Positioning During PNL

Abstract

Classical percutaneous nephrolithotomy consists of several steps executed in a sequence beginning in the lithotomy position followed by a second one in the prone position. For many years, this represented the standard technique. A number of limitations like patient obesity and the necessity of puncturing the upper pole led to several modifications. The lateral position and Bart’s position were recommended for obese patients. Prone flexed position shifts the kidney downward, facilitating access to the upper pole. With the advent of miniaturized flexible instruments, simultaneous antegrade and retrograde access to the kidney became possible. Split leg prone position was proposed for such a dual access. But the main change of paradigm was the arrival of the supine Valdivia position with its variants, especially the Galdakao-modified supine Valdivia position. The latter is a modification of the lithotomy position with the patient slightly tilted toward the site opposite to the stone and the ipsilateral arm crossing the chest.

All these different positions were thoroughly evaluated with comparative studies. No superiority of prone or supine variants could be established regarding stone-free and complication rates; however, the supine position reduces operative time.

Finally, the decision regarding positioning belongs to the surgeon, taking into account his personal experience and preferences and his operative environment.