1527Vol. 11 | No. 02 | March- April 2014 |U R O LO G Y J O U R N A L Complete Supine Tubeless Percutaneous Nephrolithotomy Siavash Falahatkar, Alireza Farzan, Aliakbar Allahkhah, Nadia Rastjou Herfeh, Samaneh Esmaeili Corresponding Author: Siavash Falahatkar, MD Urology Research Center, Guilan University of Medical Sciences, Rasht, Iran. Tel: +98 131 5525259 E-mail: Falahatkar_s@yahoo.com Urology Research Center, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran. VIDEO INTRODUCTION Although,‎percutaneous‎nephrolithotomy‎(PCNL)‎has‎been‎usually‎performed‎in‎the‎prone‎position‎but‎recently‎other‎positions‎like‎supine‎and‎complete‎supine‎have‎been‎recommended‎by‎some‎endourologists.(1-8)‎The‎prone‎position‎has‎numerous‎ disadvantages‎but‎a‎lot‎of‎published‎data‎have‎denoted‎some‎advantages‎of‎the‎supine‎PCNL,‎ including less patient handling, easier access to the urethra, position changing in spinal or regional‎anesthesia‎is‎easier,‎better‎access‎to‎the‎airway‎of‎the‎patients,‎easier‎access‎to‎the‎ upper‎calyces,‎evacuation‎of‎stone‎fragment,‎feasibility‎of‎simultaneous‎ureteroscopy,‎punc- ture‎site‎is‎far‎from‎the‎fluoroscopy‎tube,‎shorter‎operative‎time,‎more‎comfort‎for‎the‎patient,‎ less‎risk‎of‎colon‎injury‎and‎higher‎tolerance‎for‎pulmonary‎or‎cardiovascular‎disease.(1,7-8) We‎aimed‎to‎share‎our‎experience‎of‎the‎complete‎supine‎percutaneous‎nephrolithotomy‎ (csPCNL)‎with‎others‎by‎a‎video‎presentation‎with‎the‎details‎of‎the‎technique.‎ Keywords:‎nephrostomy;‎percutaneous;‎methods;‎humans;‎kidney‎calculi;‎surgery. 1528 | Video SURGICAL TECHNIQUE This‎movie‎presents‎complete‎supine‎PCNL‎in‎a‎52-year‎ old‎man‎with‎multiple‎stones‎in‎his‎right‎kidney.‎After‎ure- teral catheterization, the patient is drawn toward the edge of‎the‎bed.‎It‎is‎not‎necessary‎to‎draw‎the‎patient‎more,‎be- cause‎the‎metal‎density‎of‎the‎bed‎might‎interfere‎during‎the‎ access.‎Flank‎elevation‎or‎changing‎the‎position‎of‎leg‎isn’t‎ needed‎in‎complete‎supine‎position.‎ The‎puncture‎sites‎are‎selected‎between‎mid‎and‎posterior‎ auxiliary‎line‎under‎the‎12th‎rib‎(Figure) The‎subcostal‎upper‎pole‎access‎is‎feasible‎in‎csPCNL‎with‎ some‎technical‎maneuvers.(7) During the deep inspiration, the‎kidney‎moves‎to‎in‎a‎lower‎position‎and‎the‎upper‎calyx‎ achievement‎by‎subcostal‎approach‎is‎feasible.(7)‎In‎com- plete‎supine‎position‎the‎fluoroscopy‎tube‎is‎far‎from‎the‎ surgery‎field‎and‎the‎surgeon‎gets‎a‎wide‎space‎for‎working.‎ The‎kidney‎movement‎is‎the‎marker‎that‎the‎needle‎is‎on‎the‎ posterior‎surface‎of‎the‎kidney.‎Then,‎the‎surgeon‎chooses‎ the‎best‎angle‎for‎achieving‎the‎calyx.‎Because‎the‎fluid‎ may‎drench‎the‎surgeon’s‎lower‎limbs‎due‎to‎the‎sitting‎po- sition‎in‎complete‎supine,‎waterproof‎cover‎is‎used‎by‎the‎ surgeon. One‎of‎the‎most‎important‎differences‎between‎the‎com- plete‎supine‎position‎and‎the‎prone‎position‎for‎PCNL‎is‎ evacuation‎of‎stone‎fragments.‎We‎have‎frequently‎seen‎the‎ evacuation‎of‎stone‎fragments‎during‎the‎surgery.(1)‎Our‎op- tion‎for‎all‎patients‎is‎tubeless‎PCNL‎unless‎the‎presence‎ of‎significant‎residual‎stone‎or‎severe‎hemorrhage‎or‎sig- nificant‎extravasation.(2)‎The‎anesthesia‎time‎in‎the‎supine‎ position‎is‎significantly‎shorter‎than‎the‎prone‎position. CONFLICT OF INTEREST None declared. CONCLUSION As‎we‎have‎shown‎in‎the‎movie‎that‎csPCNL‎is‎feasible‎and‎ the‎surgeon‎can‎decide‎whether‎a‎nephrostomy‎tube‎should‎ be‎inserted‎or‎not? Figure . (A) Shows mid auxiliary line, the 11th and the 12th ribs and the iliac crest. The puncture site in complete supine percutaneous nephrolithotomy is usually placed in an area between mid-auxiliary line and posterior auxiliary line under the 12th rib, (B) demonstrates the puncture site. REFERENCES 1. Falahatkar S, Moghaddam AA, Salehi M, Nikpour S, Esmaili F, Khaki N. Complete supine percutaneous nephrolithotripsy comparison with the prone standard technique. J Endourol. 2008;22:2513-7. 2. Falahatkar S, Farzan A, Allahkhah A. Is complete supine percutane- ous nephrolithotripsy feasible in all patients? Urol Res. 2011;39:99- 104. 3. Rana AM, Bhojwani JP, Junejo NN, Das Bhagia S. Tubeless PCNL with patients in supine position: procedure for all seasons?-with com- prehensive technique. Urology. 2008;71:581-5. 4. Steele D, Marshall V. Percutaneous nephrolithotomy in the supine position: a neglected approach? J Endourol. 2007;21:1433-7. 1529Vol. 11 | No. 02 | March- April 2014 |U R O LO G Y J O U R N A L Tubeless PCNL | Falahatkar et al 5. Basiri A, Mohammadi Sichani M, Hosseini SR, et al. X-ray-free per- cutaneous nephrolithotomy in supine position with ultrasound guidance. World J Urol. 2010; 28:239-44. 6. De Sio M, Autorino R, Quarto G, et al. Modified supine versus prone position in percutaneous nephrolithotomy for renal stones treat- able with a single percutaneous access: a prospective randomized trial. Eur Urol. 2008; 54:196-202. 7. Falahatkar S, Enshaei A, Afsharimoghaddam A, Emadi SA, Allahkhah AA. Complete supine percutaneous nephrolithotomy with lung inflation avoids the need for a supracostal puncture. J Endourol. 2010;24:213-8. 8. Valdivia-Uria JG, Valle Gerhold J, Lopez Lopez JA, et al. Technique and complications of percutaneous nephroscopy: experience with 557 patients in the supine position. J Urol. 1998;160:1975-8.