Urolithiasis (2014) 42:87–93
DOI 10.1007/s00240-013-0614-3
ORIGINAL PAPER
Is the supine position superior to the prone position
for percutaneous nephrolithotomy (PCNL)?
Xiaohua Zhang • Leilei Xia • Tianyuan Xu •
Xianjin Wang • Shan Zhong • Zhoujun Shen
Received: 25 July 2013 / Accepted: 12 October 2013 / Published online: 20 October 2013
Ó Springer-Verlag Berlin Heidelberg 2013
Abstract The objective of this study is to update the two
previous meta-analyses in order to evaluate the efficacy
and safety of percutaneous nephrolithotomy (PCNL) for
patients in the prone position versus supine position. An
electronic database search of MEDLINE, EMBASE, go-
ogle scholar, and the Cochrane library was performed up to
June, 2013. All studies comparing prone with supine
position for PCNL were included. The outcome measures
were stone-free rate, operative time, complication and
hospital stay. Two randomized controlled trials (RCTs) and
7 non-RCTs, including 6,413 patients (4,956 patients in the
prone position group and 1,457 patients in the supine
position group), met the inclusion criteria. Meta-analysis of
extractable data showed that PCNL in the supine position
was associated with a significantly shorter operative time
(WMD: 21.7; 95 % CI 2.46–40.94; p = 0.03) but lower
stone-free rate (OR: 1.36; 95 % CI 1.19–1.56; p \ 0.0001)
than PCNL in the prone position. There was no difference
between the two positions regarding hospital stay
(WMD = 0.05; 95 % CI -0.16–0.25; p = 0.66) and
complication rate (OR: 1.1; 95 % CI 0.94–1.28; p = 0.24).
In conclusion, the present study found different results
from the two previous meta-analyses results regarding
stone-free rate; PCNL in the supine position had a signif-
icantly lower stone-free rate than that in prone position.
Keywords Percutaneous nephrolithotomy
PCNL

Prone
Supine
X. Zhang and L. Xia contributed equally to this work.
X. Zhang
L. Xia
T. Xu
X. Wang
S. Zhong
Z. Shen (&)
Department of Urology, Ruijin Hospital, Shanghai Jiaotong
University School of Medicine, 197 Ruijin No. 2 Road,
Shanghai 200025, China
e-mail: zxh340@yeah.net
Introduction
Since the first successful stone extraction through a
nephrostomy in 1976 [1], percutaneous nephrolithotomy
(PCNL) has became the preferred procedure for the treat-
ment of renal stones, especially for large, complex and
staghorn calculi. For decades, this technique has been
performed in the prone position. More recently, particular
interest has been focused on supine position because as
compared to the prone position, the supine position has the
following advantages [2]: safer and easier for the patient;
less cardiovascular change; no need for patient reposi-
tioning (with less operative time and less relevant risk of
nervous system injuries); and more comfortable and less
radiation exposure to the surgeon; but also allows a
simultaneous PCNL and ureteroscopy. Despite the poten-
tial advantages, the supine position necessitates more lat-
eral displacement of the renal puncture site than the prone
position, which may increase the possibility of visceral
injuries and cause trauma to intrarenal vessels [3]. There-
fore, controversy has emerged as to which is the better
position for PCNL. Two very recent meta-analyses com-
paring supine versus prone position for PCNL have been
published [4, 5], both of which were based on 4 publica-
tions that met their inclusion criteria—2 prospective RCTs
and 2 case control studies. Both meta-analyses concluded
that the two positions showed equivalency for stone-free
rate, length of hospital stay, and complication rate. In
addition, both found supine PCNL had shorter operative
time than prone PCNL. Despite these two meta-analyses
published, many studies have been published in the liter-
ature from then and yielded inconsistent results. The best
access to PCNL represents still a controversial issue.
Herein, the purpose of this study is to update the two
previous meta-analyses to evaluate the efficacy and safety
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of PCNL with the patient in the prone versus supine
position.
Methods
Search strategy and study selection
A literature search of MEDLINE, EMBASE, google
scholar, and the Cochrane Central Register of Controlled
Trials was performed to identify relevant studies. The
search strategy was ‘‘(Nephrostomy, Percutaneous, PCNL,
PCN, PNL) [MeSH Terms] AND (supine position OR
dorsal decubitus OR dorsal position OR prone position)
[Title/Abstract]’’. The search was restricted to human
subjects and time up to June, 2013. No language was
restricted. Additional manual searches were performed of
the reference lists of included studies, reviews and meta-
analyses.
The following inclusion criteria were used: (1) patients
with renal or upper ureteral stones, (2) patients were treated
with PCNL in supine versus prone position, (3) outcomes
including the efficacy and safety of the PCNL, (4) a ran-
domized controlled trial (RCT) or retrospective compara-
tive study design, and (5) where more than one publication
of one study exists, only the publication with the most
complete data will be included.
The following exclusion criteria were used: (1) the
inclusion criteria were not met, (2) pediatric patient pop-
ulation, (3) unclear position of PCNL, or other position and
(4) authors of the included studies were contacted wherever
the data were unavailable or unclear. If data were not
provided or clarified, the study was excluded.
The quality of RCT studies was assessed by the Coch-
rane Collaboration’s tool, which included assessment of
sequence generation, allocation concealment, blinding,
incomplete outcome data, selective reporting of outcomes,
and other possible sources of bias. The non-RCT studies
were assessed with a modification of the Newcastle-Ottawa
Scale [20]: scores [5 were defined as high quality, and a
score \5 as low quality. Two reviewers performed the
quality assessment independently. Discrepancy was
resolved in consultation with the third reviewer.
Data extraction
Two reviewers independently extracted data from the
included studies, and disagreements were resolved by dis-
cussion until a consensus was reached. The following
variables were extracted from each study: investigator,
date, country of study, position of operation, characteristics
of the patients (age, BMI, stone burden, location), stone-
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Urolithiasis (2014) 42:87–93
free rate, complications, the length of hospital stay, and
operative time. We divided patients into supine and prone
groups according to patients’ position in PCNL. The pri-
mary outcome was the stone-free rate, followed by oper-
ative time, length of hospital stay, and complication rate as
secondary outcomes.
Statistical analysis
The meta-analyses were performed using Review Manager
(RevMan v.4.2). The weighted mean difference (WMD)
and odds ratio (OR) were used to compare continuous and
dichotomous variables, respectively. For studies that pre-
sented continuous data as median and range values, the
standard deviations (SD) were calculated using statistical
algorithms described by Hozo et al. [6]. All results were
reported with 95 % confidence intervals (CI). Statistical
heterogeneity between studies was assessed using the v2
test with significance set at p \ 0.05, and heterogeneity
was quantified using the I2 statistic. I2 values of 25, 50, and
75 % correspond to low, medium, and high levels of het-
erogeneity. A fixed-effect model was used unless statisti-
cally significant high heterogeneity(i.e., I2 [ 50 %) existed
between studies. A random effects model was used if
heterogeneity existed. Sensitivity analysis was performed
to explore the influence of low-quality studies. Publication
bias was evaluated using a funnel plot.
Results
Literature search and characteristics of the included
studies
We identified 129 studies, of which 71 were excluded
because of irrelevance based on the titles and 37 excluded
because of irrelevance based on the abstracts (Fig. 1). Full
manuscripts were evaluated in 21 studies. After reading the
full manuscripts, we excluded 12 studies for various rea-
sons according to our exclusion criteria. Finally, 9 studies
were included in a pooled meta-analysis [7–15]. Of the 9
included studies, 1 was a prospective non-randomized
study [7], 6 were retrospective studies with no randomi-
sation [8–13], and 2 were RCTs [14, 15]. Quality assess-
ment showed that 4 of the 7 non-RCT studies were deemed
as high quality, the other as low quality. Although two
RCTs were adequate in sequence generation and incom-
plete outcome data, inadequate in allocation concealment
and blinding, because of the limitation of ethics factor and
characteristic of surgery studies, they were deemed as high
quality. All the 9 studies reported on the patient demo-
graphics, stone size, stone-free rate and complications. Six
Urolithiasis (2014) 42:87–93 89

Fig. 1 Flow diagram of studies

identified, included, and
excluded

Table 1 Trial and preoperative patient characteristics

Investigator Reference Country No. of No. of Sexa, M/F Agea, BMIa, Stone burdena Stone
patientsa proceduresa year kg/m2 locationa,
left/right

McCahy [8] Australia 36 vs. 36 41 vs. 41 23/13 vs. NA 53.1 vs. 53.4 26.2 vs. 25.7 vs. 32.6 mm NA vs. NA
30.13
Wang [11] China 12 vs. 6 12 vs. 6 8/4 vs. 4/2 43.8 vs. 44.8 24.2 vs. 24.5 33 vs. 36 mm 5/7 vs. 3/3
Sanguedolce [10] Spain 52 vs. 65 52 vs. 65 28/24 vs. 49 vs. 53 27.1 vs. 26 18.1 vs. 20.6 mm 27/25 vs.
41/24 35/30
Mazzucchi [9] Brazil 12 vs. 30 24 vs. 32 2/10 vs. 12/18 38.3 vs. 49 34.2 vs. 34 11.28 vs. 10.2 cm2 8/16 vs. 12/20
Valdivia [12] CROES 4,637 4,585 vs. 2,662/1,975 48.8 vs. 51.0 26.7 vs. 26.6 449.1 vs. NA vs. NA
vs. 1,126 vs. 470.6 mm2
1,138 594/544
Falahatkar [15] Iran 40 vs. 40 40 vs. 40 18/22 vs. 43.2 vs. 26.3 vs. 25.6 40.3 vs. 40.6 mm 16/24 vs.
23/17 45.35 15/25
Sio [14] Italy 36 vs. 39 36 vs. 39 16/20 vs. 41 vs. 38 26 vs. 28 33 vs. 34 mm 17/19 vs.
17/22 19/20
Sesmero [13] Spain 54 vs. 50 51 vs. 47 30/24 vs. 53.9 vs. 54.1 NA vs. NA 416 vs. 399 mm2 24/30 vs.
23/27 24/26
Shoma [7] Egypt 77 vs. 53 77 vs. 53 43/34 vs. 47.4 vs. 43.6 NA vs. NA NA vs. NA 44/33 vs.
34/19 26/27

NA Not available, CROES Research Office of the Endourological Society

a
The data for the prone versus supine position are given, respectively

studies reported on the operative time and the length of Meta-analysis results
hospital stay. A total of 6,413 patients were included, 4,956
patients in the prone group and 1,457 patients in the supine Analysis results showed were as follows:
group. Table 1 shows the study characteristics of the 9
1. Stone-free rate In meta-analysis of 9 studies, the stone-
studies. Baseline information seems comparable between
free rate was 77.3 % (3,804/4,918) in the prone
supine and prone position groups.

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Fig. 2 Forest plots of outcomes: a stone-free rate, b operative time, c complication, d hospital stay
position versus 72.9 % (1,057/1,449) in the supine
position (OR: 1.36; 95 % CI 1.19–1.56; p \ 0.0001),
indicating that there was a significantly higher stone-
free rate in the prone position than in the supine
position (Fig. 2a).
2. Operative time Six studies including 6,102 patients
reported on the operative time for PCNL in both
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Urolithiasis (2014) 42:87–93
positions. Meta-analysis demonstrated a shorter oper-
ative time in the supine position than in the prone
position (WMD: 21.7; 95 % CI 2.46–40.94; p = 0.03)
(Fig. 2c).
3. Hospital stay Six studies including 6,102 patients
reported on the length of hospital stay for PCNL in
both positions. No statistically significant difference
Urolithiasis (2014) 42:87–93
Fig. 3 Funnel plot of stone-free
rate
was found between the two groups (WMD = 0.05;
95 % CI -0.16–0.25; p = 0.66) (Fig. 2c).
4. Complication rate In meta-analysis of 9 studies, the
complication rate was 20.3 % (1,001/4,901) in the
prone position versus 18.3 % (266/1,442) in the supine
position, showing that both positions had similar
complication rates (OR: 1.1; 95 % CI 0.94–1.28;
p = 0.24) (Fig. 2d).
Sensitivity analysis
When small numbered cohorts were removed [11], there
were still no difference between the two groups regarding
complication rate (OR: 1.07; 95 % CI 0.92–1.25; p = 0.37),
or length of hospital stay (WMD = 0.06; 95 % CI
-0.14–0.27; p = 0.54). However, the prone group still had a
significantly higher stone-free rate than the supine group
(OR: 1.36; 95 % CI 1.19–1.56; p \ 0.0001), while the
supine group still had a significantly shorter operative time
than the prone group (WMD: 21.7; 95 % CI 2.46–40.94;
p = 0.03), which was similar to the general analysis.
Publication bias analyses
We analyzed possible publication bias by generating funnel
plots of the studies used for all of the evaluated compari-
sons of outcomes. No clear bias was apparent. As an
example, we present the funnel plot of stone-free rate
showing no obvious asymmetry (Fig. 3).
Discussion
Two previous meta-analyses [4, 5], both of which were
based on 4 studies involving 182 renal units of supine
91
position and 207 renal units of prone position, showed
equivalency for stone-free rate, length of hospital stay and
complication rate between prone and supine position, and
found shorter operative time in the supine position than in
the prone position. In present study, we included 9 studies
involving 4,918 renal units of prone position and 1,449
renal units of supine position, and found similar results
from the two previous meta-analyses regarding operative
time, complication rate and length of hospital stay. How-
ever, in terms of stone-free rate, we found that there was a
significantly higher stone-free rate in the prone position
than in the supine position, which was different to the two
previous meta-analyses results. The reasons why our study
have found different results comparing with the two pre-
vious meta-analyses might be found in the following:
Firstly, both of the two previous meta-analyses were only
based on 4 studies with small sample size (182 for supine
group and 207 for prone group), but our meta-analysis was
based on 9 studies with larger sample size. Secondly, dif-
ferent studies had different methods to assess stone-free
rate. Thus, the data obtained were not homogenous.
The reasons why PCNL in the prone position have
higher stone-free rate than that in the supine position may
be attributed to the following: due to the effects of gravity
on the irrigating fluid, and an unrestricted range of move-
ment for the nephroscope, the prone position are easier
access to the renal upper pole calices, a more distended
collecting system for better vision, therefore, better clear-
ance of stones [16, 17]. In contrast, supine PCNL have a
more difficult nephroscopy because of decreased filling of
the collecting system [18]. Consequently, the collecting
system is constantly collapsed, and as a result, the surgical
filed is relatively small for nephroscopic maneuvers [19].
The supine position also allows limited space for planning
renal access, as the flank is relatively poorly exposed and
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may result in reduced ability to maneuver the nephroscope,
especially for anterior calyceal calculi.
Our pooled analysis and two previous meta-analyses for
operative time showed that PCNL in the supine position
has significantly shorter operative time than that in prone
position. We believe that the majority of the time saving is
from not having to reposition the patient from the lithot-
omy to the prone position with consequent reprepping,
redraping, and staff rescrubbing and regowning. There is
also some time saved with the ability to perform simulta-
neous retrograde and caliceal puncture using two surgeons,
and less requirement for repeated nephroscope insertion
[15].
For complications rate and hospital stay, regardless of
our pooled analysis or two previous meta-analyses, the
results were similar between the two groups. These data
suggested that the PCNL in the supine position was safe.
Although the supine position was as safe as the prone
position, and has shorter operative time than the prone
position, this approach had some disadvantages; for
instance, collapse of the collecting system, difficulty in
nephroscopy and in approaching the upper calix, and small
surgical field for nephroscopy. These limitations may result
in lower stone-free rate. Therefore, certain recommenda-
tions can be made based on the results. The supine position
should be used in patients with cardiovascular risk or
patients who cannot tolerate long-time procedures because
these patients are not likely to tolerate the hemodynamic
effects of anesthesia in the prone position, and the proce-
dure should been completed in short time as soon as pos-
sible in order to reduce risk of anesthesia or related risk of
operation. On the contrary, the prone position is recom-
mended in patients without these risks because of the prone
position having high stone-free rate.
The present meta-analysis has some limitations that
must be considered. The main limitation is that there were
just two RCTs, and most of the included studies were non-
RCT studies. In addition, another limitation of this study
was that the data obtained were not homogenous because
different studies had different methods to assess stone-free
rate and operative time. This may potentially have resulted
in a lack of a unified reporting methodology. Despite these
limitations, our study has large sample size through precise
search strategy to include all of the studies related to PCNL
in a comparison between supine position and prone posi-
tion. Furthermore, to reduce the confounding, limit the
bias, and draw a scientific and statistically robust conclu-
sion, sensitivity analysis was preformed.
In conclusion, the present study found different results
from the two previous meta-analyses results regarding
stone-free rate; PCNL in the supine position had a signif-
icantly lower stone-free rate than that in prone position.
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Urolithiasis (2014) 42:87–93
Conflict of interest The authors declare that there is no conflict of
interest.
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