This week’s Guest Post is by Denby Steele, an Adelaide Urologist, an expert in the management of complex kidney stone disease and pioneer of supine PCNL in Australia
"Marberger, Clayman and Whickam, in different parts of the world, were instrumental with the development of percutaneous stone surgery in the late 1970’s and early 1980’s, and for many years this has been performed in the prone position. Extracorporeal shock lithotripsy in the early 1990’s and flexible ureteroscopic laser lithotripsy in the later 1990’s have provided less invasive alternatives for upper tract stone surgery but percutaneous surgery still offers an excellent minimally invasive option, particularly for larger stones.
"Traditionally, percutaneous stone surgery has been performed in the prone position but since the first description of this in the supine position by Valdivia et al in the Journal of Urology in 1998, there have been pockets of interest and increasing expertise in surgery in this position.
"My series of 322 cases published in the Journal of Endourology in 2007 is still the second largest published series, but there are increasing reports from around the world and numerous reviewers and commentators have highlighted the advantages of surgery in this position. Randomised trials have proven the safety, efficacy and time saving.
"The supine position was presumably neglected because of fear of colonic injury, but it has been shown radiologically that the colon floats further away from the kidney in the supine position, exposing a greater area for safe percutaneous puncture. With the patient tilted over a 3 litre bag under the flank it is possible to puncture even more posteriorly than some prior prone punctures. There have been no reports of colonic perforation in the supine position in the literature.
"There has been debate about which position is best, but this will depend on the sex of the patient, body habitus, whether concomitant rigid lower tract instrumentation is required, stone burden and position of the colon relative to the kidney. I recommend a 3 litre (1 litre in small patients) saline bag under the ipsilateral flank, a pillow under the ipsilateral leg for males, and lithotomy position for females or males requiring a rigid cystoscopy or ureteroscopy. The ipsilateral arm is always brought across the chest. The flank and perineum are prepared and draped together for a single stage procedure starting with flexible cystoscopy and ureteric catheterisation over a glide wire. The image intensifier is angled back 5 – 10 degrees to allow for the patient tilt. Kidney puncture, tract dilatation and stone surgery are then performed in the standard fashion. I tend to leave a ureteric stent afterwards and drain the bladder but do not leave a nephrostomy tube.
"The supine position is very attractive to nursing staff, anaesthetists and surgeons, and offers the following advantages:
- Reduced manual handling with no position change
- No dangerous prone position
- No patient shoulder strain
- Single set up and draping
- Easy concomitant rigid cystoscopy and ureteroscopy
- Comfortable surgery in the sitting position
- Reduced radiation to the surgeon as hands not under the image intensifier
- Increased safety as it is easy to pass a wire through the puncture and out the urethra
- Stone fragments will spontaneously exit the obliquely placed sheath
- Reduced operating theatre time
"I have performed percutaneous surgery in the supine position in all 680 cases since 1999 and regularly lecture and run workshops in Australia and overseas to promote and teach this simple and improved technique."
Denby Steele is a Urologist in private practice in North Adelaide South Australia, a Senior Visiting Urologist at the Royal Adelaide Hospital, the inaugural Chairman of the Endourology Special Advisory Group of the Urological Society of Australian and New Zealand, the immediate past Chairman of the SA & NT branch of the Urological Society of Australian and New Zealand and an examiner in Urology for the Royal Australian College of Surgeons.