Elsevier

European Urology

Volume 54, Issue 6, December 2008, Pages 1393-1403
European Urology

Endo-urology
Endoscopic Combined Intrarenal Surgery in Galdakao-Modified Supine Valdivia Position: A New Standard for Percutaneous Nephrolithotomy?

https://doi.org/10.1016/j.eururo.2008.07.073Get rights and content

Abstract

Background

Percutaneous nephrolithotomy (PCNL), the gold standard for the management of large and/or complex urolithiasis, is conventionally performed with the patient in the prone position, which has several drawbacks. Of the various changes in patient positioning proposed over the years, the Galdakao-modified supine Valdivia (GMSV) position seems the most beneficial. It allows simultaneous performance of PCNL and retrograde ureteroscopy (ECIRS, Endoscopic Combined Intra-Renal Surgery) and has unquestionable anaesthesiological advantages.

Objective

To prospectively analyse the safety and efficacy of endoscopic combined intrarenal surgery (ECIRS) in GMSV position for the treatment of large and/or complex urolithiasis.

Design, setting, and participants

From April 2004 to December 2007, 127 consecutive patients who were followed in our department for large and/or complex urolithiasis were selected for surgery (American Society of Anesthesiologists [ASA] score 1–3, no active urinary tract infection [UTI], any body mass index [BMI]).

Intervention

All the patients underwent ECIRS in GMSV position. Technical choices about percutaneous access, endoscopic instruments and accessories, and postoperative renal and ureteral drainage are detailed.

Measurements

Patients’ mean age plus or minus standard deviation (± SD) was 53.1 yr ± 14.2. Of the 127 patients, 5.5% had congenital renal abnormalities, 3.9% had solitary kidneys, and 60.6% were symptomatic for renal colics, haematuria, and recurrent UTI. Mean stone size ± SD was 23.8 mm ± 7.3 (range: 11–40); 33.8% of the calculi were calyceal, 33.1% were pelvic, 33.1% were multiple or staghorn, and 4.7% were also ureteral.

Results and limitations

Mean operative time ± SD was 70 min ± 28, including patient positioning. Stone-free rate was 81.9% after the first treatment and was 87.4% after a second early treatment using the same percutaneous access during the same hospital stay (mean ± SD: 5.1 d ± 2.9). We registered overall complications at 38.6% with no splanchnic injuries or deaths and no perioperative anaesthesiological problems.

Conclusions

ECIRS performed in GMSV position seems to be a safe, effective, and versatile procedure with a high one-step stone-free rate, unquestionable anaesthesiological advantages, and no additional procedure-related complications.

Introduction

Percutaneous nephrolithotomy (PCNL) has undergone considerable evolution since its introduction in 1976 [1], driven by the improvement in access techniques, instrumentation, lithotripsy, and endoscopic technology [2]. Efforts have also been made to decrease the procedure's morbidity, analgesic requirements, and hospitalisation time [3], [4], [5]. PCNL has become an increasingly common, minimally invasive surgical procedure and is the gold standard for the management of large or otherwise complex urolithiasis [6], [7].

PCNL was initially performed with the patient in the supine-oblique position, but the prone position later became the conventional one. The prone position provides a larger area for the percutaneous renal access, a wider space for instrument manipulation, and a claimed lower risk of splanchnic injury. It is, however, associated with patient discomfort, increased radiological hazard to the urologist's hands, and the need for several nurses to be present for intraoperative changes of the decubitus in case of simultaneous retrograde instrumentation of the ureter (implying evident risks related to pressure points and possible ocular, spinal, or peripheral nerve injuries). The prone position also implies important anaesthesiological disadvantages (poorly perceived by urologists but very familiar to anaesthesiologists through experience with the prone position also for neurosurgical and orthopaedic pathologies), including circulatory, haemodynamic, and ventilatory difficulties, particularly in obese patients [8]. To overcome these drawbacks, various safe and effective changes in patient positioning for PCNL have been proposed over the years, including the reverse lithotomy position [9], the prone split-leg position [10], [11], the lateral decubitus [12], [13], the supine position [14], [15], [16], and the Galdakao-modified supine Valdivia (GMSV) position [8]. None of these changes has succeeded in overcoming the habit to the prone position.

Interest in routinely combining PCNL with retrograde ureteroscopy (i.e. endoscopic combined intrarenal surgery [ECIRS]) for large and/or complex urolithiasis arose when we decided to abandon the prone position for the above-mentioned reasons and adopted the GMSV position. In the present paper, we report our experience in testing the safety and efficacy of this procedure in this position.

Section snippets

Methods

The computerised data of 127 consecutive patients who underwent ECIRS in GMSV position between April 2004 and December 2007 in our centre were prospectively collected and analysed. Data are reported as numbers and percentages or as mean plus or minus standard deviation (±SD) and median, as appropriate.

Patient demographics and stone features (Tables 2 and 3)

Of 127 patients, 77 (60.6%) were symptomatic for renal colics, haematuria, and recurrent urinary tract infections with fever. In addition to obesity (only about 17% had average BMI), comorbidities were present in 55 patients (43.3%), and ASA 3 was assigned in 37 cases (29.1%). BMI had no influence on treatment outcome provided that extra-long instruments and larger jelly pillows were used. Congenital renal abnormalities included two duplex systems, two horseshoe kidneys, and three

Advantages of the Galdakao-modified supine Valdivia position

Starting in April 2004, we routinely adopted the GMSV position to perform ECIRS in patients affected by large and/or complex urolithiasis. We abandoned the prone position because, for us, it is unacceptable to have even one of the anaesthesiological or neurological complications reported in the literature, which imply long-term and irreversible consequences, while treating such a benign pathology as urolithiasis.

Anaesthesiological advantages include absence of cardiovascular, respiratory,

Conclusions

Criticisms to our study may include lack of a comparison control group (ECIRS in prone split-leg position). With this limitation in mind, we believe that this feasibility trial has at least shown the efficacy and safety of this antero-retrograde endourological procedure with the patient in a modified supine position [14], [15], [16], [29], [30]. Further randomised studies will be needed to demonstrate the impact of ECIRS in GMSV position on the one-step complete resolution of large and/or

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