Supine PCNL is the way to go!

摘要

The fact that operating a patient in the supine positionis easier than in a prone position is rather intuitive:apart from PCNL and, obviously, spinal surgery,there is no surgery of retroperitoneal organsperformed in the prone position.So, why is it that nowadays PCNL is performed in thesupine position only in 20% of cases worldwide? [1].Indeed, the prone position was adopted in the pioneeringera of PCNL only on an intuitive basis withthe thought that in the supine position no windowfor puncture was present because of colon interposition.This was assumed as a postulate. As a consequence,this approach was supposed to be the onlyone able to prevent colonic perforation which was,and still is, considered one of the most frighteningcomplications of PCNL. And probably at that timeit really was, neither CT nor US scans were availableand no chance to detect organs that lied in betweenthe skin and kidney was possible. For decades, thisconcept never came into question and it was unquestionablyadopted by the following generations.But at this moment in time in which no patients undergoa PCNL without a preoperative CT scan, perseverancein this attitude is meaningless.Also because, as already demonstrated, the incidenceof a retrorenal colon is higher in the prone thanin the supine position (10 vs. 1.9%) [2]. Moreover,we also have to consider that, as done by the majorityof urologists, the fact that the preoperative CTscan is mostly carried out in the supine position,can be misleading when planning a prone PCNL [3].As such, only in these anecdotal cases of retrorenalcolon, the surgeon can decide to go back to the proneposition.