Endourology and Stones

Effect of Supine vs Prone Position on

Outcomes of Percutaneous Nephrolithotomy
in Staghorn Calculi: Results From the Clinical
Research Ofce of the Endourology Society
Study
Gaston Astroza, Michael Lipkin, Andreas Neisius, Glenn Preminger, Marco De Sio,
Hiren Sodha, Christian Saussine, and Jean de la Rosette, on behalf of the CROES PNL
study group
OBJECTIVE To analyze the effect of patient positioning on outcomes of percutaneous nephrolithotomy (PNL)
among patients with staghorn stones. The choice of optimal position for these patients under-
going PNL remains challenging. No previous studies exclusively addressing this point have been
performed.
METHODS From November 2007 to December 2009, prospective data were collected by the Clinical
Research Ofce of the Endourological Society. We included all patients with staghorn stones.
Patients were divided on the basis of the position used during PNL (prone/supine). Patient
characteristics, stone burden, operative details, and outcomes were compared. Multivariate
analysis was performed to evaluate the relationship between patient position and stone-free rate
and complication rate adjusting for number of access puncture sites.
RESULTS A total of 1079 PNLs were performed in prone and 232 in supine positions. There were no
differences in comorbidities or preoperative stone burden. A higher percentage of patients in the
prone position had access through the upper pole (P <.001). Surgical time was shorter (P <.001)
and stone-free rate was higher (P <.001) for patients in the prone position. There were no
differences in complication rates. In multivariate analysis, patients in prone position had a higher
stone-free rates (P .0013) after adjusting for the method used for determining stone-free status
and number of renal access.
CONCLUSION Higher stone-free rates are achieved in the prone position during PNL for patients with staghorn
calculi. Complication rates were similar for both positions. UROLOGY 82: 1240e1245, 2013.
2013 Elsevier Inc.
P
ercutaneous nephrolithotomy (PNL) is the
recommended technique for the treatment of
large renal calculi, including staghorn stones.
1
Traditionally, PNL has been performed with the patient
in the prone position. After 1998 when Valdivia Uria rst
described a series of patients who underwent PNL in the
supine position,
2
multiple changes in patient position
have been attempted to optimize outcomes and avoid
some of the complications associated with prone
positioning.
In patients with staghorn stones, the PNL is a more
difcult procedure and its outcomes are different than the
associated outcomes for patients with nonstaghorn
stones.
3
The role of positioning during the surgery in this
group of patients has not yet been determined.
The PNL Global Study from the Clinical Research
Ofce of the Endourological Society (CROES) has
generated a PNL database of patients who underwent
PNL during a 1-year period assessing the stone-free rates
Financial Disclosure: The authors declare that they have no relevant nancial interests.
Funding Support: The CROES PCNL Global Study was supported by an unrestricted
educational grant from Olympus. This work has been partially supported by the
Endourological Society and Cook Urological (G.A.; Research Endourology Sponsored
Fellowship) and by a Ferdinand Eisenberger grant of the Deutsche Gesellschaft fr
Urologie (German Society of Urology), NeA1/FE-11 (A.N.).
From the Department of Urology, Duke University Medical Center, Durham, NC;
the Department of Urology, Second University of Naples, Naples, Italy; RG Stone
Urology & Laparoscopy Hospital, Mumbai, India; the Department of Urology,
University of Strasbourg, Strasbourg, France; and the Department of Urology, AMC
University Hospital, Amsterdam, The Netherlands
Reprint requests: Jean de la Rosette, M.D., Ph.D., Department of Urology, AMC
University Hospital, Meibergdreef 9, 1105 AZ Amsterdam Z-O, The Netherlands.
E-mail: J.J.delaRosette@amc.uva.nl
Submitted: January 31, 2013, accepted (with revisions): June 21, 2013
1240 2013 Elsevier Inc. 0090-4295/13/$36.00
All Rights Reserved http://dx.doi.org/10.1016/j.urology.2013.06.068
and complications. (CROES; Global PNL Observational
Study; http://www.croesofce.org/OngoingProjects/PCNL
Study.aspx).
No study has previously analyzed the role of posi-
tioning using the CROES PNL database focusing exclu-
sively on patients with staghorn calculi.
PATIENTS AND METHODS
Data Source
From November 2007 to December 2009, prospective data were
collected by CROES for consecutive patients who underwent
PNL over a 1-year period in 96 centers globally.
4
This study included all adult patients who were enrolled in
the Global PNL study who were classied as having staghorn
calculi. A stone was classied as staghorn when located in the
renal pelvis and was in at least 2 of the calices. Patients with
renal congenital anomalies were excluded from the analysis.
Patients were divided into 2 groups on the basis of the position
used at operation (prone or supine). Patient demographics
characteristics (age, body mass index [BMI], gender, comorbid-
ities, and American Society of Anesthesiologist classication
(ASA)), operative details (renal puncture site and numbers,
surgical time), and outcomes (stone-free rate, retreatment rate,
length of hospital stay, complications, and decrease in hemo-
globin level) were compared between both groups. The distri-
bution of imaging modality for determining stone-free status and
the distribution of caseload were calculated. Caseload was
dened as the median estimated caseload per year. Multivariate
analysis was performed to evaluate the relation between patient
position and stone-free rate and complication rate adjusting for
number of access puncture sites.
All statistical analysis was performed using R-statistical
programming software version 2.12.2, and the level of statistical
signicance was set at .05.
RESULTS
A total of 1311 patients with complete or incomplete
staghorn stones were included in the analysis. A total of
1079 (82.3%) PNLs were performed in prone position
and 232 (17.7%) in supine.
The mean age was higher in the supine group, and
there was a higher number of male patients in the prone
group. No differences in BMI, diabetes mellitus, and
cardiovascular disease were found between both groups.
However, the prone group had a higher percentage of
patients with lower ASA classication.
Patients demographic characteristics and comorbid-
ities are summarized in Table 1.
The mean stone burden was similar in both groups with
446.4 mm
2
in the supine and 402.2 mm
2
in the prone
position (P .997).
In the group of patients treated in the prone position,
a higher percentage of multiple nephrostomy tracts was
used (19.1% vs 9.6%). There was a higher percentage of
upper pole access in the prone group compared with the
supine group (12.6% vs 3.6%; P <.001). The surgical
time was signicantly shorter in the prone group as well
(P <.001). Intraoperative details and complications are
specied in Table 2.
The stone-free rate was higher for the patients in the
prone vs the supine position. (P <.001) Retreatment rate
was higher in the supine group, which is consistent with
the stone-free rate.
Stone-free rates were 48.4% vs 59.2% (P <.001),
retreatment 36.1% vs 29.5% (P <.05), and length of
hospital stay 5.7 days (standard deviation 4.3) vs 5.2 days
(standard deviation 4.1; P .094) for supine and prone,
respectively.
Multivariate analysis (Fig. 1) demonstrated that
patients who were treated in the prone position had
signicant higher stone-free rates compared with those
treated in the supine position (P <.01) after adjusting
for the method used for determining stone-free status
Table 1. Patient demographics and history of previous
treatment
Characteristic
Supine
N 232
Prone
N 1079 P Value
Age (y; mean [SD]) 51.8 (15.1) 49.8 (15.4) <.05
BMI (mean [SD]) 26.4 (5.3) 27.1 (6.1) .089
Gender distribution
Male (%) 41.0 55.2 <.001
Female (%) 59.0 44.8
Comorbidities
Diabetes mellitus (%) 13.7 16.7 .226
Cardio vascular
disease (%)
23.7 25.7 .619
Previous treatment
ASA classication
ASA I (%) 39.9 50.6 <.01
ASA II (%) 45.6 34.0
ASA III (%) 12.5 14.1
ASA IV (%) 2.0 1.3
ASA, American Society of Anesthesiologist; BMI, body mass index;
SD, standard deviation.
Table 2. Intraoperative details and outcomes
Characteristic
Supine
N 232
Prone
N 1079
P
Value
Renal puncture site
Upper pole (%) 3.6 12.6 <.001
Middle pole (%) 16.9 14.8
Lower pole (%) 69.9 53.6
Multiple poles (%) 9.6 19.1
Location of access
Above 11th rib (%) 1.6 2.7 <.001
Above 12th rib (%) 8.1 20.2
Below 12th rib (%) 90.3 77.1
Operative duration
Operative time
(min; mean [SD])
123.1
(52.8)
103.2
(52.7)
<.001
Intraoperative
complications
Failed access (%) 4.0 1.4 <.01
Perforation (%) 6.0 4.5 .142
Hydrothorax (%) 0.4 2.1 .053
Blood loss parameters
Change in hemoglobin
(mg/dL; mean [SD])
4.2 (3.0) 4.1 (3.6) .913
Abbreviation as in Table 1.
UROLOGY 82 (6), 2013 1241
and the number of renal access puncture sites. Patients
who needed multiple renal access did not achieve
a statistically signicant difference in the stone-free rate
(P .12) compared with patients with a single access
tract.
If we compare the different imaging modalities used to
assess the stone-free rate, the patients who were assessed
using uoroscopy and patients using ultrasound were
judged to have higher stone-free rates compared with
those evaluated using computed tomography (CT) image
(P <.001 and P .30, respectively). The percentages of
ultrasound and kidney, ureter, and bladder x-ray were 6.3
and 76.1 for prone position and 20.9 and 62.3 for supine
position (P <.001 for both). The distribution of CT did
not differ signicantly between the groups (17.6 and 16.7
respectively; P .770). Supine position was rarely per-
formed in high-volume centers (2.9% vs 97.1% in low-
volume centers), whereas the prone position was more
equally distributed (44.1% vs 55.9% in low-volume
centers). This distribution differed signicantly
(P <.001). Median caseload was established at 27 esti-
mated cases per year.
There was no statistically signicant difference in
complication rates between patients with staghorn stones
who underwent PNL in prone or supine position (P
.480). After adjusting for the patient position, patients
who had multiple renal access punctures had signicantly
more complications compared with those who had single
puncture. (P <.0001; Fig. 2).
COMMENT
PNL is the rst-line therapeutic option recommended in
the management of staghorn calculi. As these complex
stones are associated with a high recurrence rate if not
Patient position
C
h
a
n
c
e

s
t
o
n
e

f
r
e
e
(
%
)
Supine Prone
40
45
50
55
60
65
70
-
-
-
-
P < .01
No. puncture sites
C
h
a
n
c
e

s
t
o
n
e

f
r
e
e
(
%
)
Single Multiple
40
45
50
55
60
65
70
-
-
-
-
P = .12
Stone free check method
C
h
a
n
c
e

s
t
o
n
e

f
r
e
e
(
%
)
CT US KUB
40
45
50
55
60
65
70
-
-
-
-
-
-
P = .30 P < .001
Figure 1. Effect of patient position on stone-free rate among staghorn stone bearing patients adjusting for number of
puncture sites and method of checking stone-free status.
Patient position
C
h
a
n
c
e

o
f

c
o
m
p
l
i
c
a
t
i
o
n

(
%
)
Supine Prone
0
10
20
30
40
50
-
-
-
-
P Value .480
No. puncture sites
C
h
a
n
c
e

o
f

c
o
m
p
l
i
c
a
t
i
o
n

(
%
)
Single Multiple
0
10
20
30
40
50
-
-
-
-
P Value < .001
Figure 2. Effect of patient position on complication rate
among staghorn bearing patients who underwent percuta-
neous nephrolithotomy adjusted for number of punctures.
1242 UROLOGY 82 (6), 2013
completely removed, it is important to evaluate various
factors that might yield the highest stone-free rate.
5
Recently, Valdivia et al
6
have published the results of
CROES series comparing prone vs supine positioning in
all the patients enrolled in the Global PNL study, but
staghorn stones were not independently analyzed.
Prone PNL remained the only position used until
Valdivia Uria rst described the supine technique in
1998.
2
This modication in patients positioning has been
associated with a decrease in the operative time because it
avoids repositioning the patient to the prone position.
7
Different results were found in our series in which oper-
ative time was longer in the supine than in prone position
similar to the ndings previously described by de la
Rosette et al.
8
The supine position could also potentially
decrease some of the complications associated with the
prone position, such as respiratory restriction and
cardiovascular problems in obese patients.
9
No difference
between the complication rates in both groups was found
in our study after adjusting for the number of tracts,
although the supine group had a signicantly higher
percentage of patients with higher ASA score. Multiple
access punctures were associated with higher rate of
complications independent of patient position.
Another advantage listed for the supine position is
a longer distance between percutaneous tract and the
colon when it has been compared with the prone posi-
tion.
10
This would be the result of the movement of the
intra-abdominal organs when the abdominal wall is
compressed during the prone position. In this series, there
were no colon injuries reported in either position.
The supine position might keep the intrarenal pressure
at a lower level because of the descending position of the
percutaneous tract. This factor could be associated with
the collapse of the collective system and the consequent
decrease of vision during the procedure.
11
There is also
a narrower area for trocar insertion and instrument
movements compared with the prone position.
11
Some of
these factors might account for the lower stone-free rates
associated with patients treated in the supine position in
the present study.
The stone-free rate was higher for the group of patients
treated in the prone position after adjusting for the
number of access sites and the type of imaging method
used to determine the stone-free status. Therefore,
varying imaging modalities was not responsible for the
differences reported.
The difference in stone-free rate for staghorn stones in
our series is larger than the difference reported by Val-
divia et al
6
when they analyzed all the patients from the
CROES database. This nding could be associated with
the limitations to perform an upper pole access in patients
with staghorn stones in supine position; something that
has been previously reported and that is rarely needed in
nonstaghorn calculi.
7,12
In the present study, a higher
percentage of patients in prone position had an upper
pole access. Upper pole access might be associated with
a higher stone-free rate, and thus serves as a confounder
for this relationship. Unfortunately, we have limited data
on patients with upper pole access, which prevents us
from performing regression analysis. We would have
needed a larger sample to establish whether this rela-
tionship truly exists, so this remains speculative.
There are a number of limitations to this study. The
denition of staghorn stone was not standardized on the
data entry form and therefore was subject to the bias of
the surgeon. Although the data were collected prospec-
tively, no randomization was used. This issue can be
associated with a selection bias. However, with respect to
factors that could inuence the choice of position, espe-
cially BMI, no signicant differences were found between
the groups. In addition, it is important to note that the
international CROES database is an observational data-
base and some differences in the follow-up protocol can
be found. At the same time, some of our ndings could be
related to the fact that the centers performing the highest
number of supine PNL are not the highest volume centers
taking part in this study.
3,6,13
Although we found an
association between caseload and position in this study, it
probably reects a coincidental relationship, not a causal
one. Because we found no difference in key patient
characteristics, choice of position is not related to prog-
nostic factors.
Different imaging modalities are associated with
differing stone-free rates.
14
Because the imaging modali-
ties differ between the groups in this study, this could be
a severe limitation. Nevertheless, CT is used equally in
both groups. Given that CT is the most detailed diag-
nostic tool, and thus the most likely to detect any
differences in stone-free rate, this distribution is not
considered to be problematic.
Another limitation is the lack of standardization for
how PNL was performed in terms of access (balloon vs
serial dilators) and lithotrites (ultrasound vs pneumatic vs
laser), although we do not believe this affected the results
considerably.
15
Yet, to our knowledge, this is the rst
study specically analyzing the role of the positioning
during PNL management of staghorn stones. The large
number of patients included in this study is a signicant
strength.
CONCLUSION
Higher stone-free rates are achieved with patients in the
prone position during PNL management of staghorn
calculi. Complication rates are not different between the
2 positions. Further prospective randomized trials might
be necessary to ultimately determine the optimal patient
position during PNL management of staghorn calculi.
References
1. Preminger GM, Assimos DG, Lingeman JE, et al. Chapter 1: AUA
guideline on management of staghorn calculi: diagnosis and treat-
ment recommendations. J Urol. 2005;173:1991-2000.
2. Valdivia Uria JG, Valle Gerhold J, Lopez JA, et al. Technique and
complications of percutaneous nephroscopy: experience with 557
patients in the supine position. J Urol. 1998;160(6 Pt 1):1975-1978.
UROLOGY 82 (6), 2013 1243
3. Desai M, De Lisa A, Turna B, et al. The clinical research ofce of
the endourological society percutaneous nephrolithotomy global
study: staghorn versus nonstaghorn stones. J Endourol. 2011;25:
1263-1268.
4. de la Rosette J, Assimos D, Desai M, et al. The Clinical Research
Ofce of the Endourological Society Percutaneous Nephrolithotomy
Global Study: indications, complications, and outcomes in 5803
patients. J Endourol. 2011;25:11-17.
5. Beck EM, Riehle RA Jr. The fate of residual fragments after
extracorporeal shock wave lithotripsy monotherapy of infection
stones. J Urol. 1991;145:6-9; discussion 9-10.
6. Valdivia JG, Scarpa RM, Duvdevani M, et al. Supine versus prone
position during percutaneous nephrolithotomy: a report from the
clinical research ofce of the endourological society percutaneous
nephrolithotomy global study. J Endourol. 2011;25:1619-1625.
7. Liu L, Zheng S, Xu Y, et al. Systematic review and meta-analysis
of percutaneous nephrolithotomy for patients in the supine versus
prone position. J Endourol. 2010;24:1941-1946.
8. de la Rosette JJ, Tsakiris P, Ferrandino MN, et al. Beyond prone
position in percutaneous nephrolithotomy: a comprehensive review.
Eur Urol. 2008;54:1262-1269.
9. Pearle MS, Nakada SY, Womack JS, et al. Outcomes of contem-
porary percutaneous nephrostolithotomy in morbidly obese patients.
J Urol. 1998;160(3 Pt 1):669-673.
10. Tuttle DN, Yeh BM, Meng MV, et al. Risk of injury to adjacent
organs with lower-pole uoroscopically guided percutaneous neph-
rostomy: evaluation with prone, supine, and multiplanar reformat-
ted CT. J Vasc Interv Radiol. 2005;16:1489-1492.
11. De Sio M, Autorino R, Quarto G, et al. Modied supine versus
prone position in percutaneous nephrolithotomy for renal stones
treatable with a single percutaneous access: a prospective random-
ized trial. Eur Urol. 2008;54:196-202.
12. Rodrigues N, Ikonomidis J, Ikari O, et al. Comparative study of
percutaneous access for staghorn calculi. Urology. 2005;65:659-663.
13. Opondo D, Tefekli A, Esen T, et al. Impact of case volumes on the
outcomes of percutaneous nephrolithotomy. Eur Urol. 2012;62:
1181-1187.
14. Skolarikos A, Papatsoris AG. Diagnosis and management of
percutaneous nephrolithotomy residual stone fragments. J Endourol.
2009;23:1751-1755.
15. Pietrow PK, Auge BK, Zhong P, Preminger GM. Clinical efcacy of
a combination pneumatic and ultrasonic lithotrite. J Urol. 2003;
169:1247-1249.
APPENDIX
SUPPLEMENTARY DATA
Supplementary data associated with this article can be found,
in the online version, at http://dx.doi.org/10.1016/j.urology.
2013.06.068.
EDITORIAL COMMENT
Percutaneous nephrolithotomy (PCNL) is the treatment of
choice for large, complex, and staghorn kidney stones. The
effect of patient positioning during any type of surgery and
specically PCNL can be profound. Proper patient positioning is
a critical part of the surgery and has a major inuence on success
rates and complication rates.
1
Since PCNL was rst introduced,
the prone position has been the preferred approach, which
enables good access to all renal calyces. During the last several
years, other approaches have been suggested for this surgery,
with supine PCNL becoming an attractive option especially for
patients with medical comorbidities such as morbid obesity,
skeletal deformities, and signicant heart or lung disease.
2
In
this article, the Clinical Research Ofce of the Endourology
Society study group authors investigated a large cohort of
patients who underwent PCNL for staghorn stones. They
analyzed for the rst time the effect of patient positioning
(prone vs supine) on outcomes in patients undergoing PCNL for
staghorn stone. The study included 1311 patients, of whom
82.3% underwent surgery in prone position and the reminder in
supine position. They found that surgical time was signicantly
shorter in the prone group and that the stone-free rate was
higher with a lower retreatment rate for this group of patients
comparing with patients who underwent the surgery in the
supine position. Surprisingly, in contrast to the common
assumption that the supine position could also potentially
decrease some of the complications associated with the prone
position such as respiratory restriction and cardiovascular
problems, no difference between the complication rates of both
groups was found. They also found that the supine position was
rarely performed in high-volume centers. This can partially
explain the poorer results in stone-free rates and surgical time in
the supine group of patients compared with the group of patients
who underwent surgery in prone position.
The authors recommended that further prospective random-
ized trials might be necessary to ultimately determine the
optimal patient position during PCNL management of staghorn
calculi.
Their impressive results might suggest that until proven other-
wise and if there are no contraindications for prone position, this
should be the preferred option to achieve better stone-free rates
in patients undergoing PCNL for staghorn calculi. The supine
position or other modications should be reserved for specic
patient groups with comorbidities that make the prone position
impossible and be reserved for selected experienced centers.
Mordechai Duvdevani, M.D., Department of Urology,
Hadassah Hebrew University Hospital, Jerusalem, Israel
References
1. Akhavan A, Gainsburg DM, Stock JA. Complications associated
with patient positioning in urologic surgery. Urology. 2010;76:1309-
1316.
2. DasGupta R, Patel A. Percutaneous nephrolithotomy: does position
matter? e prone, supine and variations. Curr Opin Urol. 2013;23:
164-168.
http://dx.doi.org/10.1016/j.urology.2013.06.072
UROLOGY 82: 1244, 2013. 2013 Elsevier Inc.
REPLY
We are rapidly moving from a time of urinary stone treatment
when only limited options were available: semirigid uretero-
scopy, prone percutaneous nephrolithotomy (PCNL), and shock
wave lithotripsy, to a more exciting present. Currently, the
window of opportunities is rapidly increasing for a multitude of
approaches facilitated by the availability of sophisticated
endoscopic equipment enabling us to customize the treatment to
each patients situation.
Historically, PCNL has been performed in the prone position,
and there is nothing wrong with that. It therefore comes to no
surprise that this is the dominating method taught to many and
consequently reected in the data from the global PCNL study
by the Clinical Research Ofce of the Endourology Society.
1
Because endourologists are innovators, during the past years,
the need to improve results to treat patients with increasing
comorbidity and surgical innovation has revolutionized the
1244 UROLOGY 82 (6), 2013
approach to PCNL. Besides the increased use of exible ure-
teroscopes for the treatment of larger renal stones,
2
we do
witness a signicant downsizing on the instruments for PCNL.
3
Within that perspective, the endourological community has also
assessed whether other approach positions might be more
favorable for patients. In this line, an increasing number of
communications has been published to date.
4
Nevertheless, we should not forget to look at a larger picture.
It is not only the position of the patient or the instruments used
that drive improvements in outcomes but most likely their
combination. Renal stone treatment has changed dramatically
over the past years, and increasingly larger renal stones (in
increasingly complicated patients) are being treated in
a combined approach: transureterally by exible ureteroscopes
with a size barely larger than a ureter stent and simultaneously
percutaneous with semirigid nefroscopes in combination with
exible nefroscopes.
5
Overall, operative time and stone-free rates favor prone
PCNL, but on the issue of patient safety, supine PNCL seems to
overweight its prone counterpart. Indeed, a thorough evaluation
of these new approaches is a must, and we should neither reject
the old ones nor straightforward embrace the new comers.
4
I
therefore sympathize with my colleges concluding that at present,
the prone approach for staghorn stones seems to be more favor-
able. But I am condent that they will also agree that the nal
choice on patients position should be tailored to individual
patient characteristics and to surgeons preferences. Finally, I
want to encourage centers of excellence to bring together data
that support the use of the supine approach within the perspec-
tive of Combined Endoscopic Intra Renal Surgery. In such
a work, not only safety should be studied but also other outcomes,
including stone-free rate, avoidance of multiple percutaneous
tracts, need for auxiliary treatments, and in-hospital stay.
The future for advancements in endourology is in our hands,
and by now we are aware that collaborative work such as from
the Clinical Research Ofce of the Endourology Society has the
capability to meaningfully contribute to that. Through such
work we will eventually reach the ultimate goal of our profes-
sional work: to provide the absolute best, least invasive, quality
of care for all patients.
Jean de la Rosette, M.D., Ph.D., Department of Urology,
AMC University Hospital, Amsterdam, The Netherlands
References
1. de la Rosette J, Assimos D, Desai M, et al. The Clinical Research
Ofce of the Endourological Society Percutaneous Nephrolithotomy
Global Study: indications, complications, and outcomes in 5803
patients. J Endourol. 2011;25:11-17.
2. Hyams ES, Munver R, Bird VG, et al. Flexible ureterorenoscopy and
holmium laser lithotripsy for the management of renal stone burdens
that measure 2 to 3 cm: a multi-institutional experience. J Endourol.
2010;24:1583-1588.
3. Bader MJ, Gratzke C, Seitz M, et al. The "all-seeing needle": initial
results of an optical puncture system conrming access in percuta-
neous nephrolithotomy. Eur Urol. 2011;59:1054-1059.
4. Valdivia JG, Scarpa RM, Duvdevani M, et al. Supine versus prone
position during percutaneous nephrolithotomy: a report from the
clinical research ofce of the endourological society percutaneous
nephrolithotomy global study. J Endourol. 2011;25:1619-1625.
5. Scoffone CM, Cracco CM, Cossu M, et al. Endoscopic combined
intrarenal surgery in Galdakao-modied supine Valdivia position:
a new standard for percutaneous nephrolithotomy? Eur Urol. 2008;
54:1393-1403.
http://dx.doi.org/10.1016/j.urology.2013.06.073
UROLOGY 82: 1244e1245, 2013. 2013 Elsevier Inc.
UROLOGY 82 (6), 2013 1245