title: When prone position is contraindicated or not preferable, can supine percutaneous nephrolithotomy solve the problem?
abstract: OBJECTIVE
  To assess safety and efficacy of supine percutaneous nephrolithotomy in patients for whom prone position or general anesthesia is contraindicated or not preferable due to associated comorbidities, overweight or ipsilateral upper ureteric calculi.
  
  
  METHODS
  Fifty two patients (37 males and 15 females, mean age 33 ± 10.2 years) were included in this study. Supine position was selected due to anesthetic considerations (preexisting compromised cardiopulmonary status, morbid obesity (body mass index > 40 kg/m²) and/or other associated medical comorbidities), impossible prone position due to bone deformities or associated ipsilateral upper ureteric stone. Regional anesthesia was used in 24 patients while 28 patients underwent general anesthesia. After standard cystoscopy and retrograde ureteropyelography in the dorsal lithotomy position, the position was modified using 3 liters of saline bag below the ipsilateral upper flank. Percutaneous access to the pelvicalyceal system was performed through the posterior axillary line under fluoroscopic guidance.
  
  
  RESULTS
  Successful renal puncture was achieved in all cases. Single access via the lower calyx was the most commonly used access (36 cases). Stone-free rate was 92.3%. Postoperative complications classified according to Clavien Dindo classification included bleeding requiring transfusion (3.8%), prolonged fever (7.7%), deep venous thrombosis (1.9%) [grade II in all] and urinary leakage requiring ureteric stenting (5.8%) [grade IIIa].
  
  
  CONCLUSIONS
  The modified supine position for percutaneous nephrolithotomy is a safe and effective option that offers several advantages with an excellent outcome. It can be performed safely for morbidly obese patients and those with cardiopulmonary compromise.
authors.affiliation: Urology Department, Ain Shams University, Cairo, Egypt.
authors.forename: A
authors.initials: A
authors.lastname: Youssef
authors.forename: M
authors.initials: M
authors.lastname: Esmat
authors.forename: M
authors.initials: M
authors.lastname: Wael
mesh_terms: D000293:Adolescent; D000328:Adult; D000075202:Contraindications; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009403:Nephrostomy, Percutaneous / Q000379:methods* / Q000592:standards; D056888:Patient Positioning / Q000379:methods*; D016684:Prone Position; D011446:Prospective Studies; D011859:Radiography; D016683:Supine Position; D014514:Ureteral Calculi / Q000000981:diagnostic imaging / Q000601:surgery*; D055815:Young Adult