The debate over percutaneous nephrolithotomy positioning: A comprehensive review

Purpose We summarized the arguments for and against prone and supine percutaneous nephrolithotomy, and determined whether any clinical characteristics warrant 1 position over the other. Materials and Methods We searched PubMed® for articles on prone anesthesia, abdominal organ movement between the prone and supine positions, and percutaneous nephrolithotomy case series since 1998. Results The prone position is associated with a decrease in the cardiac index and an increase in pulmonary functional residual capacity. An increased risk of liver and spleen injury exists for upper pole puncture with the patient supine. Potential injury to the colon is greatest during prone lower pole access. A greater surface area for percutaneous access exists with the patient prone. The supine position decreases surgeon radiation exposure and promotes spontaneous stone drainage during the procedure. Two comparative series show that the supine position is associated with significantly shorter operative time. In contrast, noncomparative case series suggest decreased operative time and blood loss when treating staghorn calculi with the patient prone. Conclusions Each position is feasible but more randomized studies are needed to accurately determine the relative efficacy and morbidity of the 2 positions.