PCNL in Sitting Position

• 23 Jun 2020 09:45:10 AM
• |Endo Urology

Dear all,

Greek Philosopher Pluto said ‘Necessity is the mother of Invention’.

The concept of a change in management of Renal Calculi commenced in 1941 when Rupel and Brown performed the first Nephroscopy by placing a rigid cystoscope through a nephrostomy tract so that stones could be removed during open surgery. This was followed much later with the introduction of Right angled Scope (I had Storz Scope for this purpose) that could be introduced to visualize the Renal Pelvis and Calyces and retrieve stones. In 1955, Willard Goodwin is credited with placing a nephrostomy tube percutaneously. This approach would lead to the realization that a percutaneous tract could be used to access the kidney.

Today there are no takers for open surgery for renal calculi even for more complex cases. The present mentors are adapt at PCNL but not with open surgical techniques. Hence it is not surprising that the present trainees do not even know the nuances of open techniques. This has been mentioned by Noor Bucholz as early as 2006.

In 1976, Fernström and Johansson were the first to describe a technique for extracting renal calculi through a percutaneous nephrostomy under radiological control.  Wickham described the initial procedure as being performed over several days. After placement of a small caliber nephrostomy tube, the tract was serially dilated over several days to 22Fr to 26 Fr prior to removal of the nephrostomy tube and insertion of a standard rigid 21 Fr cystoscope used to access the calyceal system. Arthur Smith coined the term ‘Endourology’ to describe closed, controlled manipulation of the genitourinary tract.

Innovations in renal access, optics, radiology and improvements in lithotripsy all contributed to the modern way of performing PCNL. This has allowed us to fulfill the Hippocratic oath that ‘I will not cut for stones’.

We should be proud that over the past decade and half, Indian Urologists have led the way in perfecting PCNL more.

Many even now perform PCNL in Prone position and all subsequent ways developed to perform PCNL are compared to the outcomes obtained with Prone PCNL and hence considered the “gold standard’. Since Valdivia Uría postulated that PCNL could be performed in the supine decubitus position’, many modifications have been developed to perform Supine PCNL safely. Galdakao and Bart independently modified Valdivia technique. Priyadarshi Kumar et al (2012) introduced ‘Bart’s Flank Free Modified Supine Tecchnique’. Giusti introduced his technique to facilitate east access without any inconvenience. The supine position, either in traditional Valdivia-Galdakao or in Giusti-modified Valdivia position, can facilitate simultaneous manipulation antegrade and retrograde transurethral approaches to complex stone disease. ECIRSsupine PCNL with the addition of retrograde transurethral flexible ureteroscopy (fURS) was popularized by Scoffone in order to maintain high stone free rates of PCNL while decreasing the need for additional punctures to render patients stone free. ECIR in Prone position was developed by Grasso in 1993. Mahesh Desai et al (2007) is an early bird at performing Supine PCNL as well.

A new technique has been suggested by performing PCNL in ‘Sitting Position’. This has been performed in a patient with severe COPD and was performed under LA. Can this procedure be developed as an alternative to existing procedures for PCNL? Anesthesiologists are familiar with procedures performed in sitting position.

https://bmcurol.biomedcentral.com/track/pdf/10.1186/s12894-020-00640-3

Will this procedure described have a future is to be seen. All new techniques were developed due to necessity hoping to make a procedure safer than what could be accomplished by an earlier technique. But once a technique performed successfully will lead others to take it up but with some reservations. Even today, Supine PCNL in spite of establishing itself is probably performed in not more than 20% of cases.

With Warm regards,

Venu

Comments(3)

• 

  Nitesh Jain

  25 Jun 2020 12:20:59 AM

  Sir supine is going to stay and have got distinct advantage specially with advent of ECIRS ... improving the stone clearance, decreasing the no of puncture required.... PCNL in sitting position not sure how advantageous it will be for the anaesthetist or surgeon .... and doing a UC punture , anti gravity drainage may be a concern ...I think supine probably achieves all at present 

• 

  Ravindra Sabnis

  25 Jun 2020 10:13:54 AM

  Sitting position PCNL is not going to be standard position. I do not think there is even intent to make this as new standard. But certainly there is need to do PCNL in sitting position - very occasionally. We have done 2-3 cases in last 25-30 years. But what we did was multistage sitting position in PCNL. Case with severe kyphoscoliosis, Severe breathing problem. Pt not able to sleep even at home due to deformity & lung compromise. Having symptomatic stone. We did first under LA - just PCN, then tract dilatation later & stone removal under LA. Those who need sitting position PCNL are unfit for anaesthesia. & hence every thing needs to be done under LA & hence multistage .Obviously USG guide is only way to access kidney

  But personally I feel sitting position has lot of limitations & only in desperate situation it can be done. 
  

    

  

• 

  S K PAL

  03 Jul 2020 05:21:31 PM

  Due to compulsion, we had to do PCN in few cases in sitting posture and that too under local anaesthesia.  It was due to severe skeletal deformities or due to respiratory disorders because of which patient was unable to lie in prone or even supine position. Such patients , even go to sleep also, almost in sitting posture. Although space available for working was adequate to access any calyx, rather more than what we get in supine PCNL, biggest problem was organising free and proper movement of C arm around the patient.

  In the days to come, if we start doing all PCNLs, totally under Ultrasound guidance, PCNL in sitting posture may turn out to be a better and preffered modality.

  Worth keeping in mind and exploring in future.

  S.K.Pal