Impact of patient position on the outcomes of percutaneous neprolithotomy for complex kidney stones.

Fabio Carvalho Vicentini,Vinicius M. G. Souza,Marcelo Hisano,Joaquim Francisco de Almeida Claro,Claudio Bovolenta Murta,Rodrigo Perrella

doi:10.1590/s1677-5538.ibju.2018.0163

Abstract

ABSTRACTPurpose:To evaluate the impact of the patient position on the outcomes of PCNL among patients with complex renal stones.Material and Methods:From July 2011 to July 2014, we collected prospective data of consecutive patients who underwent PCNL. We included all patients with complex stones (Guy's Stone Score 3 or 4 (GSS) based on a CT scan) and divided them based on the position used during PCNL (prone or supine). The variables analyzed were gender, age, body mass index, ASA score, stone diameter, GSS, number of punctures, calyx puncture site, intercostal access and patient positioning. Complications were graded according to the modified-Clavien Classification. Success was considered if fragments ≤ 4mm were observed on the first postoperative day CT scan.Results:We analyzed 240 (46.4%) of 517 PCNL performed during the study period that were classified as GGS 3-4. Regarding patient positions, 21.2% were prone and 79.8% were supine. Both groups were comparable, although intercostal access was more common in prone cases (25.5% vs 10.5%; p=0.01). The success rates, complications, blood transfusions and surgical times were similar for both groups; however, there were significantly more visceral injuries (10.3% vs 2.6%; p=0.046) and sepsis (7.8% vs 2.1%; p=0.042) in prone cases.Conclusion:Supine or prone position were equally suitable for PCNL with complex stones and did not impact the success rates. However, supine position was associated with fewer sepsis cases and visceral injuries.

Highlights

Percutaneous nephrolithotomy (PCNL) is the gold standard treatment for large kidney stones [1, 2], taking the place of morbid and invasive open surgery
The aim of this study was to evaluate the impact of the patient position on the outcomes, including complications and success ratios, of PCNL with complex stones, using Guy’s stone score classification [10]
We included all patients with complex stones, defined as grade 3 or 4 of the Guy’s Stone Score (GSS) [10, 11], based on the preoperative CT scan analysis

Summary

Introduction

Percutaneous nephrolithotomy (PCNL) is the gold standard treatment for large kidney stones [1, 2], taking the place of morbid and invasive open surgery. Much discussion has emerged in the recent literature about patient positioning. Since Valdivia-Uria study in 1987 [3], the use of a supine position was recognized as feasible, and approximately 10 years later, good outcomes were reported by the same group [4], making this approach more accessible and even more popular with recent variations [5]. The possibility of treating the patient without changing the position to prone is most widely accepted as its best virtue [6]. Prone PCNL with upper pole access has been accepted as the standard for treating complex stones, and the applicability of supine PCNL for these cases is still controversial [7]. There are ibju | Nephrolithotomy for complex kidney stones only a few randomized studies that compared both positions, and they showed few differences in outcomes and complications [8, 9]. Considering the low number of staghorn calculi included in these studies, this question cannot be answered by the current literature

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