Positions for percutaneous nephrolithotomy: Thirty-five years of evolution

Figures & data

Table 1 A timeline of positions for PCNL.

Year	Ref	Position	Type	Comment
1976	[1]	Classic prone	Prone	First description of percutaneous stone extraction
1988	[8]	Reverse lithotomy	Prone	First simultaneous antegrade and retrograde access
1990	[9]	Original supine	Supine	First series of PCNL while supine. Initial case reports 2 years before
1990	[9]	Modified supine for simultaneous PCNL and ureteroscopy	Supine
1991	[2]	Split-leg prone	Prone
1993	[3]	Flank roll position	Supine	For patients having preoperative percutaneous access
1994	[4]	Lateral decubitus	Flank	First PCNL in the lateral position
2007	[10]	Galdakao-modified Valdivia	Supine	Renewed the interest for supine position
2007	[5]	Crossed-leg supine	Supine
2008	[7]	Barts technique	Flank	Very good simultaneous ante- and retrograde access
2008	[11]	Complete supine	Supine	No support is placed under the flank
2009	[6]	Prone-flexed	Prone
2012	In press	Barts flank-free modified	Supine	The best exposure of the flank among the supine positions

Table 2 Advantages and disadvantages of positions for PCNL.

Position	Advantages	Disadvantages
Prone
Classic prone	Excellent exposure of lumbar area	Patient repositioning during the procedure
Classic prone with supporting equipment	Easier access to upper pole	Hard to manage cardio-respiratory emergencies
	Kidney close to puncture site and less mobile	Respiratory/cardiovascular function compromised
Reverse lithotomy	Depended renal pelvis and thus increased pressure (better visibility and room for movement)	Increased risk of injuries from pressure (less if special mattress is used) (less if supporting equipment is used)
Split leg prone
Prone-flexed		Theoretical risk of ocular complications
		Surgeon standing/non-ergonomic position
		Theoretically greater exposure to radiation
		Retrograde access not possible in classic prone (feasible in ‘split leg’ and ‘reverse lithotomy’)
Lateral
Lateral decubitus and lateral flexed	Can be used in patients with severe obesity, kyphoscoliosis	Patient repositioning is required (easier than in prone position)
‘Barts technique’	Less impact on respiratory/cardiac function	Difficult access to kidney with fluoroscopy
	Good exposure of flank
	Option for simultaneous retrograde access
	General anaesthesia can be avoided
Supine
Original Valdivia	Patient is positioned and draped once	Reduced exposure of flank area (less in the ‘Barts flank-free’ position)
Modified Valdivia	Comfortable position for patient	Access to posterior calyces not always possible
Flank roll	Surgeon in ergonomic position	Kidney sometimes more mobile (difficult puncture)
Crossed leg	Theoretically less exposure to radiation	Instrument movements can be restricted. (less in the ‘Barts flank-free’ position)
Galdakao	Excellent control of airway by anaesthetists	Collapsed collecting system because of reduced pressure makes nephroscopy more demanding
Complete supine	Allows easier retrograde access
Barts flank-free	Dependent access (spontaneous evacuation of fragments, less fluid absorption)
	General anaesthesia can be avoided

Figure 1 The prone position.

Figure 2 The Montreal mattress, with the Proneview helmet.

Figure 3 The split-leg position. (Taken from [3] with permission from the author, courtesy of Professor Michael Grasso).

Figure 4 The prone-flexed position. (Taken from [6] with permission from the author, courtesy of Dr. R. John D’A. Honey).

Figure 5 ‘The Barts technique’.

Figure 6 The ‘Valdivia’ supine position (courtesy of Professor José Gabriel Valdivia Uría).

Figure 7 The modified ‘Valdivia’ position (courtesy of Professor José Gabriel Valdivia Uría).

Figure 8 The Galdakao-modified Valdivia position (courtesy of Dr. Cesare Marco Scoffone).

Figure 9 The complete supine position. (Taken from [35] with permission from the author, courtesy of Dr. Siavash Falahatkar, Professor of Urology).

Figure 10 The Barts flank-free supine position.

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