Prone split leg and flank roll positioning: simultaneous antegrade and retrograde access to the upper urinary tract

The simultaneous endoscopic approach to upper urinary tract pathology in both an antegrade and retrograde fashion can be cumbersome. The prone split leg and flank roll positions allow such simultaneous access. Of 111 patients in whom the prone split leg position was employed, 41% were treated with simultaneous antegrade and retrograde endoscopy in a two-team approach. Treating large staghorn calculi in this manner, one team debulked the stone burden accessible through the flank nephroscopically, while another team approached the remainder of the stone burden using the pulsed-dye laser ureteroscopically in a retrograde manner. The flank roll position was employed in 15 patients who presented with percutaneous nephrostomies and were deemed treatable preoperatively in a retrograde manner. They were positioned in this manner to allow intraoperative access to the percutaneous nephrostomy tract. Nine of these patients required antegrade treatment. The application of these two positions and the concept of the two-team approach added to the efficiency of treating not only staghorn calculi, but other upper tract pathology. Simultaneous procedures require at least two skilled endoscopists as well as dual light sources, various lithotrites, and several rigid and flexible endoscopes.