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Initial Outcomes of Supine PCNL in the United States: Another Arrow for the Urologist's Quiver
Priyanka Bearelly, MD1, Sanchita Bose, MD1, Jacqueline M. Speed, MD2, Jerilyn M. Latini, MD3, Ruslan Korets, MD3.
1Boston Medical Center, Boston, MA, USA, 2Brigham and Women's Hospital, Boston, MA, USA, 3Veterans Affairs Boston Healthcare System, Harvard Medical School, Boston, MA, USA.
Background:
Percutaneous nephrolithotomy (PCNL) is a treatment of choice for complex renal calculi. Traditionally, prone position for PCNL has been the preferred approach. Valdivia was the first to describe the technique and advantages of performing PCNL in supine position so as to minimize the risks associated with the classic prone position. Over time, the supine position has gradually gained traction in Europe, Asia and South America. However, the technique is utilized in only 1.5% of PCNLs performed in North America and to our knowledge has never been reported in the United States. The purpose of this study is to describe technique, outcomes and complications following initial implementation of supine PCNL.
Methods:
Between September 2016 and March 2017, 24 patients underwent PCNL in the supine position at a New England tertiary referral center. Galdakao-modified Valdivia position was utilized for cases where concomitant contralateral ureteroscopy was planned. Bart’s flank-free modified supine position was used for all other cases. Renal access was obtained in the operating room with fluoroscopic guidance. Patient demographics, stone characteristics, access time, total operative times, estimated blood loss, fluoroscopy time, radiation dose, stone-free rates, and complications based on the Clavien-Dindo classification system were collected. To assess the effect of the learning curve, perioperative outcomes were compared between the first and last 12 cases.
Results:
Patients had a median age of 67.5 years, ASA 3, and Guy’s stone score of 3. Lower pole access was used in 14 (58.3%) patients, while upper pole access was obtained in 7 (29.3%) of cases. Two patients required multiple tracts. Median operative time was 119 minutes (IQR: 108, 140) and estimated blood loss was 100cc. In 4 patients, concomitant contralateral retrograde ureteroscopy with laser lithotripsy was performed as urethral access was readily available. Tubeless PCNL was performed in 12 (50%) cases. No patients required blood transfusions and median length of stay was 1 day. On follow-up imaging 20 out of 24 (83%) patients were considered stone-free after surgery. Minor complications (Clavien ≤2) occurred in 2 (8.3%) patients, and 1 patient required stent placement two days after initial procedure (Clavien 3). Over time, there was significant improvement in renal access times and operative times.
Conclusions:
Like most surgical procedures, an initial learning curve exists. However, for urologists facile with percutaneous nephrolithotomy, supine position for PCNL can be easily and safely implemented into practice. Supine positioning has the benefit of eliminating risks associated with prone positioning in patients with neuromuscular conditions, high body mass index, and cardiopulmonary disease. Additionally, it provides ease of access to the lower urinary tract as well as retrograde access to the contralateral side without need for repositioning.
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