Comparative study of percutaneous nephrolithotomy performed in the traditional prone position and in three different supine positions

Melo, Petronio Augusto de Souza; Vicentini, Fabio Carvalho; Perrella, Rodrigo; Murta, Claudio Bovolenta; Claro, Joaquim Francisco de Almeida

doi:10.1590/S1677-5538.IBJU.2018.0191

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Original Article • IBJUInt. braz j urol 45 (1) • Jan-Feb 2019 • https://doi.org/10.1590/S1677-5538.IBJU.2018.0191 copy

Comparative study of percutaneous nephrolithotomy performed in the traditional prone position and in three different supine positions

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Purpose:

To compare the outcomes of percutaneous nephrolithotomy (PCNL) performed in the prone position (PRON) and in three variations of the supine position.

Materials and Methods:

We performed a retrospective analysis of patients that underwent PCNL at our institution from June 2011 to October 2016 in PRON and in three variations of the supine position: complete supine (COMPSUP), original Valdivia (VALD), and Galdakao - modified Valdivia (GALD). All patients had a complete pre - operative evaluation, including computed tomography (CT). Success was defined as the absence of residual fragments larger than 4 mm on the first post - operative day CT.

Results:

We analyzed 393 PCNLs: 100 in COMPSUP, 94 in VALD, 100 in GALD, and 99 in PRON. The overall success rate was 50.9% and was similar among groups (p = 0.428). There were no differences between groups in the number of punctures, stone - free rate, frequency of blood transfusions, drop in hemoglobin level, length of hospital stay, and severe complications (Clavien ≥ 3). COMPSUP had a significantly lower operative time than the other positions. COMPSUP had lower fluoroscopy time than VALD.

Conclusion:

Patient positioning in PCNL does not seem to impact the rates of success or severe complications. However, COMPSUP is associated with a shorter surgical time than the other positions.

Keywords:
Nephrolithotomy; Percutaneous; Prone Position; Kidney Calculi

		COMPSUP	VALD	GALD	PRON	p value
n (patients)		100	94	100	99
Age (years), mean ± SD		48.86 ± 12.59	47.86 ± 12.43	50.71 ± 12.12	47.66 ± 12.58	0.293
Gender						0.256
	Male, %	37.0%	29.8%	43.0%	33.3%
	Female, %	63.0%	70.2%	57.0%	66.7%
BMI (kg/m²), mean ± SD		27.40 ± 4.75	27.96 ± 5.79	26.97 ± 4.61	27.10 ± 5.40	0.550
ASA score						0.321
	ASA 1, %	34.0%	23.4%	26.0%	29.3%
	ASA 2, %	53.0%	69.1%	57.0%	58.6%
	ASA 3, %	13.0%	7.4%	16.0%	12.1%
	ASA 4, %	0%	0%	1.0%	0%
Side of the surgery						0.201
	Right, %	55.0%	61.7%	46.5%	52.5%
	Left, %	45.0%	38.3%	53.5%	47.5%
Stone largest diameter (mm), mean ± SD		31.06 ± 18.25	29.49 ± 13.61	28.73 ± 11.83	30.34 ± 11.65	0.673
Guy's Stone Score						0.283
GSS 1, %		15.0%	16.0%	10.0%	22.2%
GSS 2, %		33.0%	21.3%	27.0%	21.2%
GSS 3, %		31.0%	42.6%	43.0%	37.4%
GSS 4, %		21.0%	20.2%	20.0%	19.2%

		COMPSUP	VALD	GALD	PRON	TOTAL	p value
Number of PCNL, n		100	94	100	99	393
Number of puncture tracts, median(range)		1 (1-5)	1 (1-4)	1 (1-3)	1 (1-3)	1 (1-5)	0.381
Operative time (min), mean (±SD)		90.50 (44.36)	111.02 (40.87)	120.85 (49.49)	123.48 (45.14)	111.44 (46.84)	< 0.001
Fluoroscopy time (min), mean (±SD)		12.12 (7.50)	15.60 (8.07)	14.23 (9.47)	15.08 (8.08)	14.23 (8.39)	0.020
Success rate (RF ≤ 4mm), %		58.0%	48.9%	49.0%	47.5%	50.9%	0.428
Stone-free rate, %		43.0%	34.0%	35.0%	37.4%	37.4%	0.565
Blood transfusion rate, %		8.0%	2.1%	3.0%	8.1%	5.3%	0.118
Drop in hemoglobin level (g/dL), mean (SD)		2.22 (1.46)	1.91 (1.28)	1.97 (1.22)	2.34 (1.39)	2.11 (1.35)	0.092
Complications, n							0.001
	Clavien I	3	1	0	8	12
	Clavien II	7	5	1	6	19
	Clavien III	6	5	7	6	24
	Clavien IV	4	0	1	3	8
	Clavien V	0	0	0	0	0
Total, %		20.0%	11.7%	9.0%	23.2%	16.0%	0.019
Major complications (Clavien higher or equals to III), %		10.0%	5.3%	8.0%	9.1%	8.1%	0.663
Hospital stay (hours), mean (SD)		53.12 (49.38)	53.66 (36.68)	54.30 (32.99)	67.92 (58.75)	57.23 (45.90)	0.070
Tubeless rate, %		31.3%	21.3%	14.0%	10.1%	19.1%	0.001

	GSS 1	GSS 2	GSS 3	GSS 4	TOTAL	p value
DDH	93.3%	72.7%	51.6%	19.0%	58.0%	< 0.001
VALD	100.0%	50.0%	42.5%	21.1%	48.9%	< 0.001
GALD	80.0%	51.9%	55.8%	15.0%	49.0%	0.003
VENT	90.9%	42.9%	37.8%	21.1%	47.5%	< 0.001
Total	91.9%	56.4%	47.0%	19.0%	50.9%	< 0.001
p value	0.347	0.127	0.365	0.958	0.428

Type of complication	Position				Total
Type of complication	COMPSUP	VALD	GALD	PRON	Total
Urinary tract infection	5 (5.0%)	2 (2.1%)	0	2 (1.0%)	9 (2.3%)
Blood transfusion	8 (8.0%)	2 (2.1%)	3 (3.0%)	8 (8.1%)	21 (5.3%)
Tract leakage > 24 h	2 (2.0%)	0	1 (1.0%)	1 (1.0%)	4 (1.0%)
Renal injury	0	1 (1.1%)	0	1 (1.0%)	2 (0.5%)
Pain	3 (3.0%)	1 (1.1%)	0	3 (3.0%)	7 (1.8%)
Calculi migrating to ureter	1 (1.0%)	3 (3.2%)	2 (2.0%)	1 (1.0%)	7 (1.8%)
Colon injury	0	1 (1.1%)	1 (1.0%)	2 (2.0%)	4 (1.0%)
Pleura injury	1 (1.0%)	0	3 (3.0%)	6 (6.1%)	10 (2.6%)
Pseudoaneurysm	2 (2.0%)	0	0	0	2 (0.5%)
Bronchospasm	0	1 (1.1%)	0	0	1 (0.3%)
Pulmonary embolism	1 (1.0%)	0	0	1 (1.0%)	2 (0.5%)
Duodenal injury	0	0	0	1 (1.0%)	1 (0.3%)

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[1] Correspondence address: Petronio Augusto de Souza Melo, MD Divisão de Urologia do Centro de Saúde Masculina do Hospital Brigadeiro Avenida Brigadeiro Luis Antonio, 2791 São Paulo, SP, 01401-000, Brasil Telephone: + 55 11 95251-4632 E-mail: petronio_augusto@hotmail.com