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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 34  |  Issue : 2  |  Page : 93-97

Flank suspended supine position versus standard supine and prone positions in percutaneous nephrolithotomy


Department of Urology, Benha University, Benha, Egypt

Date of Submission27-Jan-2017
Date of Acceptance20-Feb-2017
Date of Web Publication20-Nov-2017

Correspondence Address:
Salah A El Hamshary
Urology, Benha, Postal code:13511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bmfj.bmfj_12_17

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  Abstract 


Background and aim The aim of this article was to compare the outcome of percutaneous nephrolithotomy (PCNL) in flank suspended supine position (FSSP), standard prone position, and standard supine position.
Patients and methods This study was conducted on 60 patients with renal stone disease from March 2013 to October 2016 in the Department of Urology, Benha University Hospital, and they were divided randomly into three groups: group A had 20 patients who underwent PCNL in FSSP, group B had 20 patients who underwent PCNL in standard supine position, and group C had 20 patients who underwent PCNL in prone position.
Results A total of 60 patients were divided into three groups − A, B, and C − with 20 patients in each group. Mean age in group A was 30.05±14.93 years, in group B was 49.35±14.31 years, whereas in group C was 35.15±15.18 years. The mean BMI by kg/m2 in group A was 25.81±6.16, in group B was 27.68±6.74, and in group C was 30.94±6.65. There were 38 males and 22 females who were divided into three groups: group A had 11 (55%) males and nine (45%) females, group B, had 10 (60%) males and 10 (40%) females, whereas group C had 13 (75%) males and seven (25%) females. There were 33 right renal stones and 27 left renal stones, which were divided into three groups. Group A had 11 (65%) right renal stone cases and nine (35%) left renal stones, group B had 13 (70%) right renal stones and seven (30%) left renal stones, whereas group C had nine (45%) right renal stones and 11 (55%) left renal stones.
Conclusion In conclusion, PCNL in the FSSP position is safe, effective, and suitable for patients, especially morbidly obese patients; it has several advantages like less operative time because of less patient handling and needing drape only once.

Keywords: flank suspended supine position, percutaneous nephrolithotomy, prone, stones, supine


How to cite this article:
El Hamshary SA, El Barky EM, Mostafa MM, Abd El Al AM, Hassanine MA. Flank suspended supine position versus standard supine and prone positions in percutaneous nephrolithotomy. Benha Med J 2017;34:93-7

How to cite this URL:
El Hamshary SA, El Barky EM, Mostafa MM, Abd El Al AM, Hassanine MA. Flank suspended supine position versus standard supine and prone positions in percutaneous nephrolithotomy. Benha Med J [serial online] 2017 [cited 2018 Oct 20];34:93-7. Available from: http://www.bmfj.eg.net/text.asp?2017/34/2/93/218825




  Introduction Top


Percutaneous nephrolithotomy (PCNL) has become the choice of modality for the treatment of large and complicated renal calculi [1].

Prone position remains the standard method for positioning patients for PCNL and has several advantages including wide operation field and a large room for instrument maneuvering [2].

To reduce the drawbacks, several other methods for positioning of the patient have been developed for PCNL including supine, supine oblique, flank positions, and others, which have also been used with varying results [3].

PCNL in the supine position has also certain disadvantages that make it a disputable alternative. The first problem with the supine position is that there is not enough space for a third tract if needed [4].

A new positioning called the flank suspended supine position (FSSP) is proposed to avoid most of the inherit drawbacks of supine and prone positions. First, we raise the patient flank and align the body contour to the side of the table. These modifications provide bigger room for puncture and maneuver of the instruments. Second, the jack knife position on the table can immobilize the kidney and facilitate the puncture. Third, the FSSP position can lower the affected kidney, making most calices easily accessible. Fourth, immobilization of the abdomen with V-shaped tapes places pressure on the abdomen, resulting in shorter track and a less mobile kidney [5].


  Patients and methods Top


This study was conducted on 60 patients with renal stone disease from March 2013 to October 2016 in the Department of Urology, Benha University Hospital, and were divided randomly into three groups: group A had 20 patients who underwent PCNL in FSSP, group B had 20 patients who underwent PCNL in standard supine position, and group C had 20 patients who underwent PCNL in the prone position. The study was approved by the institutional Research Ethical Committee, a written informed consent was obtained from all participants.

Group A: flank suspended supine position percutaneous nephrolithotomy

The patients were placed in the supine position with the shoulder and the buttock raised by a 3-l bag of water suspending the flank of the affected side. The body contour was aligned to the edge of the table. The operating table was adjusted to the jack knife position, with the tip of the lower part of the table slightly lowered. The leg of the affected side of the patent was straightened dorsally flexed and slightly inner rotated, with the knee of the other side flexed. The patients were then immobilized at the chest and the pelvis with two adherent tapes which crossed each other at the abdomen to form a ‘V’ shape.

Group B: supine percutaneous nephrolithotomy

The patient remains in the supine position, with the side of interest at the edge of the table, with a small cushion placed under the flank to elevate it 15–20°.

Group C: prone percutaneous nephrolithotomy

The patient was turned prone by putting a bridge or a towel under his chest and pelvis leaving the abdomen free for respiration, and then sterilization of the skin was done by povidone-iodine 10% solution. Thereafter, toweling of the patient was done.


  Results Top


A total of 60 patients were divided into three groups − A, B, and C − with 20 patients in each group. Mean age in group A was 30.05±14.93 years, in group B was 49.35±14.31 years, whereas in group C was 35.15±15.18. The mean BMI by kg/m2 in group A was 25.81±6.16, in group B was 27.68±6.74, and in group C was 30.94±6.65. There were 38 males and 22 females divided into the three groups: in group A, there were 11 (55%) males and nine (45%) females, in group B 10 (60%) males and 10 (40%) females, whereas in group C 13 (75%) males and seven (25%) females. There were 33 right renal stones and 27 left renal stones divided into the three groups. Group A had 11 (65%) right renal stone cases and nine (35%) left renal stones cases, group B had 13 (70%) right renal stones and seven (30%) left renal stones cases, whereas group C had nine (45%) right renal stones and 11 (55%) left renal stones cases. According to the stone multiplicity in group A, there were 11 (55%) cases of single renal stone and nine (45%) cases of multiple renal stones; in group B, there were 13 (65%) single renal stone cases and seven (35%) cases of multiple renal stones; whereas as in group C, there were 15 (80%) single renal stone and five (20%) multiple renal stone cases. As for the size of the stones in cm, in group A, the mean size was 2.82±0.9; in group B, the mean size was 3.4±0.59; whereas in group C, the mean size was 1.8±0.59. As for the stone locations, in group A, there were three (15%) upper calyceal stones, four (20%) middle, eight (40%) lower, and five (25%) renal pelvic stones; in group B, there were no upper calyceal stones, six (30%) cases of middle calyceal stones, nine (45%) cases of lower calyceal stones, and five (25%) cases of renal pelvic stones; whereas in group C, there was one (5.3%) case of upper calyceal stones, seven (36.8%) cases of middle calyceal stones, six (31.6%) cases of lower, and three (11.5%) cases of multisite renal stones. In group A patients who underwent FSSP PCNL, there was one (5%) patient who had intraoperative morbidity; in group B patients, two (10%) had intraoperative morbidity; whereas in group C, three (15%) patients had intraoperative morbidity. In group A (FSSP group), two (10%) patients had postoperative morbidity; in group B, three (15%) patients had postoperative morbidity; and in group C, two (10%) patients had postoperative morbidity. Among the patients who needed retreatment, in group A, one (5%) patients who underwent FSSP PCNL needed second-look PCNL, whereas another patient needed auxiliary treatment (5%) in the form of Extracorporeal Shock Wave Lithotripsy (ESWL); in group B (supine), three (10%) patients underwent second-look PCNL and another two (10%) patients needed auxiliary treatment in the form of ESWL; and in group C, two (5%) patients needed second-look PCNL, three (10%) patients needed auxiliary treatment in the form of ESWL, and another one (5%) needed ureteroscopy treatment ([Table 1],[Table 2],[Table 3] and [Figure 1],[Figure 2],[Figure 3]).
Table 1 Comparison of the three groups according to the site of the stones

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Table 2 The puncture site among the three groups

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Table 3 The intraoperative morbidity in the three groups

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Figure 1 The side, the number, and the size in the three groups

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Figure 2 The operative time in the three groups

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Figure 3 The blood loss, which needed blood transfusion, in the three groups

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  Discussion Top


Prone position has been widely used for more than 20 years in PCNL and widely accepted by urologists worldwide. It was not until 1988, when the first large series of PCNL was performed by Valdivia Uria et al. [6]. In this series, 577 patients underwent PCNL in supine position, with a success rate of 93.3%.

In this study, we propose the FSSP, in which we try to avoid the inherent drawbacks of supine and prone positions. First, we raise the patient flank and align the affected body contour to the side of the table; this modification allows bigger room for puncture and maneuvering the instruments, as has been stated by Pan et al. [5] in a study performed in 2015 on 150 cases.

In the FSSP group, the posterior axillary line was chosen as the site of puncture like the study performed by Pan et al. [5]. In the present study, we choose the midaxillary line as a site of skin puncture (in the supine group). However, Valdivia Uria et al., De Sio et al., and Neto et al. [6],[7],[8],[9] chose the posterior axillary line and Ng et al., chose the anterior axillary line in the supine position [5],[6],[7],[8].

In the FSSP group, middle calyceal puncture was done in four cases, and lower calyceal puncture was done in most cases (16 cases). In supine group, middle calyceal puncture was done in six cases and lower calyceal puncture also was done in most cases (14 cases), whereas in the prone group, middle calyceal puncture was done in four cases, and 16 cases had lower calyceal puncture, with no significant difference.

Regarding FSSP, Pan et al. [5], reported 150 cases in which five cases were middle calyceal puncture, one case was upper calyceal puncture, whereas the remaining 144 cases were lower calyceal puncture.

Regarding supine PCNL, Valdivia Uria et al. [6], reported 557 cases: two cases by upper calyceal puncture, 23 cases by middle calyceal puncture, and 517 cases by lower calyceal puncture. Shoma et al. [10] reported 63 cases, eight cases by upper calyceal puncture, 13 cases by middle calyceal puncture, and 42 cases by lower calyceal puncture. Manohar et al. [3], reported 62 cases: five cases by upper calyceal puncture, 25 cases by middle calyceal puncture, and 32 cases by lower calyceal puncture. De Sio et al. [7], reported 39 cases: seven cases by middle calyceal puncture and 32 cases by lower calyceal puncture, with no reported cases of upper calyceal puncture. Falahatkar [11], reported 32 cases: three cases by upper calyceal puncture, two cases by middle calyceal puncture, and 27 cases by lower calyceal puncture. Rana et al. [12] reported 184 cases: six cases by upper calyceal puncture, 46 cases by middle calyceal puncture, and 132 cases by lower calyceal puncture. Basiri and Sichani [13], reported 19 cases: one case by upper calyceal puncture, three cases by middle calyceal puncture, and 15 cases by lower calyceal puncture.

As in the prone position, we preferred a posterior calyx puncture to limit bleeding, as reported by Shoma et al. [10], and Neto et al. [9]. On the contrary, Valdivia Uria et al. [6], preferred the anterior calyx. In the present study, we performed two anterior calyceal punctures where the stones were in the anterior calyces as we could not reach the anterior calyx through a puncture in the posterior calyx because the lateral deflection of the nephroscopy to reach the anterior calyx was hindered by the side of the bed.

So independent of the puncture site, it is safe to say that the FSSP position is an effective well-tolerated position for most PCNL as reported by Pan et al. [5].

In the present study, the mean operative time was 61.65±15.14 min in FSSP position, 75.95±18.11 min in supine position, and 78.4±9.7 min in the prone position, with significant statistical difference between the three groups. In other series like Pan et al. [5], the reported mean operative time was 78.29 min in FSSP position, and Steele et al. [14], reported that the mean operative time was 68 min in prone position and 43 min in the supine position.

There had been concerns that the supine approach may have put the colon at a higher risk of injury than the prone position. In all the published studies on 1459 cases, there was no colonic injury in patients treated in the supine position. The contemporary data regarding PCNL with the patient in the supine position have not yet reported a single incidence of injury to the colon [12]. In this study, there was no colonic or any visceral injury in all groups.

In the present study, the postoperative morbidity of the group A (FSSP), two (10%) patients had postoperative morbidity, where one patient had postoperative fever which was relieved by antipyretics and in another patient, his nephrostomy tube had slipped but was passed under conservative treatment; in group B patients (supine group), three (15%) patients had postoperative morbidity, where two of them had postoperative fever, which was relieved by antipyritic, and another patient who had perinephric collection, upon which he had blood transfusion preoperative and postoperative, fluids, antibiotics, antipyritic and a JJ stent was placed which was removed on month later, and in group C patients(prone group), two (10%) patients had postoperative morbidity one patient had postoperative fever and the other had postoperative urinary tract infection both patients received antibiotics, antipyretics and fluids, there was no statistical difference between the three groups.


  Summary and conclusion Top


PCNL was first described by Fernstorm and Johansson in 1976 in prone position, which is accepted globally because of its familiarity, excellent understanding of the anatomy in this position, and reduced risk of visceral complications [3].

PCNL in supine position was first described by Valdivia Uria et al. [6] and has similar advantages as prone position. In addition to greater versatility of stone manipulation along the whole upper ureter, it has the advantages of less patient handling, needing drape only once, ability to perform simultaneous PCNL and ureteroscopic procedures, and better control of the airway during the procedure.

PCNL in the FSSP was described by Pan et al. [5] regarding evaluation its safety, efficacy, and the ability to avoid some of the drawbacks inherited from the prone and standard supine positions.

The aim of the work is to compare the outcome of PCNL in FSSP, standard prone, and standard supine position.

This study was conducted on 60 patients with renal stone disease from March 2013 to October 2016 in the Department of Urology, Benha University Hospital, and were divided randomly into three groups: group A had 20 patients who underwent PCNL in FSSP, group B had 20 patients who underwent PCNL in standard supine position, and group C had 20 patients who underwent PCNL in the prone position.

Comparison between the three groups had been done regarding calyceal puncture, operative time, stone-free rate, intraoperative blood loss, intraoperative and postoperative morbidity, and the need of auxiliary treatment or retreatment.

Regarding calyceal puncture in FSSP, lower calyceal puncture was done in 70% and middle calyceal puncture was done in 30%; in prone position, lower calyceal puncture was done in 80% and middle in 20%; and in supine position, lower in 70% and middle in 30%, with no significant statistical difference between both groups.

The mean operative time in FSSP group was 61.65 min, in prone group was 78.4 min, whereas in supine group was 75.95 min. The stone-free rate in FSSP was 95%, prone group was 85%, and supine group was 80%. The blood loss required blood transfusion in FSSP was 10%, in prone group was 15%, and in supine group was 15%.

The intraoperative morbidity of FSSP group was 5%, prone group was 15%, and supine group was 10%. The postoperative morbidity of FSSP group was 10%, prone group was 10%, and supine group was 15%.

Regarding the patient who needed retreatment with PCNL, in the FSSP group was 5%, in prone group was 5%, and in supine group was 10%, whereas the patients who needed auxiliary treatment in the FSSP group was 5%, in prone group was 10%, and in supine group was 10%.

In conclusion, PCNL in the FSSP position is safe, effective, and suitable for the patients, especially morbidly obese patients. It has several advantages like less operative time because of less patient handling and needing drape only once, ability to increase the space between the last rib and the iliac crest, increasing the maneuvering space for the instruments, and better control of airway during the procedure, as it combines some of the advantages of supine and prone positions. However, the supine position and the FSSP position are not a substitute for the prone position for PCNL. We need more prospective randomized studies in this field to draw an affirmative conclusion.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cracco CM, Scoffone CM, Poggio M, Scarpa RM. The patient position for PNL: does it matter? Arch Ital Urol Androl 2010; 82:30–31.  Back to cited text no. 1
    
2.
Miano R, Scoffone C, De Nunzio C, Germani S, Cracco C, Usai P et al. Position: prone or supine is the issue of percutaneous nephrolithotomy. J Endourol 2010; 24:931–938.  Back to cited text no. 2
    
3.
Manohar T, Jain P, Desai M. Supine percutaneous nephrolithotomy: effective approach to high-risk and morbidly obese patients. J Endourol 2007; 21:44–49.  Back to cited text no. 3
    
4.
Zhou X, Gao X, Wen J, Xiao C. Clinical value of minimally invasive percutaneous nephrolithotomy in: the supine position under the guidance of real time ultrasound: report of 92 cases. Urol Res 2008; 36:111–114.  Back to cited text no. 4
    
5.
Pan TJ, Li GC, Ye ZQ, Wen HD, Shen GQ, Zhang JQ. Flank suspended supine position for percutaneousnephrolithotomy. Urologia 2015; 79:58–61.  Back to cited text no. 5
    
6.
Valdivia Uria JG, Valle Gerhold J, Lopez JA, Villarroya Rodriguez S, Ambroj Navarro C, Ramirez Fabian M et al. Technique and complications of percutaneous nephroscopy: experience with 557 patients in the supine position. J Urol 1998; 160:1975–1978.  Back to cited text no. 6
    
7.
De Sio M, Autorino R, Quarto G, Calabrò F, Damiano R, Giugliano F et al. Modified supine versus prone position in percutaneous nephrolithotomy for renal stones treatable with a single percutaneous access: a prospective randomized trial. Eur Urol 2008; 54:196–203.  Back to cited text no. 7
    
8.
Ng MT, Sun WH, Cheng CW, Chan ES. Supine position is safe and effective for percutaneous nephrolithotomy. J Endourol 2004; 18:469–474.  Back to cited text no. 8
    
9.
Neto EA, Mitre AI, Gomes CM, Arap MA, Srougi M. Percutaneous nephrolithotripsy with the patient in a modified supine position. J Urol 2007; 178:165–168; discussion 8.  Back to cited text no. 9
    
10.
Shoma AM, Eraky I, El-Kenawy MR, El-Kappany HA. Percutaneous nephrolithotomy in the supine position: technical aspects and functional outcome compared with the prone technique. J Urol 2002; 60:388–392.  Back to cited text no. 10
    
11.
Falahatkar S, Moghaddam AA, Salehi M, Nikpour S, Esmaili F, Negin Khaki N. Complete supine percutaneous nephrolithotripsy comparison with the prone standard technique, J Endourol 2008; 22:2513–2518.  Back to cited text no. 11
    
12.
Rana AM, Bhojwani JP, Junejo NN, Das Bhagia S. Tubeless PCNL with patient in supine position: procedure for all seasons − with comprehensive technique. Urology 2008; 71:581–585.  Back to cited text no. 12
    
13.
Basiri A, Sichani MM. Supine percutaneous nephrolithotomy, is it really effective? A systematic review of literature. Urol J 2009; 6:73–77.  Back to cited text no. 13
    
14.
Steele D, Marshall V. Percutaneous nephrolithotomy in the supine position: a neglected approach? J Endourol 2007; 21:1433–1437.  Back to cited text no. 14
    


    Figures

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    Tables

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