|Year : 2021 | Volume
| Issue : 2 | Page : 110-111
Supine percutaneous nephrolithotomy in a patient with a history of previous spinal surgeries
Rajendra B Nerli, Shashank D Patil, Shoubhik Chandra
Department of Urology, JN Medical College, KLE Academy of Higher Education and Research, JNMC Campus, Belagavi, Karnataka, India
|Date of Submission||10-May-2021|
|Date of Acceptance||31-May-2021|
|Date of Web Publication||18-Aug-2021|
Rajendra B Nerli
Department of Urology, JN Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), JNMC Campus, Belagavi - 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
Patients with abnormal body habitus because of spinal deformities and patients having undergone previous spinal surgeries present a challenge during surgical, anesthesiologic, and technical procedures. In these patients, management of urolithiasis may be difficult because of anatomic variations and respiratory dysfunction, stone size, spinal deformities, or risk of spinal injuries. Percutaneous nephrolithotomy (PCNL) as monotherapy has advantages in removing large stones and achieving excellent results with minimal morbidity. PCNL in supine position has several advantages attached to it, which include improvement in anesthetic management, decreased intrarenal pressures, decreased radiation exposure and improved ergonomics of fluoroscopy, improvements in patient positioning, and shorter operative time. We report a case of supine PCNL in a patient who was operated previously on the cervical and lumbar spine.
Keywords: Endourology, percutaneous nephrolithotomy, stone, supine
|How to cite this article:|
Nerli RB, Patil SD, Chandra S. Supine percutaneous nephrolithotomy in a patient with a history of previous spinal surgeries. J Sci Soc 2021;48:110-1
| Introduction|| |
Percutaneous nephrolithotomy (PCNL) has become the standard of care in the management of large renal stones and has evolved over time, resulting in a decrease in invasiveness and morbidity and improvements in ergonomics and outcomes., Originally, PCNL was performed in the prone position due to concerns of inadvertent colon injury during percutaneous puncture of the kidney. Intravenous pyelography was then the standard imaging modality for stone disease. Today, modern cross-sectional imaging techniques such as ultrasound or computed tomography (CT) are available and are commonly used to define perirenal anatomy by the modern urologist.
PCNL can also be performed in the supine decubitus position with similar outcomes and with potential advantages in terms of ergonomics and the administration of anesthesia.,, Performing PCNL in supine position has several advantages attached to it, which include improvement in anesthetic management, decreased intrarenal pressures, decreased radiation exposure and improved ergonomics of fluoroscopy, improvements in patient positioning and shorter operative time, easier endoscopic combined intrarenal surgery or simultaneous bilateral endoscopic surgery, and improved endoscopic access to the upper pole from lower pole puncture tract. We report a case of supine PCNL in a patient who was operated previously on the cervical and lumbar spine.
| Case Report|| |
A 70-year-old male presented with right flank pain. Computed tomography (CT) of kidney, ureter and bladder region revealed a right renal calculus measuring 2.8 cm × 2.5 cm of 914 Hounsfield units [Figure 1]. The patient was operated (laminectomy with L2–5 fusion with bone grafting) a year back for L2–5 lumbar canal stenosis and had undergone C7-T1 vertebral fixation for cervicothoracic spine injury 10 years ago [Figure 2]a and [Figure 2]b. The patient had no neurological deficits.
|Figure 1: CT scan showing right renal calculus and fusion of L2–5 lumbar vertebrae|
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|Figure 2: (a) Plain radiograph shows spinal fusion C7–T1. (b) Plain radiograph shows fusion of L2–5 lumbar vertebrae|
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In view of his previous spinal surgeries, a neurosurgical opinion was sought, and the neurosurgeon opined that the patient needed to be shifted carefully during surgery for the renal stone. In view of this opinion, we planned a supine PCNL under regional anesthesia. The patient was positioned as suggested by Valdivia Uría et al. Supine PCNL was carried out using a single inferior calyceal puncture under fluoroscopy guidance. The stone was completely cleared and a nephrostomy was left in place. The nephrostomy was removed within 24 h, and the patient was discharged 48 h later. There were no major complications noted.
| Discussion|| |
Performing PCNL in the supine position results in decreased workload for operating room personnel because there is no need to reposition the patient after ureteral catheter placement as is the case with the standard prone PCNL, thus resulting in shorter operating time. For supine PCNL a single draping and position are used throughout the entire procedure. This advantage is even more evident in obese patients.
Goumas-Kartalas and Montanari assessed the feasibility and efficacy of PCNL in patients with spinal deformities. Eight patients (nine renal units) with a mean stone burden of 372 mm2 (160–840 mm2) and spinal deformities underwent ten PCNLs. There was a 40% complication rate related to the number of procedures, complete stone clearance per kidney after one PCNL was 55.5% (5/9 PCNLs), increasing to 66.6% (6/9 PCNLs) after a second PCNL. Four of nine (44.4%) renal units needed additional procedures after one PCNL (shockwave lithotripsy, retrograde intrarenal surgery [RIRS], combined simultaneous PCNL, and RIRS). At the 3-month follow-up, the overall stone-free rate was 88.8% (eight renal units). Five of these patients had undergone supine PCNL, and the authors concluded that supine PCNL offered advantages in terms of patient comfort, protection of cardiorespiratory function, and the ability to perform a simultaneous combined ureteroscopic approach.
Our patient had undergone two major spinal surgeries previously and was at risk to develop intraoperative injuries during positioning and repositioning during a standard prone PCNL. As it was a large stone, we approached the stone through a supine access. Supine PCNL is safe and effective in selected patients with previous spinal surgery.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]