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PRESENTATIONThe patient position for PNL: Does it matter?Cecilia Maria Cracco, Cesare Marco Scoffone, Massimiliano Poggio,Roberto Mario ScarpaDepartment of Urology, San Luigi University Hospital, Orbassano (Torino), ItalySummaryCurrently, PNL is the treatment of choice for large and/or otherwise complex urolithiasis.PNL was initially performed with the patient in a supine-oblique position, butlater on the prone position became the conventional one for habit and handiness. Theprone position provides a larger area for percutaneous renal access, a wider space forinstrument manipulation, and a claimed lower risk of splanchnic injury. Nonetheless,it implies important anaesthesiological risks, including circulatory, haemodynamic, and ventilatorydifficulties; need of several nurses to be present for intraoperative changes of the decubitusin case of simultaneous retrograde instrumentation of the ureter, implying evident risksrelated to pressure points; an increased radiological hazard to the urologist’s hands; patient discomfort.To overcome these drawbacks, various safe and effective changes in patient positioningfor PNL have been proposed over the years, including the reverse lithotomy position, theprone split-leg position, the lateral decubitus, the supine position, and the Galdakao-modifiedsupine Valdivia (GMSV) position. Among these, the GMSV position is safe and effective, andseems profitable and ergonomic. It allows optimal cardiopulmonary control during generalanaesthesia; an easy puncture of the kidney; a reduced risk of colonic injury; simultaneousantero-retrograde approach to the renal cavities (PNL and retrograde ureteroscopy = ECIRS,Endoscopic Combined IntraRenal Surgery), with no need of intraoperative repositioning of theanaesthetized patient, less need for nurses in the operating room, less occupational risk due toshifting of heavy loads, less risk of pressure injuries related to inaccurate repositioning, andreduced duration of the procedure; facilitated spontaneous evacuation of stone fragments; acomfortable sitting position and a restrained X-ray exposure of the hands for the urologist. But,first of all, GMSV position fully supports a new comprehensive attitude of the urologist towardsa variety of upper urinary tract pathologies, facing them with a rich armamentarium of rigidand flexible endoscopes and a versatile antero-retrograde approach. Prone position may still beuseful in case of important vertebral malformations, specifically hindering the supine position,or for simultaneous bilateral PNL, without having to move the patient intraoperatively, so isstill present in the complementary techniques of a skilled endourologist.KEY WORDS: PNL; Ureteroscopy; Patient position.Submitted 9 May 2009; Accepted 30 June 2009In 1941 Rupel and Brown performed the first percutaneousrenal instrumentation, passing a cystoscope downan openly placed nephrostomy tract. In 1955 Goodwinand colleagues described the technique for percutaneousrenal access; about twenty years later Fernstroem andJohansson developed the percutaneous nephrolithotomy(PNL) procedure for the treatment of large renal stones.Currently, PNL remains the treatment of choice for largeand/or otherwise complex urolithiasis. It was initiallyperformed with the patient in a supine-oblique position,but later on the prone position became the conventionalone because of habit and handiness.The prone position provides a larger area for percutaneousrenal access, a wider space for instrument manipulation,and a claimed lower risk of splanchnic injury.Nevertheless, it implies:a) important anaesthesiological risks – poorly perceivedby urologists, but very familiar to anaesthesiologists,experiencing this position also for neurosurgery andorthopedic interventions –, including circulatory,haemodynamic, and ventilatory difficulties, particularlyin obese patients and in case of long-lasting procedures;b) need of several nurses to be present for intraoperative30Archivio Italiano di Urologia e Andrologia 2010; 82, 1