|Year : 2021 | Volume
| Issue : 1 | Page : 17-21
Our initial experience in supine percutaneous nephrolithotomy
Vipin Chandra1, Vishrut Bharti2, Rajesh Tiwari2, Vijoy Kumar2, Ahsan Ahmad2, Rohit Upadhyay2, Khalid Mahmood2, Nikhil Ranjan2
1 Department of Urology, All India Institute of Medical Sciences, Patna, Bihar, India
2 Department of Urology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
|Date of Submission||31-Dec-2020|
|Date of Decision||03-Mar-2021|
|Date of Acceptance||27-Mar-2021|
|Date of Web Publication||28-Jun-2021|
Department of Urology, All India Institute of Medical Sciences, Patna - 801 505, Bihar
Source of Support: None, Conflict of Interest: None
Background: Percutaneous nephrolithotomy (PCNL) is a routine procedure for removal of kidney stones. We are doing this procedure in a prone position due to traditional training, but now, we have started doing PCNL in supine position also in IGIMS, Patna. Supine position is used when there is anesthesia-related contraindication for prone position, access to the ureter and pelvicalyceal system (PCS) is needed simultaneously, and in patients where only lower or middle calyceal puncture is needed to clear the stone.
Materials and Methods: We have selected five patients with different stone characters to start with. All patients had undergone standard evaluation before the procedure. Standard consent for doing PCNL was obtained. We have used the usual instruments as used in routine prone PCNL cases. Use of nephrostomy tube (NT) or double-J (DJ) stent was decided at the end of the procedure depending on bleeding, residual fragments, injury to PCS, and extravasation of fluid. NT was removed after 48 h if given and DJ stents were removed after 4 weeks.
Results: Three patients were male and two were female, aged 22–55 years. The body mass index range was 19.6–24.6. Stone clearance was achieved to 100% extent in every case as seen on post fluoroscopic image. All procedures were uneventful. One patient had both ureteric stone and renal stone and we did ureteroscopy (URS) and PCNL simultaneously to clear the stone. In one case of upper ureteric stone, we started with ureteroscopic lithotripsy but after retropulsion stone migrated to PCS, then in the same position, we did PCNL to clear that stone.
Conclusion: PCNL is a standard procedure for renal stone using either supine or prone position. We should be accustomed to do PCNL in supine also and can utilize this position for doing PCNL. This practice will be extremely useful in patients who cannot be operated in prone position at all due to anesthesia region, due to spinal/bony deformity, or where both URS and PCNL are needed simultaneously.
Keywords: Kidney stone, percutaneous nephrolithotomy, prone position, supine position
|How to cite this article:|
Chandra V, Bharti V, Tiwari R, Kumar V, Ahmad A, Upadhyay R, Mahmood K, Ranjan N. Our initial experience in supine percutaneous nephrolithotomy. J Indira Gandhi Inst Med Sci 2021;7:17-21
|How to cite this URL:|
Chandra V, Bharti V, Tiwari R, Kumar V, Ahmad A, Upadhyay R, Mahmood K, Ranjan N. Our initial experience in supine percutaneous nephrolithotomy. J Indira Gandhi Inst Med Sci [serial online] 2021 [cited 2021 Dec 5];7:17-21. Available from: http://www.jigims.co.in/text.asp?2021/7/1/17/318919
| Introduction|| |
Renal stone management is a common practice in urology. We are doing percutaneous nephrolithotomy (PCNL) for the last 8 years for the renal stone disease. It is the standard of care and most recommended minimal invasive procedure. Prone positioning for doing PCNL is the standard of teaching and used by most of the urologists. Supine positioning for PCNL is also an established approach but is not done routinely by the urologists due to unfamiliarity with the positioning and puncturing technique under fluoroscopic guidance. We are now starting to do PCNL in supine position in our institute also and the purpose of this article is to document our beginning and initial experience.
| Materials and Methods|| |
Surgical indications and contraindications are the same for both supine and prone PCNL. We have excluded the patients having positive urine culture, coagulopathy, location of stone and requiring upper pole puncture and patients with fusion anomaly of the urinary system. Consent for standard PCNL was obtained after explaining the procedure. We are not initiating a new or experimental procedure, we are just beginning the practice of an established procedure for the renal stone disease. Armamentarium was the same as used for standard PCNL. Standard preprocedure evaluation was done including complete hemogram, renal function test, coagulation profile, ultrasound (USG) of the urinary system, X-ray and intravenous pyelogram (IVP), and urine examination and culture. We have used 22 Fr Richard Wolf nephroscope for the procedure. Galdakao-modified Valdivia position was used for the procedure [Figure 1]. The procedure was started with the placement of the ureteric catheter in the target kidney to get a pyelogram (RGP). For puncture C-arm image in a single plane is needed, but it can be rotated if needed. Puncture point was restricted to a line beyond the posterior axillary line, marked prior to patient positioning. After getting access of pelvicalyceal system (PCS), guide wire and guide rod were placed. Sequential dilatation of the tract by Teflon dilator was done (24–30 Fr) depending on the required size. A standard nephroscope of size 22 Fr was used for visualization and pneumatic lithotripter for stone fragmentation.
Stone clearance was assessed by comparing control and postprocedure fluoroscopic images. Placement of double-J (DJ) stent and nephrostomy tube (NT) was decided at the end of the procedure depending on the circumstances such as bleeding, residual stone, injury of PCS, and extravasation of fluid. NT was removed after 48 h if placed and DJ stent was removed after 4 weeks.
Five cases were selected for the supine PCNL procedure. The baseline characteristics and procedure-related information of each of these cases are summarized in [Table 1]. We are describing the details in each of these cases below.
|Table 1: Details of the patients who underwent supine percutaneous nephrolithotomy|
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The first case selected was a-43-year-old male having left pelvic stone of size 1.9 cm in maximum diameter on USG. On IVP, the stone was found to be in the renal pelvis with extension toward ureter [Figure 2]a, [Figure 2]b, [Figure 2]c. We did PCNL on him in the supine position by puncturing middle calyx and sequential dilatation up to 28 Fr. Stone was cleared as shown in [Figure 2]d. We had given DJ stent and NT both in this case because of the edematous PU junction. Postoperative (post-op) period was uneventful. NT was removed after 48 h. The patient was discharged on post-op day 5. DJ stent was removed after 4 weeks on follow-up.
|Figure 2: Preprocedural images a, b, and c (case 1): (a) X-ray showing stone in left kidney, (b) Intravenous pyelography showing the stone position in the renal pelvis, (c) Fluoroscopic image. Postprocedure fluoroscopic image (d) showing stone clearance|
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This was a case of 22 year-old male with a left inferior calyceal stone about 1.9 cm in size on USG. A second small radio-opaque shadow was also seen in another calyx in a position lower than the larger shadow in X-ray [Figure 3]a and IVP [Figure 3]b. Supine PCNL was planned. Along with the large stone, small stone also retrieved. Complete stone clearance was achieved uneventfully, as shown in [Figure 3]c. Only DJ stent was placed which was removed on follow-up at 4 weeks. The patient was discharged on post-op day 4.
|Figure 3: Pre-procedural images a and b (case 2): (a) X-ray showing stone in left kidney, (b) Intravenous pyelography showing stone position in inferior calyx. Post procedure fluoroscopic image (c) showing stone clearance|
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This was a 55-year-old female with inferior calyceal stone 1.8 cm in the left kidney and large left ureteric stone 1.5 cm in the lower ureter near vesioureteric junction [Figure 4]a and [Figure 4]b. In supine position [Figure 4]c, both ureteroscopic lithotripsy and PCNL were simultaneously done. Stones were cleared from both the sites. Only DJ stent was placed post procedure and removed at 4 weeks post-op. The patient was discharged on post-op day 5.
|Figure 4: Preprocedural images a and b (case 3): (a) X-ray showing stone in left kidney and left lower ureter, (b) Intravenous pyelography showing the stone position in the inferior calyx. image (c) position for doing both ureteroscopy and percutaneous nephrolithotomy simultaneously|
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This was a 35-years-old female patient with prior history of right-sided ureteric stone surgery and DJ stenting 6 years back. DJ stent was removed as per history, but later on, after getting pain in the right flank, she was evaluated by the district hospital and a fragmented stent was fund along with stone formation [Figure 5]a and [Figure 5]b in the right kidney and was referred to our institute for management. We evaluated the case and planned right-sided PCNL in supine position. The procedure was done uneventfully with complete retrieval of the stone and the fragmented DJ stent. NT and DJ stent were placed after the procedure. No significant blood loss occurred. NT was removed after 48 h and the patient was discharged on post-op day 6. DJ stent was removed at 4th week on follow-up.
|Figure 5: Case 4; X-ray (a) showing radio-opaque shadow in the right renal area; intravenous pyelogram (b) showing stone formation with a foreign body in the right renal pelvis|
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This was a case of right renal stone and left upper ureteric stone [Figure 6]a and [Figure 6]b in a 43-years-old male patient. Left-sided stone clearance was planned. The procedure was started in a modified supine position initially with ureteroscopy (URS) but after retropulsion, the stone migrated to the renal pelvis which was then removed with a middle calyceal puncture in the same sitting by doing PCNL. The tract was dilated up to 28 Fr. Blood loss during the procedure was about 100 ml. Post-op recovery was uneventful. The patient was discharged on post-op day 5. DJ stent was removed on follow-up at 4 weeks.
|Figure 6: Case 5; X-ray (a) showing radio-opaque shadow in the right renal area; left upper ureter area. Intravenous pyelography image at 30 min (b) showing stone location in the right renal pelvis and left upper ureter|
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| Discussion|| |
Renal stone disease is common worldwide, with a prevalence of 7% in adults and ≥30% recurrence rate within 10 years.,,,,, The incidence of kidney stones is globally increasing with an estimated prevalence ranging up to 15%. During lifetime, approximately 7% of women and 13% of men will develop a kidney stone.,
There are multiple modes of treatment starting from observation for tiny calculi to open pyelolithotomy for staghorn stones. However with the technical advancements, PCNL is now the gold standard for renal stone disease, especially for a stone of size more than 2 cm, but lesser size can be dealt with mini and ultra-mini PCNL. Initially, a prone position was used to puncture the PCS by a radiologist which was continued by the urologist also. From the beginning, the teaching is that patient should be in the prone position for the PCNL because of multiple advantages. Later on, researchers used to change the position for doing PCNL as mentioned in case reports prior to 1985. Valdivia had published the experience of supine PCNL in 557 patients, since then supine position was considered safe for the procedure. Even after that, this position was not widely used until 2007 when Galdakao-modified supine Valdivia position was published. The advantages of a PCNL performed in this position have multiple advantages from both urological and anesthesia points of view. Many other authors have suggested other modifications in supine and prone positions, also such as lateral position, lateral flexed position, lateral position with abducted legs, and prone position with splitting of leg.,,, There are some advantages of doing PCNL in prone position. Prone positioning for PCNL allows wider access for puncture from superior calyx to lower calyx and if multiple accesses are required, this position is helpful. Upper pole puncture is easier with a prone position. An upper pole puncture allows the urologist to work with minimal torque with nephroscope and hence reduces the chance of parenchymal injury due to shear. In a patient with staghorn calculus and renal stone in a horseshoe kidney, upper pole puncture is required and prone position is thus helpful. Upper pole puncture is also easy with dilatation because of the minimal mobility. For percutaneous intervention, distention of the collecting system is also adequate with the prone position. Then, the question comes why the supine position for doing PCNL?
Making prone after general anesthesia and ureteric catheter placement is a cumbersome task, especially for obese patients. Risk of injury to the cornea, bony points, cervical injury, and displacement of a catheter can occur if no extra care taken. Anesthesia risk is increased in prone position due to pushed diaphragm and compressed vena cava. We cannot do urethroscopy or URS in a prone position if required.
Supine position for doing PCNL is more ergonomical. This position is comfortable for the surgeon as he can perform surgery in a sitting position with his hands away from X-ray beam. One of the best technical advantages of the supine position is the ability to perform simultaneously PCNL and URS. With the two endoscopes inside the kidney, it is easier to find, fragment, remove, and deliver the stone. This position facilitates gravity-dependent drainage of stone fragments. This also guarantees low intrarenal pressure and reduces the time that it is necessary to work with water in supine position, although to make proper visualization, we need a distended PCS. Colon injury is minimal with a supine position because the colon floats away from the kidney in this position. Upper pole puncture is difficult with a supine position because of the rib cage, we can preplan this position if no superior calyceal puncture was needed.
Fluoroscopic image of the PCS may not be understandable to delineate all cayceal anatomy initially for the surgeon who are used to with prone images. There is a restricted mobility of nephroscope in supine position due to conflicts with the operating table. Although the supine position is favorable from an anesthesia point of view in case of obese patients, in review by de la Rosette, prone position PCNL is better for obese patients and patients with staghorn calculus in terms of stone clearance and bleeding and operating time.
| Conclusion|| |
PCNL is a standard procedure for renal stone using either supine or prone position. Both the positions have their own advantages and as an urologist, we should be accustomed to do PCNL in either position depending on the case. We should use a supine position for doing PCNL in the patient who cannot be made prone due to anesthesia region, due to spinal/bony deformity, or where both URS and PCNL are needed simultaneously.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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