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SUPINE VS PRONE PERCUTANEOUS NEPHROLITHOTOMY: AN ANAESTHETIST'S VIEW

Prone positioning of the anaesthetized patient is necessary to allow optimal surgical access for many surgical specialties. Within urological surgery this includes percutaneous nephrolithotomy (PCNL) because the prone position is considered to afford the easiest approach to the kidney. However, two recent meta-analyses in the literature have shown that supine PCNL has a signifi cantly shorter operating time than PCNL in the prone position and an equivalent stone-free rate, complication rate, transfusion rate and fever rate [ 1,2 ] . The authors concluded that PCNL in the supine position was as effective and safe as PCNL in the prone position and was an alternative option for removal of renal stones in PCNL [ 2 ] . Although not widely adopted in the UK, possibly because of fear of colonic injury and a lack of training in this position in educational centres [ 3 ] , supine positioning of the patient for PCNL confers several anaesthetic advantages. The present comment paper aims to outline the potential problems with the prone position which may be taken into account when a centre is considering offering a supine PCNL service. If PCNL is to be performed prone then we believe an understanding by both surgeon and anaesthetist of the predictable physiological changes and the many complications that are associated with the prone position is essential for its safe use. Accepted for publication 21 April 2011 [12]. Miura et al. [8] recommended the use of i.v. carbapenems to treat multiresistant E. coli sepsis after transrectal prostate biopsy. They identified an increasing risk of fluoroquinolone resistance in patients with an obstructive lower urinary tract and who had a previous history of fluoroquinolone use. Feliciano et al. [7] found an overall incidence of infections after biopsy of 2.4%, and an overall incidence of fluoroquinoloneresistant infection of 1.2%. They identified an increasing trend for fluoroquinolone resistance in recent years, which may be related to the overuse of broad spectrum antibiotics.