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supine PCNL percutaneous nephrolithotomy position

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supine PCNL percutaneous nephrolithotomy technique advantages complications 2024

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PMID: 40086594

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PMID: 39692421

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supine PCNL percutaneous nephrolithotomy patient positioning setup

A clinical procedural photograph illustrating the Galdakao-modified supine Valdivia position for percutaneous nephrolithotomy (PCNL). The patient is placed in a modified supine position on a surgical table with blue drapes, utilizing stirrups for leg positioning: the ipsilateral leg is extended straight, while the contralateral leg is flexed and abducted. Bolsters are placed under the hip and chest to elevate the flank, providing surgical access to the renal area. Surface anatomy markings in purple ink identify critical landmarks for the procedure: (a) the posterior axillary line, (b) the iliac crest, and (c) the level of the 12th rib. An ECG electrode is visible on the chest wall. This image serves as an educational guide for urological surgical positioning, demonstrating the necessary surface markers and table configuration required to safely perform supine renal access for stone management.

A clinical procedural photograph illustrating the Galdakao-modified supine Valdivia position for percutaneous nephrolithotomy (PCNL). The patient is placed in a modified supine position on a surgical table with blue drapes, utilizing stirrups for leg positioning: the ipsilateral leg is extended straight, while the contralateral leg is flexed and abducted. Bolsters are placed under the hip and chest to elevate the flank, providing surgical access to the renal area. Surface anatomy markings in purple ink identify critical landmarks for the procedure: (a) the posterior axillary line, (b) the iliac crest, and (c) the level of the 12th rib. An ECG electrode is visible on the chest wall. This image serves as an educational guide for urological surgical positioning, demonstrating the necessary surface markers and table configuration required to safely perform supine renal access for stone management.

Clinical photograph of a urological surgical procedure, likely Percutaneous Nephrolithotomy (PCNL), demonstrating a modified supine-oblique (Valdivia-Galdakao) patient positioning. The patient is draped in a sterile blue field with the right flank exposed and prepared for percutaneous access. A C-arm fluoroscopy unit is positioned over the patient's torso for intraoperative imaging, with a monitor in the background displaying real-time visual data. The surgical team is arranged to allow simultaneous access: one surgeon operates at the flank, performing a renal puncture or nephroscopy, while an assistant is positioned between the patient's abducted and secured legs to perform retrograde endourological maneuvers (e.g., ureteroscopy or catheter placement). The patient's legs are secured independently in a slightly abducted, non-flexed position to facilitate this dual access to the upper and lower urinary tract. This configuration optimizes workflow for endoscopic combined intrarenal surgery (ECIRS) by providing wide flank exposure and retrograde access to the bladder.

Clinical photograph of a urological surgical procedure, likely Percutaneous Nephrolithotomy (PCNL), demonstrating a modified supine-oblique (Valdivia-Galdakao) patient positioning. The patient is draped in a sterile blue field with the right flank exposed and prepared for percutaneous access. A C-arm fluoroscopy unit is positioned over the patient's torso for intraoperative imaging, with a monitor in the background displaying real-time visual data. The surgical team is arranged to allow simultaneous access: one surgeon operates at the flank, performing a renal puncture or nephroscopy, while an assistant is positioned between the patient's abducted and secured legs to perform retrograde endourological maneuvers (e.g., ureteroscopy or catheter placement). The patient's legs are secured independently in a slightly abducted, non-flexed position to facilitate this dual access to the upper and lower urinary tract. This configuration optimizes workflow for endoscopic combined intrarenal surgery (ECIRS) by providing wide flank exposure and retrograde access to the bladder.

A clinical photograph illustrating the Valdivia position, a specific surgical setup used in urological procedures such as Percutaneous Nephrolithotomy (PCNL). The patient is shown in a modified supine decubitus position on an operating table. To optimize surgical access to the renal area, a large saline bag or firm pillow is placed under the ipsilateral flank, creating a subtle lateral tilt and elevating the kidney. The patient's legs are positioned in a modified lithotomy style: the ipsilateral leg remains extended while the contralateral leg is flexed and abducted. Standard perioperative monitoring is visible, including a pulse oximeter on the index finger and an intravenous line in the forearm. This positioning is designed to allow simultaneous antegrade and retrograde access to the urinary tract while maintaining the hemodynamic advantages of the supine position compared to prone positioning.

A clinical photograph illustrating the Valdivia position, a specific surgical setup used in urological procedures such as Percutaneous Nephrolithotomy (PCNL). The patient is shown in a modified supine decubitus position on an operating table. To optimize surgical access to the renal area, a large saline bag or firm pillow is placed under the ipsilateral flank, creating a subtle lateral tilt and elevating the kidney. The patient's legs are positioned in a modified lithotomy style: the ipsilateral leg remains extended while the contralateral leg is flexed and abducted. Standard perioperative monitoring is visible, including a pulse oximeter on the index finger and an intravenous line in the forearm. This positioning is designed to allow simultaneous antegrade and retrograde access to the urinary tract while maintaining the hemodynamic advantages of the supine position compared to prone positioning.

A clinical photograph in grayscale illustrating the 'Giusti position' for supine percutaneous nephrolithotomy (PCNL). The patient is positioned supine with a 15-20 degree rotation toward the contralateral side, supported by padding under the scapula and buttocks to expose the flank. The ipsilateral leg (same side as the stone) is extended and kept straight, while the contralateral leg is abducted and flexed in a cystoscopy or lithotomy position to facilitate simultaneous retrograde endourological access. On the exposed flank, dark surgical skin markings indicate critical anatomical landmarks for renal access, including the posterior axillary line, the lower rib margin, and the iliac crest. This surgical setup is designed for endourological procedures like PCNL, allowing for improved spontaneous fragment passage and ease of simultaneous ureteroscopy or retrograde contrast studies without the need for patient repositioning.

A clinical photograph in grayscale illustrating the 'Giusti position' for supine percutaneous nephrolithotomy (PCNL). The patient is positioned supine with a 15-20 degree rotation toward the contralateral side, supported by padding under the scapula and buttocks to expose the flank. The ipsilateral leg (same side as the stone) is extended and kept straight, while the contralateral leg is abducted and flexed in a cystoscopy or lithotomy position to facilitate simultaneous retrograde endourological access. On the exposed flank, dark surgical skin markings indicate critical anatomical landmarks for renal access, including the posterior axillary line, the lower rib margin, and the iliac crest. This surgical setup is designed for endourological procedures like PCNL, allowing for improved spontaneous fragment passage and ease of simultaneous ureteroscopy or retrograde contrast studies without the need for patient repositioning.

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PMID: 39614229

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Supine PCNL: Complete Overview

1. Background and History

Percutaneous nephrolithotomy (PCNL) was first described by Fernstrom and Johansson in 1976 and has been traditionally performed in the prone position. Supine PCNL was first described by Valdivia Uría et al. in 1987, and has since evolved through multiple positional variants. While prone access remains the global default, supine PCNL has gained substantial ground, particularly with the popularization of the Galdakao-modified supine Valdivia position.
  • Grainger & Allison's Diagnostic Radiology, p. 2170
  • Hinman's Atlas of Urologic Surgery, p. 253

2. Indications for PCNL (General)

Supine PCNL shares the same stone indications as prone PCNL:
IndicationDetails
Renal pelvic stones>2 cm
Staghorn calculiComplete or partial
Lower pole stones>1 cm
Hard stonesCT density >1000 HU
Cystine stonesRelative indication
Stones with poor drainageCalyceal diverticula, horseshoe kidney
Failed ESWL or URSResidual or recurrent stones
Special anatomyPelvic kidneys (with assistance)
Additional indications for percutaneous access include antegrade pyelography, Whitaker test, PUJ obstruction dilation/incision, urothelial tumor resection, and foreign body retrieval.
  • Smith and Tanagho's General Urology, p. 143
  • Grainger & Allison's Diagnostic Radiology, p. 2170
Specific indications that favor supine over prone:
  • Patients with severe cardiopulmonary disease who cannot tolerate prone positioning
  • Morbid obesity (abdominal compression in prone reduces venous return and ventilation)
  • Concomitant ipsilateral ureteral stones (allows simultaneous retrograde URS)
  • Patients with spinal deformities or inability to lie prone
  • Cases requiring simultaneous antegrade-retrograde access (ECIRS)
  • Solitary kidney (reduces cardiovascular risk)

3. Supine Positional Variants

Several modifications exist, each with slightly different flank exposure:

3a. Classic Valdivia (Total Supine)

  • Patient lies completely flat on back
  • A small bolster placed under the ipsilateral flank to slightly elevate the kidney
  • Ipsilateral leg extended; contralateral leg flexed/abducted (modified lithotomy)
  • Allows retrograde access simultaneously

3b. Galdakao-Modified Supine Valdivia (GMSV)

  • Most widely used supine variant
  • Ipsilateral leg extended flat; contralateral leg in stirrup (flexed and abducted)
  • Bolster under ipsilateral hip and chest to create flank elevation
  • Key anatomical surface markings: posterior axillary line, iliac crest, 12th rib level
  • Allows simultaneous flexible ureteroscopy and PCNL (ECIRS)

3c. Barts Flank-Free Modified Supine (FFMS)

  • A newer enhanced variant
  • Designed to maximize flank exposure without needing manual support
  • Systematic review (PMID 39692421, 2024): surgery duration significantly shorter than prone (MD -15.48 min, p=0.006); no significant difference in stone-free rate, complications, or hospital stay

3d. Giusti Position

  • 15-20 degree rotation toward the contralateral side
  • Supported by padding under scapula and buttocks
  • Skin markings on posterior axillary line, lower rib margin, iliac crest
Below are clinical photographs of positioning setups:
Galdakao-modified supine Valdivia position with anatomical landmarks marked
Galdakao-modified supine Valdivia position: ipsilateral leg extended, contralateral leg in stirrup, flank elevated with bolsters. Surface landmarks (a) posterior axillary line, (b) iliac crest, (c) 12th rib level are marked in purple.
Valdivia position with C-arm for ECIRS setup
Supine PCNL operating setup allowing simultaneous retrograde endourological access (ECIRS) - note surgeon at the flank and assistant between the patient's legs.
Valdivia position with saline bag under flank
Classic Valdivia position: saline bag under the ipsilateral flank, ipsilateral leg extended, contralateral leg flexed and abducted.
Giusti position
Giusti position: 15-20 degree contralateral rotation with anatomical markings on the exposed flank.

4. Technical Considerations

Access and Puncture

  • In supine PCNL, the posterior calyces are accessed since the kidney rotates slightly anteriorly in the supine position
  • Bolsters create slight flank elevation of the operative side to bring the posterior kidney surface into a more accessible plane
  • Fluoroscopy or ultrasound can both be used for guidance - same principles as prone approach
  • The collecting system tends to collapse slightly compared to prone (gravity-dependent drainage is lost) - this can make puncture marginally more challenging
  • The surgical field is smaller than prone and upper pole calyceal puncture is more difficult
  • More lateral and anterior puncture carries higher risk of bowel injury - the surgeon must account for bowel position

Simultaneous Retrograde Access (ECIRS)

A key advantage of supine PCNL is the ability to perform combined antegrade PCNL and retrograde flexible ureteroscopy simultaneously (ECIRS - Endoscopic Combined Intrarenal Surgery). The contralateral leg positioning in stirrups allows the assistant to work between the patient's legs while the surgeon accesses the kidney percutaneously. This is particularly useful for:
  • Staghorn calculi requiring both antegrade and retrograde clearance
  • Concomitant ureteral stones
  • Difficult calyces that cannot be reached through the percutaneous tract
  • Comprehensive Clinical Nephrology, p. 2403

No Need for Patient Repositioning

Unlike prone PCNL (where the patient is intubated supine then flipped), supine PCNL allows the entire procedure - including ureteral catheter insertion at cystoscopy - to be done without repositioning. This saves 15-30 minutes of operating time and reduces anesthetic risk.

5. Advantages vs. Prone PCNL

FeatureSupine PCNLProne PCNL
AnesthesiaSafer; better airway accessHigher risk especially in obese/cardiopulmonary compromise
RepositioningNone neededRequired after ureteral catheter placement
Operative timeGenerally shorterLonger (includes repositioning)
Retrograde accessSimultaneous possible (ECIRS)Also possible but less convenient
Surgical fieldSmallerLarger; more working space
Upper pole accessMore difficultEasier
Multiple tractsMore difficultEasier (larger back surface)
Bowel riskLower (retrorenal colon less frequent supine)Slightly higher retrorenal colon risk
Ventilation (obese)BetterAbdominal compression reduces FRC
HemodynamicsMore stableProne compression can reduce venous return
RadiationComparableComparable
A key anatomical fact: in a CT study of 500 patients, retrorenal colon was present in 2% supine vs. 10% prone, so the risk of colonic injury may actually be lower in supine PCNL. Colonic perforation rate in prone PCNL is 0.2-0.3%.
  • Hinman's Atlas, p. 253
  • Miller's Anesthesia, p. 8484

6. Current Evidence: Supine vs. Prone Outcomes

Large Meta-Analysis (PMID 40086594, Lachkar et al., 2025 - 43 studies, 11,774 patients):

  • Stone-free rate: No significant difference (RR=0.99, p=0.70)
  • Operative time: Significantly shorter in supine (SMD=-0.39, p=0.008)
  • Overall complications: Significantly fewer in supine (RR=0.87, p=0.003)
  • Major complications: Significantly fewer in supine (RR=0.75, p=0.015)
  • Hemoglobin drop, hospital stay, visceral injury, transfusion, sepsis, urinary leakage, pleural effusion: No significant difference
  • Conclusion: Supine PCNL is a viable alternative with shorter operative time and fewer complications

Barts FFMS vs. Prone (PMID 39692421, 4 studies, 2024):

  • Surgery duration: Significantly shorter for Barts FFMS (MD -15.48 min, p=0.006)
  • Stone-free rate, fever, transfusion, nephrostomy use, hospital stay: No significant difference
  • Neither position is superior overall - choice should be based on surgeon preference and patient status

Pediatric Meta-Analysis (PMID 39614229, 8 studies, 492 patients, 2024):

  • Stone-free rate: No significant difference (OR 0.67, p=0.17)
  • Operative time: Significantly shorter in supine (MD 13.75 min, p=0.004)
  • Hospital stay: Shorter in supine (MD 0.61 days, p<0.0001)
  • Total complication rate: No significant difference
  • Conclusion: Supine PCNL equivalent in SFR with shorter operative time and hospital stay in pediatric patients

7. Complications Specific to Supine PCNL

General PCNL Complications (applying to both positions)

ComplicationRate/Notes
Bleeding requiring transfusion~5-8%; major hemorrhage 1-3%
Sepsis/urosepsis~1-5%
Urine leakageCommon; usually resolves with drainage
Pleural injury (pneumothorax/hydrothorax)Higher with supracostal/upper pole access
Colonic injury0.2-0.3%; may actually be lower in supine
Pelvic injury/perforation~3-4%
HypothermiaFrom large volumes of irrigation fluid
Acute anemiaBleeding or dilutional

Supine-Specific Concerns

  • Smaller working field - instrument manipulation more limited
  • Upper pole access is harder - may require steep angulation; pleural injury risk still present
  • Collapsed collecting system in supine - can impair visualization and navigation
  • Miller's Anesthesia notes: "Supine positioning...results in a smaller surgical field, collapse of the renal collecting system, and increased difficulty in upper pole calyceal puncture"
  • Retrorenal colon risk is lower in supine (2% vs 10% prone)

Monitoring During PCNL (Anesthesia)

  • Airway pressures, end-tidal CO2, O2 saturation (for pleural injuries)
  • Hemodynamics (for bleeding)
  • Temperature (hypothermia from irrigation)

8. Drainage After Supine PCNL

Like prone PCNL, end-of-procedure drainage options include:
  1. Standard nephrostomy tube (30Fr tract) - recommended if:
    • Second-look procedure planned
    • Significant bleeding or collecting system perforation
    • Upper pole access with pleural risk
    • Multiple tracts created
    • High probability of residual stones
    • Significant infection
  2. Tubeless PCNL (ureteral catheter/stent only, no nephrostomy) - gaining support, reduces postoperative morbidity
  3. Totally tubeless (JJ stent only) - selected patients
  • Hinman's Atlas, p. 253

9. Special Populations Favored for Supine PCNL

  • Morbid obesity: Less abdominal compression, better ventilation, easier airway access
  • Cardiopulmonary compromise: Hemodynamically more stable, airway always accessible
  • Spinal deformities / inability to go prone: Cannot tolerate prone positioning
  • Solitary kidney: Reduced anesthetic risk
  • Horseshoe kidney / pelvic kidney: Supine with US or laparoscopic guidance may be needed
  • Simultaneous bilateral stones: Some reports of bilateral supine PCNL in one session

10. Contraindications to PCNL

Contraindications apply to all PCNL positions:
  • Uncorrected coagulopathy
  • Active, untreated urinary tract infection (relative - treat infection first)
  • Patient anatomy making safe percutaneous access impossible

Summary

Supine PCNL is an effective, well-validated alternative to prone PCNL with equivalent stone-free rates across large meta-analyses (11,774 patients). Its main advantages are shorter operative time, reduced anesthetic risk (especially in obese/cardiopulmonary patients), and the ability to perform simultaneous retrograde endoscopy (ECIRS) without repositioning. The main limitations are a smaller surgical field, difficulty with upper pole access, and collapse of the collecting system. The Galdakao-modified supine Valdivia and Barts FFMS positions are currently the most utilized variants. Position choice remains largely surgeon-preference dependent, and proficiency in either technique requires a dedicated learning curve.
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