade 3b) general anaesthesia; Grade 4, life-threatening complications requiring a stay in an intensive care unit (grade 4a, single organ; grade 4b, multi-organ dysfunction); Grade 5, death. Results The median operative duration was 130 min, and the median duration of X-ray exposure was 10 min. The mean (SD) volume of irrigant fluid was 22.2 (3.7) L. Figure 1 The patient position. One puncture was used to enter the collecting system in 51 renal units (94%), while three renal units (6%) with a staghorn stone needed two punctures. We used a stone size of <5 mm as the protocol for there being no need for further treatment. Of the 54 re- nal units treated, 49 had no or <5 mm residual frag- ments, resulting in a stone-free (success) rate of 91%. Of the five renal units with residual stones, two were treated by a second supine PCNL through the already present nephrostomy tract, and these were rendered stone-free. One patient with a prolonged urine leak had his ureteric catheter changed for a double pigtail stent and had ESWL 2 weeks after discharge. The other two patients had ESWL with no stent for a calyceal Figure 2 The puncture site. residual stone. All patients were stone-free at a 3-month follow-up. Any reduction in haemoglobin level, and the vital A 0.9 mm (0.038 inch) guidewire was inserted, fol- signs, were recorded; the mean (SD) reduction in hae- lowed by dilatation of the tract using PTFE dilators moglobin level was 1 (1.15) g/dL, with two patients up to 12 F; this was followed by inserting a second requiring a transfusion. In our practice we remove the (safety) guidewire. The tract was dilated up to 30 F nephrostomy tube 2 days after surgery, and in the ab- using metallic telescopic dilators (Alkan’s dilators), fol- sence of a urine leak and/or fever, we remove the ure- lowed by the insertion of a 30 F Amplatz sheath. teric catheter 24 h afterwards. Percutaneous nephrolithotomy in the supine position: Safety and outcomes 65 removed; the median (range) hospital stay was 5 (3–8) Table 2 Outcomes of the procedure. days. Patients were scheduled for a follow-up at 1 month Variable Value and were assessed by urine culture, together with a plain Operative duration (min) abdominal film and/or CT of the urinary tract before the Median (range) 130 (90–210) follow-up visit (Table 2). Mean (SD) 134.9 (29.3) X-ray exposure (min) Median (range) 10 (4–19) Discussion Mean (SD) 10.5 (4.7) Access, n (%) PCNL is widely accepted as the treatment of choice for Single 51 (94) large renal stones, including staghorn stones. It is less Multiple 3 (6) invasive, effective, safer and has a lower complication Irrigant fluid (L) rate than open renal surgery [10]. PCNL is usually done Median (range) 21 (18–33) with the patient prone, which carries several disadvan- Mean (SD) 22.2 (3.6) Stone clearance, n (%) 49 (91) tages to the patient, anaesthesiologist and urologist. In 1987, Valdivia et al. [11] reported the first study on Auxiliary procedure, n (%) 5 (9) the feasibility of PCNL in the supine patient, but it was 2nd PCNL 2 (3.5) JJ insertion + ESWL 1 (2) 1998 before the same authors reported their 10-year ESWL 2 (3.5) experience of PCNL with the patient supine [6], and that Complications, n (%) this technique was then reintroduced. The results were Grade 1 2 (4) similarly good in several other reports [12–14], confirm- Grade 2 10 (19) ing the efficacy and safety of supine PCNL for treating Grade 3 3 (5) most renal stones. Total 15 (28) The supine position offers several advantages. Gen- Transfusion rate 2 (3.7) eral anaesthesia is less hazardous, no repositioning of Organ injury 0 the patient is needed, it is more comfortable for the sur- Hospital stay (days) geon, who can work while seated. The X-ray exposure to Median (range) 5 (3–8) the surgeon during the entire procedure is decreased be- Mean (SD) 4.6 (1) cause the surgeon’s hands are no longer in the fluoro- scopic field and stone fragments are cleared easily. There were complications in 15 patients (28%); two In the present study PCNL was used in 54 patients; had a persistent urine leak for >24 h after nephrostomy the median (range) and the mean (SD) BMI were 30 removal (4%, grade 1) and they were managed conser- (17–42) and 30.2 (6.9) kg/m , respectively, denoting that vatively. Ten patients (19%) had grade 2 complications, most patients included in the study were overweight. with eight having a fever of >38 C, who responded to The median (range) operative duration, including the antibiotics and antipyretics, and two had bleeding neces- time of ureteric catheter insertion, was 130 (90–210) sitating a blood transfusion (transfusion rate 3.7%). min. Mean operative times of 85 and 98 min were re- Three patients needed an auxiliary endoscopic proce- ported by Valdivia et al. [6] and Falahatkar et al. [14], dure under anaesthesia (5% grade 3). There was no case respectively (Table 3) [12]. Hoznek et al. [12] reported of organ injury or fistula (urinary or vascular). a mean (range) operative duration of 123 (50–245) min. If there were no complications the patients were dis- Puncturing the upper calyces with the patient supine is charged on the same day that the urinary catheter was almost impossible, but staghorn stones were amenable to Table 3 Evaluation of outcome in a series of supine PCNL for large stones. Variable Study [12] [15] [14] [6] [16] Renal units 47 53 117 557 39 Mean (range) stone 29 (10–75) NA 36 (10–80) NA 34 (25–51) Burden (mm) Staghorn stones, n (%) 7 (14) 3 (5.6) 11 (9) NA 0 Mean (range) operative 123.5 (50–245) NA 98 (20–180) 85(15–240) (25–120) Duration (min) Stone-free rate, n (%) 38 (81) 47 (89) 91 (77.5) NA 34 (88.7) Transfusion rate, n (%) 1 (2) 5 (9) 17 (14) 8 (1.4) 0 Organ injury, n (%) 0 0 0 0 0 Hospital stay (days) 3.4 (2–12) 2.5 3.2 (1–7) NA 4.3 (2.2–8.4) NA, not available. 66 Nour et al. treatment during supine PCNL. The present study in- infundibulum. There was anteromedial renal displace- cluded 12 patients with staghorn stones (22%) for whom ment during tract dilatation, rendering the procedure the median (range) stone burden was 30 (10–55) mm. Se- more difficult, and this was managed by supporting ven patients (14%) with a staghorn stone were included the kidney while creating the tract. in the study of Hoznek et al. [12]. Falahatkar et al. [14] in- Twelve of the present patients had staghorn stones, cluded 11 patients (9%) with a staghorn stone in their although their stone burden was relatively low; all but study (Table 3). one had no significant residual fragments, three needed The stones were cleared in 49 (91%) of the present multiple renal punctures, which were made easily. We patients; this was a better rate than reported by Hoznek think that these results indicate the feasibility of using et al. [12] and Falahatkar et al. [14], who achieved a supine PCNL for staghorn stones in properly selected stone clearance rate of 81% and 77.5%, respectively. patients. This might be because the stone burden in the present In a recent review of the development of PCNL posi- study was less than in the other two. Shoma et al. [15] tions in the last 35 years [19], evaluating their safety, found a stone clearance rate of 89% in their study that advantages and limitations, the authors concluded that included 53 patients. A similar result was given by De there was no perfect position for PCNL, and that ‘Urol- Sio et al. [16], who reported a stone clearance rate of ogists who perform PCNL should be familiar with the dif- 88.7% in their study of 39 renal units. ferences in the positions and be able to use the method There were complications in 15 of the present patients appropriate for each patient’. (28%), graded according to the Clavien system, but The present study has several limitations; it included most of the complications were of grade I and II a relatively small sample, and although it included pa- (23%). There was bleeding requiring a transfusion in tients with staghorn stones, the stone burden was rela- only two patients. There had been concerns that the su- tively low. This was a descriptive study lacking a pine approach might put the colon at higher risk of in- comparative arm and was not randomised. jury than the prone approach, but we think that In conclusion, supine PCNL is technically feasible, colonic injuries are potentially less frequent due to the has several potential advantages, especially in patients more anterior displacement of the colon when the pa- at high risk when under anaesthesia, and can be used tient is supine, as described by Hopper et al. [17].In to treat all stone sizes. There is no apparent added risk the present series there were no colon injuries. in using this technique, and the stone clearance and Several modifications of supine PCNL were tried, complication rates are within the accepted values cited reproduced and evaluated [18], and all of them decrease previously for the standard prone PCNL. the operative duration and X-ray exposure compared Conflict of interest with the classic prone PCNL. They also allow a quick access to the airway in case of emergencies. However, No conflict of interest to declare. they vary in the ease of puncture, tract dilatation, ability to make multiple tracts and the ability to combine simul- Funding taneous ureteroscopy. In a meta-analysis of the supine vs. the prone PCNL Nothing to disclose. [13], the incidence of colon injury in the prone position was estimated to be 0.2–0.5%. In that analysis only References one colonic injury occurred during a supine PCNL. The rate of colonic injury in supine PCNL from com- [1] Goodwin WE, Casey WC, Woolfe W. Percutaneous trocar (needle) nephrostomy in hydronephrosis. JAMA 1955;157:891. parative studies was 0.5%, similar to the rate in previ- [2] Ferstrom I, Johansson B. Percutaneous pyelolithotomy: a new ous reports of prone PCNL. Supine PCNL does not extraction technique. Scand J Urol Nephrol 1976;10:257–9. increase the risk of colonic injury, which remains a rela- [3] Kim SC, Kuo RL, Lingeman JE. Percutaneous nephrolithotomy: tively rare complication. an update. Curr Opin Urol 2003;13:235–41. PCNL with the patient supine has some limitations. [4] Michel MS, Trojan L, Rassweiler JJ. Complications in percuta- neous nephrolithotomy. Eur Urol 2007;51:899–906. It decreases the filling of the collecting system, making [5] Lehman T, Bagley DH. Reverse lithotomy. Modified prone it constantly collapsed, and thus nephroscopy tends to position for simultaneous nephroscopic and ureteroscopic proce- be more difficult. However, maintaining low pressures dures in women. Urology 1998;32:529–31. within the renal cavities might be important to decrease [6] Valdivia JG, Valle J, Lopez JA, Rodriguez SV, Navarro CM, fluid absorption. Upper-pole calyceal puncture is impos- Fabian MR, et al. Technique and complications of percutaneous nephroscopy: experience with 557 patients in the supine position. sible because the upper pole lies more medial and poster- J Urol 1998;160:1975–8. ior, and is concealed deeply in the rib cage. Also, renal [7] Gofrit ON, Shapiro A, Donchin Y, Bloom AI, Shenfeld OZ, puncture in the supine position requires that the nee- Landau EH, et al. Lateral decubitus position for percutaneous dle-pass lies horizontally, which in an upper calyceal nephrolithotripsy in the morbidly obese or kyphotic patient. J puncture will strike into the calyceal neck, and not the Endourol 2002;16:383–6. Percutaneous nephrolithotomy in the supine position: Safety and outcomes 67 [8] Papatsoris A, Masood J, El-Husseiny T, Maan Z, Saunders P, [14] Falahatkar S, Farzan A, Allahkhah A. Is complete supine Buchholz NP, et al. Improving patient positioning to reduce percutaneous nephrolithotripsy feasible in all patients? Urol Res complications in prone percutaneous nephrolithotomy. J Endo- 2011;39:99–104. urol 2009;23:831–2. [15] Shoma AM, Eraky I, El-Kenawy MR, El-Kappany HA. Percu- [9] Tefekli A, Ali Karadag M, Tepeler K, Sari E, Berberoglu Y, taneous nephrolithotomy in the supine position. Technical aspects Baykal M, et al. Classification of percutaneous nephrolithotomy and functional outcome compared with the prone technique. complications using the modified Clavien grading system: looking Urology 2002;60:388–92. for a standard. Eur Urol 2008;53:184–90. [16] De Sio M, Autorino R, Quarto G, Calabro` F, Damiano R, [10] Preminger GM, Assimos DG, Lingeman JE, Nakada SY, Pearle Giugliano F, et al. Modified supine versus prone position in JS, Wolf Jr JS, et al. AUA guideline on management of stag horn percutaneous nephrolithotomy for renal stones treatable with a calculi: diagnosis and treatment recommendations. J Urol single percutaneous access: a prospective randomized trial. Eur 2005;173:1991. Urol 2008;54:196–202. [11] Valdivia Urı´a JG, Lachares Santamarı´a E, Villarroya Rodrı´guez [17] Hopper KD, Sherman JL, Luethke JM, Ghaed N. The retrorenal J, Taberner Llop J, Abril Baquero G, Aranda Lassa JM, et al. colon in the supine and prone patient. Radiology 1987;162:443–6. Percutaneous nephrolithectomy: simplified technique (preliminary [18] Kumar P, Bach C, Kachrillas S, Papatsoris AG, Buchholz N, report). Arch Esp Urol 1987;40:177–80. Masood J. Supine percutaneous nephrolithotomy (PCNL): ‘in [12] Hoznek A, Rode J, Ouzaid I, Faraj B, Kimuli M, de la Taille A, vogue’ but in which position? BJU Int; 2012 May 7 [Epub ahead et al. Modified supine percutaneous nephrolithotomy for large of print]. kidney and ureteral stones. Technique and results. Eur Urol [19] Karaolides T, Moraitis K, Bach C, Masood J, Buchholz N. 2012;61:164–70. Positions for percutaneous nephrolithotomy. Thirty-five years of [13] Wu P, Wang L, Wang K. Supine versus prone position in evolution. Arab J Urol 2012;10:307–16. percutaneous nephrolithotomy for kidney calculi: a meta-analysis. Int Urol Nephrol 2011;43:67–77. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Arab Journal of Urology Taylor & Francis

Percutaneous nephrolithotomy in the supine position: Safety and outcomes in a single-centre experience

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Arab Journal of Urology (2013) 11,62–67 Arab Journal of Urology (Official Journal of the Arab Association of Urology) www.sciencedirect.com STONES/ENDOUROLOGY ORIGINAL ARTICLE Percutaneous nephrolithotomy in the supine position: Safety and outcomes in a single-centre experience Hani H. Nour , Ahmed M. Kamal, Samir E. Ghobashi, Ahmed S. Zayed, Mamdouh M. Rushdy, Ahmed G. El-Baz, Ahmed I. Kamel, Tarek El-Leithy Urology Department, Theodor Bilharz Research Institute, Giza, Egypt Received 2 November 2012, Received in revised form 8 December 2012, Accepted 9 December 2012 Available online 4 February 2013 KEYWORDS Abstract Objectives: To assess the feasibility of performing percutaneous nephro- lithotomy (PCNL) with the patient supine. Although PCNL with the patient prone is Percutaneous nephro- the standard technique for treating large (>2 cm) renal stones including staghorn lithotomy; stones, we evaluated the safety and efficacy of supine PCNL for managing large Supine; renal stones, with special attention to evaluating the complications. Renal stones; Patients and method: In a prospective study between January 2010 and December Outcome 2011, 54 patients with large and staghorn renal stones underwent cystoscopy with a ureteric catheter inserted, followed by puncture of the collecting system while they ABBREVIATIONS were supine. Tract dilatation to 30 F was followed by nephroscopy, stone disintegra- PCNL, percutaneous tion using pneumatic lithotripsy, and retrieval using a stone forceps. All patients had nephrolithotomy; a nephrostomy tube placed at the end of the procedure. The results were compared PCN, percutaneous with those from recent large series of supine PCNL. nephrostomy; Results: The median (range) operative duration was 130 (90–210) min, and the BMI, body mass index mean (SD) volume of irrigant was 22.2 (3.7) L. One puncture was used to enter the collecting system in 51 renal units (94%), while three units (6%) with a staghorn Abbreviations PCNL, percutaneous nephrolithotomy; PCN, percutaneous nephrostomy; BMI, body mass index Corresponding author. Address: Theodor Bilharz Research Insti- tute, Cornishe Elnile, El-Warak, Giza, Egypt. Tel.: +20 1111000 191. E-mail address: hani_nour@hotmail.com (H.H. Nour). Peer review under responsibility of Arab Association of Urology. Production and hosting by Elsevier 2090-598X ª 2013 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.aju.2012.12.007 Percutaneous nephrolithotomy in the supine position: Safety and outcomes 63 stone needed two punctures. The stone clearance rate was 91%, and five patients had an auxiliary procedure. There were complications in 15 patients (28%). All patients were stone-free at a 3-month follow-up. Conclusion: Supine PCNL is technically feasible; it has several advantages to patients, urologists and anaesthesiologists. It gives stone-free rates and a low inci- dence of organ injury comparable to those in standard prone PCNL. ª 2013 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. Introduction Patients and method The first documented percutaneous nephrostomy (PCN) At our centre, between January 2010 and December 2011, was by Thomas Hillier in 1865, but it was not until 1955 supine PCNL was used in 54 patients (median age when Goodwin et al. [1] reported their work on PCN for 39 years, range 19–62; 31 men and 23 women) with a med- the drainage of suppuration and urine in a hydrone- ian (range) body mass index (BMI) of 30 (17–42) kg/m . phrotic kidney that PCN gained widespread acceptance. The preoperative evaluation included history, clinical In 1976 Ferstrom and Johansson [2] reported the first examination and routine laboratory investigations. All percutaneous procedure for stone removal and since patients had IVU or noncontrast-enhanced spiral CT then percutaneous nephrolithotomy (PCNL) has been of the urinary tract to evaluate the stone location, bur- shown to be effective and safe for treating large renal den and radiolucency. The stone burden was determined stones (>2 cm), including staghorn stones. by measuring the longest diameter on the preoperative PCNL is usually done with the patient prone, as it radiological investigations; if there were multiple calculi is believed that for puncturing and dilatation of the the burden was defined as the sum of the longest diam- kidney, which is a retroperitoneal organ, the posterior eter of each stone. approach provides a large working space with a lower A preoperative sterile urine culture was mandatory incidence of splanchnic and vascular injury. However, and patients with a positive culture were treated for even in this position, major complications, including 48 h before PCNL, and the treatment continued for 7 haemorrhage and organ injury, have been reported days afterwards. A third-generation cephalosporin was in 0.9–4.7% of cases [3,4]. The prone position is asso- given as prophylaxis to patients with a sterile culture ciated with patient discomfort, a compromised circula- at the time of surgery, and was continued for 48 h after- tion and ventilation, especially in obese patients, and wards. Staghorn stones included in the study were either it is also time-consuming and increases the radiologi- one stone with branches from the renal pelvis into all cal hazards to the urologist [4]. major calyces, or a pelvic stone with multiple stones in Various modifications of patient positioning for at least two major calyceal groups. The median stone PCNL were tried as urologists understood more of size was 20 mm, 12 patients had a staghorn stone, 10 the surface anatomy of the kidney and related viscera. had a pelvic stone, and 32 had multiple stones, with a These included the reverse lithotomy [5], supine [6] mean stone burden of 29.7 mm (Table 1). and lateral decubitus [7] positions. These options were The procedure began with the patient in the lithot- shown to be safe and effective compared with the con- omy position, with insertion of an open-tip 7–8 F ure- ventional prone PCNL, yet were never popular. The teric catheter, using a 22 F cystoscope. The operative complete supine PCNL is a tempting substitute for duration was calculated from the time of ureteric cathe- prone PCNL, with the potential advantages of less pa- ter insertion until the nephrostomy tube was secured to tient handling, a quicker operation, better drainage the skin. through the Amplatz sheath, and the ability to per- After inserting the ureteric catheter, the patient was form simultaneous PCNL and ureteroscopic proce- placed supine with the ipsilateral arm secured to the dures [6–8]. Although severe complications of chest, and a 3-L fluid bag under the flank. Under fluoro- anaesthesia are infrequently reported with the patient scopic guidance an 18 G needle was used to puncture the prone, the supine position is more comfortable for collecting system. Unlike in the prone position, the nee- the anaesthetist, especially in obese patients at high- dle must remain almost horizontal or slightly inclined risk during anaesthesia [6]. upward towards the operating table. We marked the Thus we assessed supine PCNL to evaluate its safety puncture site, which lies at the level of the posterior ax- and efficacy in managing large renal stones, with special illary line under the level of the 12th rib, targeting the attention to evaluating the complications. lower posterior calyces (Figs. 1 and 2). 64 Nour et al. The increased mobility of the kidney, due to the ab- Table 1 The perioperative variables of the 54 patients. sence of support when supine, caused the guidewire to Variable Value buckle, hindering tract dilatation. This was managed Age (years) by an assistant supporting the patient’s abdomen, push- Median (range) 39 (19–62) ing it backward during dilatation. After tract dilatation Mean (SD) 38.8 (14) we used a 27 F nephroscope with a ballistic energy Sex, M/F (n) 31/23 source for stone disintegration. Stone site, R/L (n) 28/26 The volume of irrigant used and the duration of fluo- Stone location (n) roscopic exposure were recorded at the end of the proce- Pelvis 10 dure. Haemodynamic changes and any need for Pelvis + calyceal 32 transfusion were evaluated and recorded during the first Staghorn 12 24 h after surgery. BMI, kg/m A radiological examination was used to assess stone Median (range) 30 (17–42) clearance on the first day after surgery, with either a Mean (SD) 30.2 (6.9) plain film of the abdomen or CT of the urinary tract. Stone burden (mm) Perioperative complications were classified according Median (range) 30 (10–55) to the modified Clavien grading system [9]: Grade 1, Mean (SD) 29.9 (10.9) Stone radiolucency (n) any deviation from the normal postoperative course Radio-opaque 37 but with no need for pharmacological, surgical, endo- Radiolucent 11 scopic, or radiological intervention; Grade 2, complica- Mixed 6 tions requiring pharmacological treatments or blood transfusions; Grade 3, complications requiring surgical, endoscopic, or radiological intervention with no (grade 3a) or with (grade 3b) general anaesthesia; Grade 4, life-threatening complications requiring a stay in an intensive care unit (grade 4a, single organ; grade 4b, multi-organ dysfunction); Grade 5, death. Results The median operative duration was 130 min, and the median duration of X-ray exposure was 10 min. The mean (SD) volume of irrigant fluid was 22.2 (3.7) L. Figure 1 The patient position. One puncture was used to enter the collecting system in 51 renal units (94%), while three renal units (6%) with a staghorn stone needed two punctures. We used a stone size of <5 mm as the protocol for there being no need for further treatment. Of the 54 re- nal units treated, 49 had no or <5 mm residual frag- ments, resulting in a stone-free (success) rate of 91%. Of the five renal units with residual stones, two were treated by a second supine PCNL through the already present nephrostomy tract, and these were rendered stone-free. One patient with a prolonged urine leak had his ureteric catheter changed for a double pigtail stent and had ESWL 2 weeks after discharge. The other two patients had ESWL with no stent for a calyceal Figure 2 The puncture site. residual stone. All patients were stone-free at a 3-month follow-up. Any reduction in haemoglobin level, and the vital A 0.9 mm (0.038 inch) guidewire was inserted, fol- signs, were recorded; the mean (SD) reduction in hae- lowed by dilatation of the tract using PTFE dilators moglobin level was 1 (1.15) g/dL, with two patients up to 12 F; this was followed by inserting a second requiring a transfusion. In our practice we remove the (safety) guidewire. The tract was dilated up to 30 F nephrostomy tube 2 days after surgery, and in the ab- using metallic telescopic dilators (Alkan’s dilators), fol- sence of a urine leak and/or fever, we remove the ure- lowed by the insertion of a 30 F Amplatz sheath. teric catheter 24 h afterwards. Percutaneous nephrolithotomy in the supine position: Safety and outcomes 65 removed; the median (range) hospital stay was 5 (3–8) Table 2 Outcomes of the procedure. days. Patients were scheduled for a follow-up at 1 month Variable Value and were assessed by urine culture, together with a plain Operative duration (min) abdominal film and/or CT of the urinary tract before the Median (range) 130 (90–210) follow-up visit (Table 2). Mean (SD) 134.9 (29.3) X-ray exposure (min) Median (range) 10 (4–19) Discussion Mean (SD) 10.5 (4.7) Access, n (%) PCNL is widely accepted as the treatment of choice for Single 51 (94) large renal stones, including staghorn stones. It is less Multiple 3 (6) invasive, effective, safer and has a lower complication Irrigant fluid (L) rate than open renal surgery [10]. PCNL is usually done Median (range) 21 (18–33) with the patient prone, which carries several disadvan- Mean (SD) 22.2 (3.6) Stone clearance, n (%) 49 (91) tages to the patient, anaesthesiologist and urologist. In 1987, Valdivia et al. [11] reported the first study on Auxiliary procedure, n (%) 5 (9) the feasibility of PCNL in the supine patient, but it was 2nd PCNL 2 (3.5) JJ insertion + ESWL 1 (2) 1998 before the same authors reported their 10-year ESWL 2 (3.5) experience of PCNL with the patient supine [6], and that Complications, n (%) this technique was then reintroduced. The results were Grade 1 2 (4) similarly good in several other reports [12–14], confirm- Grade 2 10 (19) ing the efficacy and safety of supine PCNL for treating Grade 3 3 (5) most renal stones. Total 15 (28) The supine position offers several advantages. Gen- Transfusion rate 2 (3.7) eral anaesthesia is less hazardous, no repositioning of Organ injury 0 the patient is needed, it is more comfortable for the sur- Hospital stay (days) geon, who can work while seated. The X-ray exposure to Median (range) 5 (3–8) the surgeon during the entire procedure is decreased be- Mean (SD) 4.6 (1) cause the surgeon’s hands are no longer in the fluoro- scopic field and stone fragments are cleared easily. There were complications in 15 patients (28%); two In the present study PCNL was used in 54 patients; had a persistent urine leak for >24 h after nephrostomy the median (range) and the mean (SD) BMI were 30 removal (4%, grade 1) and they were managed conser- (17–42) and 30.2 (6.9) kg/m , respectively, denoting that vatively. Ten patients (19%) had grade 2 complications, most patients included in the study were overweight. with eight having a fever of >38 C, who responded to The median (range) operative duration, including the antibiotics and antipyretics, and two had bleeding neces- time of ureteric catheter insertion, was 130 (90–210) sitating a blood transfusion (transfusion rate 3.7%). min. Mean operative times of 85 and 98 min were re- Three patients needed an auxiliary endoscopic proce- ported by Valdivia et al. [6] and Falahatkar et al. [14], dure under anaesthesia (5% grade 3). There was no case respectively (Table 3) [12]. Hoznek et al. [12] reported of organ injury or fistula (urinary or vascular). a mean (range) operative duration of 123 (50–245) min. If there were no complications the patients were dis- Puncturing the upper calyces with the patient supine is charged on the same day that the urinary catheter was almost impossible, but staghorn stones were amenable to Table 3 Evaluation of outcome in a series of supine PCNL for large stones. Variable Study [12] [15] [14] [6] [16] Renal units 47 53 117 557 39 Mean (range) stone 29 (10–75) NA 36 (10–80) NA 34 (25–51) Burden (mm) Staghorn stones, n (%) 7 (14) 3 (5.6) 11 (9) NA 0 Mean (range) operative 123.5 (50–245) NA 98 (20–180) 85(15–240) (25–120) Duration (min) Stone-free rate, n (%) 38 (81) 47 (89) 91 (77.5) NA 34 (88.7) Transfusion rate, n (%) 1 (2) 5 (9) 17 (14) 8 (1.4) 0 Organ injury, n (%) 0 0 0 0 0 Hospital stay (days) 3.4 (2–12) 2.5 3.2 (1–7) NA 4.3 (2.2–8.4) NA, not available. 66 Nour et al. treatment during supine PCNL. The present study in- infundibulum. There was anteromedial renal displace- cluded 12 patients with staghorn stones (22%) for whom ment during tract dilatation, rendering the procedure the median (range) stone burden was 30 (10–55) mm. Se- more difficult, and this was managed by supporting ven patients (14%) with a staghorn stone were included the kidney while creating the tract. in the study of Hoznek et al. [12]. Falahatkar et al. [14] in- Twelve of the present patients had staghorn stones, cluded 11 patients (9%) with a staghorn stone in their although their stone burden was relatively low; all but study (Table 3). one had no significant residual fragments, three needed The stones were cleared in 49 (91%) of the present multiple renal punctures, which were made easily. We patients; this was a better rate than reported by Hoznek think that these results indicate the feasibility of using et al. [12] and Falahatkar et al. [14], who achieved a supine PCNL for staghorn stones in properly selected stone clearance rate of 81% and 77.5%, respectively. patients. This might be because the stone burden in the present In a recent review of the development of PCNL posi- study was less than in the other two. Shoma et al. [15] tions in the last 35 years [19], evaluating their safety, found a stone clearance rate of 89% in their study that advantages and limitations, the authors concluded that included 53 patients. A similar result was given by De there was no perfect position for PCNL, and that ‘Urol- Sio et al. [16], who reported a stone clearance rate of ogists who perform PCNL should be familiar with the dif- 88.7% in their study of 39 renal units. ferences in the positions and be able to use the method There were complications in 15 of the present patients appropriate for each patient’. (28%), graded according to the Clavien system, but The present study has several limitations; it included most of the complications were of grade I and II a relatively small sample, and although it included pa- (23%). There was bleeding requiring a transfusion in tients with staghorn stones, the stone burden was rela- only two patients. There had been concerns that the su- tively low. This was a descriptive study lacking a pine approach might put the colon at higher risk of in- comparative arm and was not randomised. jury than the prone approach, but we think that In conclusion, supine PCNL is technically feasible, colonic injuries are potentially less frequent due to the has several potential advantages, especially in patients more anterior displacement of the colon when the pa- at high risk when under anaesthesia, and can be used tient is supine, as described by Hopper et al. [17].In to treat all stone sizes. There is no apparent added risk the present series there were no colon injuries. in using this technique, and the stone clearance and Several modifications of supine PCNL were tried, complication rates are within the accepted values cited reproduced and evaluated [18], and all of them decrease previously for the standard prone PCNL. the operative duration and X-ray exposure compared Conflict of interest with the classic prone PCNL. They also allow a quick access to the airway in case of emergencies. However, No conflict of interest to declare. they vary in the ease of puncture, tract dilatation, ability to make multiple tracts and the ability to combine simul- Funding taneous ureteroscopy. In a meta-analysis of the supine vs. the prone PCNL Nothing to disclose. [13], the incidence of colon injury in the prone position was estimated to be 0.2–0.5%. In that analysis only References one colonic injury occurred during a supine PCNL. The rate of colonic injury in supine PCNL from com- [1] Goodwin WE, Casey WC, Woolfe W. Percutaneous trocar (needle) nephrostomy in hydronephrosis. JAMA 1955;157:891. parative studies was 0.5%, similar to the rate in previ- [2] Ferstrom I, Johansson B. Percutaneous pyelolithotomy: a new ous reports of prone PCNL. Supine PCNL does not extraction technique. Scand J Urol Nephrol 1976;10:257–9. increase the risk of colonic injury, which remains a rela- [3] Kim SC, Kuo RL, Lingeman JE. 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Journal

Arab Journal of Urology – Taylor & Francis

Published: Mar 1, 2013

Keywords: Percutaneous nephrolithotomy; Supine; Renal stones; Outcome; PCNL, percutaneous nephrolithotomy; PCN, percutaneous nephrostomy; BMI, body mass index

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