Endo-urologyEndoscopic Combined Intrarenal Surgery in Galdakao-Modified Supine Valdivia Position: A New Standard for Percutaneous Nephrolithotomy?
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
References (30)
- et al.
Advances in percutaneous nephrostolithotomy
Urol Clin North Am
(2007) - et al.
Feasibility of percutaneous nephrolithotomy under assisted local anaesthesia: a prospective study on selected patients with upper urinary tract obstruction
Eur Urol
(2007) - et al.
Miniperc? No, thank you!
Eur Urol
(2007) - et al.
How small can we go? Percutaneous nephrolithotomy using 6F nephroureteral catheter
Urology
(2007) - et al.
AUA guideline on management of staghorn calculi: diagnosis and treatment recommendations
J Urol
(2005) - et al.
Reverse lithotomy, modified prone position for simultaneous nephroscopic and ureteroscopic procedures in women
Urology
(1988) - et al.
Percutaneous stone removal with the patient in a flank position
J Urol
(1994) - et al.
Percutaneous nephrolithotomy in the supine position. Technical aspects and functional outcome compared with the prone technique
Urology
(2002) - et al.
ASA classification and peri-operative variables as predictors of postoperative outcome
Br J Anaesth
(1996) - et al.
Classification of percutaneous nephrolithotomy complications using the modified Clavien grading system: looking for a standard
Eur Urol
(2008)
Complications in percutaneous nephrolithotomy
Eur Urol
Access related complications during percutaneous nephrolithotomy: urology versus radiology at a single academic institution
J Urol
Techniques for fluoroscopic percutaneous renal access
J Urol
The learning curve in the training of percutaneous nephrolithotomy
Eur Urol
Outcome of percutaneous nephrolithotomy: effect of body mass index
Eur Urol
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