Percutaneous Nephrolithotripsy With The Patient In A Modified Supine Position

Main Category: Urology / Nephrology
Also Included In: Clinical Trials / Drug Trials
Article Date: 17 Nov 2007 - 0:00 PDT

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UroToday.com- To be sure, there is more than one way to "skin a cat", but I must admit I never thought that this applied to percutaneous nephrostolithotomy! I had earlier read the reports by Valdivia-Uria and his colleagues of supine rather than prone access and viewed this approach with a high level of doubt. However, since Valdivia-Uria's original work many others have employed the supine, or as in this article a modified supine, approach with a high degree of success. In this report, the authors achieved a 71% stone free rate among 88 consecutive patients with a mean stone diameter of 3.6 cm. The stone free rate was determined by ultrasound and/or plain abdominal radiographs rather than by the "gold standard" CT scan so these results may be a bit inflated. The authors note that the supine position may be more comfortable for the patient, allow for fewer difficulties during anesthesia, facilitate ureteroscopy, speed patient positioning on the table, and provide dependent drainage for stone fragments during the procedure. Of note, access was in the upper pole in only 6% of patients. Interestingly, there were no injuries to the colon with this approach. I must admit that I am not yet ready to convert to this approach and thus am awaiting someone to perform a proper prospective randomized study of prone vs. supine nephrostolithotomy. Indeed, currently with an endoscopically guided nephrostomy tube placement with the patient prone I am routinely using an upper pole approach and employing an access sheath in the ureter both for ureteroscopic access as well as drainage of stone fragments; it is my impression that our transfusion rate and stone free rate are improved however, these data are only now being collected. As with the proverbial "cat" we need a bit of science in order to determine how best to proceed … without this work, we will continue to wonder.

Neto EAC, Mitre AI, Gomes CM, Arap MA, and Srougi M

J. Urol. 178(1):165-168, July 2007
doi:10.1016/j.juro.2007.03.056

Reported by UroToday.com Contributing Editor Ralph V. Clayman, M.D

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