Percutaneous nephrolithotomy: does position matter? - prone, supine and variations

The evolution of percutaneous renal stone surgery has recently seen an increasing number undergoing surgery in the supine position rather than just the classical prone technique. Several advantages have been proposed with the supine approach, including benefits for anaesthesia (cardiovascular and airway), the patient (reduced transfer-related injuries), and surgeon (combined retrograde and antegrade surgery, and ergonomics). As the supine technique and variations have now been practised for several years, it is timely to review whether it has been adopted universally and what factors may lead to preference for one approach over another.

There have been several retrospective reports, but only two prospective randomized trials published in the literature, comparing the techniques. There have also been recent attempts at establishing national and international databases for percutaneous nephrolithotomy (PCNL) surgery to try and describe the practice patterns for this surgery, and also the factors that influence the decision to adopt a particular position. Although there appear to be no clear overall benefits for one position over another, and practice is likely to remain fairly surgeon-specific, there are some cases in which the supine PCNL may be preferable (e.g. in obese patients).

Along with the development of centres offering this surgical technical variation, endourology training programmes will increasingly offer exposure to supine PCNL, which may then affect the global practice patterns.