Prone Vs Supine Positions

of PCNL Procedures

Percutaneous
Nephrolithotomy
Currently, PCN is the treatment of
choice for large renal stones,
staghorn calculi, stone resistent to
fragmentation, stones in kidney with
abnormalities
Supine and prone position were the
choice position for percutaneous
nephrolithotomy (PCNL)

History
Prone Position -> traditional position
(first description by Goodwin et al
and Fernstrom and Johansson, 1976)
Supine Position -> first description by
Valvidia-Uria and associates, 1998)

Supine position
Advantages:
- Safer and easier for the patient
- Straightforward renal puncture
- Spontaneous evacuation of stone fragments
facilitated by horizontal sheath position
- Less cardiovascular change
- No need for patient repositioning (with less
operative time and less relevant risk of nervous
system injuries)
- More comfortable and less radiation exposure to
the surgeon

Disadvantages:
Increase the possibility of visceral injuries and
cause trauma to intrarenal vessels because
Supine position necessitates more lateral
displacement of the renal puncture site than the
prone position
Increased risk of injury to liver and spleen during
upper pole access
Decreased surface area for percutaneous access
Upper pole approach might be more difficult

Prone position
Advantages:
Provides a large surface area for the choice
of puncture site
Wide space for instrument manipulation
Access to the pyelocaliceal system
Nephroscope manipulation is easier
Provides access to the posterior calyx
without causing significant parenchymal
bleeding, peritoneal perforation, or visceral
injuries

Disadvantages:
Contraindicated for anesthesiologic
reasons because of circulatory and
ventilator difficulties, especially in
obese patients and patients with
cardiovascular problems.
Difficult in patients with structural
deformities, such as hip or lower limb
contractures.

 In a large, multi-institutional and

retrospective study of percutaneous
nephrolithotomy, including 4637 patients
and 1138 patients with prone and
supine positioning, respectively,
operative time and stone-free rates
favored the prone position, but some
patient safety parameters favored the
supine position (Valdivia et al, 2011).

 Although both the supine and flank

positions offer some potential benefits
over prone positioning in certain
settings, particularly morbid obesity and
spinal
deformities,
the
evidence
suggests no overwhelming differences,
so surgeon preference can determine the
choice of position for percutaneous renal
surgery.

Prone position

(A)True supine position.

(B) Flank position; position at the beginning
of operation and after access.
(C) Lateral position; position for renal access.

Trajectory of the puncture needle during

supine percutaneous nephrolithotomy

Meta-analysis results
Analysis results showed were as follows:
1. Stone-free rate
In meta-analysis of 9 studies, the stone free
rate was 77.3 % (3,804/4,918) in the prone
position versus 72.9 % (1,057/1,449) in the
supine position (OR: 1.36; 95 % CI 1.19
1.56;p\0.0001), indicating that there was a
significantly higher stone free rate in the
prone position than in the supine position.

2. Operative time
Six studies including 6,102 patients reported on the
operative time for PCNL in both positions. Metaanalysis
demonstrated a shorter operative time in the supine
position than in the prone position (WMD: 21.7; 95 %
CI
2.4640.94;p=0.03)
3. Hospital stay
Six studies including 6,102 patients reported on the
length of hospital stay for PCNL in both positions. No
statistically significant difference was found between
the two groups (WMD=0.05; 95 % CI-0.16
0.25;p=0.66)

4. Complication rate
In meta-analysis of 9 studies, the
complication rate was 20.3 %
(1,001/4,901) in the prone position
versus 18.3 % (266/1,442) in the
supine position, showing that both
positions had similar complication rates
(OR: 1.1; 95 % CI 0.941.28; p=0.24)

 For general patients with renal

calculi,
the
operative
time
significantly decrease in supine
position, and the stone-free rate of
supine are similar with prone
position.
Supine PCNL do not increase related
complications. The supine PCNL
would be better choice for those
patients with high risk of anesthesia.