B超引导下经皮肾镜术治疗肾下盏结石16例报告

目的:探讨在B超引导下经皮肾镜术治疗肾下盏结石的可行性和安全性。方法:对16 例肾下盏结石患者采用经皮肾镜术治疗。结石大小(0.8 cm×1.2 cm)~(1.6 cm×2.3 cm),平均1.3 cm×1.8 cm。并发有肾盏轻度积水9例,无肾盏积水7例。曾行ESWL治疗10例。结果:手术均获得成功,手术时间25~50 min,平均38 min。出血15~40 ml,平均30 ml。无一例发生大出血、漏尿及临近器官损伤等并发症。术后2周复查腹部平片未见结石残留。结论:在B超引导下经皮肾镜术治疗肾下盏结石具有简单、安全、创伤小、成功率高等优点,克服了患者ESWL治疗后等待排石和结石残留等不足。     

Computerized tomography imaging in adolescent idiopathic scoliosis: prone versus supine

Background

The aim of the present study was to assess the degree of apical vertebral rotation values in Adolescent Idiopathic Scoliosis (AIS) that were obtained on CT scans, and to analyze the influence of patient position (supine versus prone) on the degree of rotation.

Methods

The study included 50 apical vertebra rotation measurements of 34 patients with Type 1A and Type 3C curvature according to the Lenke classification. CT imaging was applied to the patients in supine and prone positions to measure the apical vertebral rotation (AVR). The average AVR angles were measured using the Aaro–Dahlborn method and the results were compared.

Results

No significant differences were found between the vertebral rotation measured in the prone and supine positions for the Lenke 1A subgroup and the Lenke 3C thoracic group (p = 0.848; p = 0.659, respectively). In the Lenke 3C lumbar group, however, the vertebral rotation in the supine position was found to be significantly lesser than that in the prone position (difference ?1.40° ± 1.79°, p = 0.007).

Conclusion

The assessment of the apical vertebra rotation is crucial in AIS. Even though the vertebral rotation in the supine position was found to be significantly lesser than that in the prone position, CT imaging in a prone position could not be considered clinically more relevant than the CT images in a supine position as there was less than 3° difference.

     

Urologists versus radiologists made PCNL tracts: the UK experience

We aim to explore the practice of who makes the PCNL tract in the UK and Northern Ireland as well as presenting our data for two different approaches to PCNL tracts in Northern Ireland. A national questionnaire survey was carried out across the National Health Services hospitals in UK. In addition, a retrospective analysis of 134 PCNL cases was carried out. Group I included 103 (77%) cases with urologist-made tracts, while group II included 31 (23%) cases with radiologists-made tracts. The survey suggested that 45% (42) of the hospitals adopted a radiologist-made tract, 44% (41) use urologist-made tract, while the remaining 11% (11) use both. Most of the radiologists’ performed tracts in our series were for complex cases. Failed access occurred in 6 (5.8%) in group I and none in Group II. The overall stone-free rate was 92 and 50% for group I and II, respectively. There is a better stone clearance rate in Group I (p = 0.0016). This however is likely to be attributed to the complexity of the cases in group II. However, urologist made percutaneous tract is safe and efficacious but a team approach with radiology is needed for more complex cases.     

Efficacy of supine versus prone biliary lithotripsy: an in vitro study

Clinical extracorporeal shock wave lithotripsy (ESWL) results have shown that the smaller the gallstone fragments following ESWL, the faster the patient will become stone-free. At ESWL, an attempt is made to produce sand-like fragments that will easily pass through the cystic and common bile ducts. Sixteen pairs of gallstones of equal shape, size, and composition were harvested from cholecystectomy specimens and then fragmented on the Dornier MPL-9000 lithotripter (Dornier Medical Systems, Inc.), individually, in a phantom oriented to duplicate either supine or prone patient positions. The number and size of remaining fragments were compared following the supine versus prone treatments. The 32 stones, ranging from 5-15 mm in diameter, received 1,500 shock waves at 21 kV. Fragments with a maximal diameter of greater than or equal to 4 mm were measured and counted after 750 and 1,500 shock waves. Fragments greater than or equal to 4 mm were found in four out of 16 stones treated supine (25%) and 16 out of 16 stones treated prone (100%). The largest residual fragment regardless of size for each stone pair occurred in the prone group in 14 out of 16 cases (88%). Biliary lithotripsy performed with supine positioning results in more efficacious gallstone fragmentation in this in vitro model; these findings suggest that supine positioning for patients could improve fragmentation and treatment success.     

Modified supine versus prone position in percutaneous nephrolithotomy for renal stones treatable with a single percutaneous access: a prospective randomized trial

OBJECTIVES: To compare operative time, safety, and effectiveness of percutaneous nephrolithotomy in the supine versus prone position in a prospective randomized trial. MATERIAL AND METHODS: From October 2005 to June 2007, 75 patients (33 men, 42 women; mean age, 39.3 yr) were prospectively enrolled and randomly divided into group A (39 patients, supine position) and group B (36 patients, prone position). Inclusion criteria were diagnosis of single or multiple renal stones (pelvic-caliceal) treatable with a single percutaneous access, stone diameter >2.5cm, body mass index (BMI) <30kg/m(2), and no contraindications to perform the operation in the prone position. Exclusion criteria were stones in more than one calyx, complete staghorn stones, and coexisting renal anomalies. RESULTS: The two groups were comparable in age, BMI, male-to-female ratio, and stone size. No significant difference was ascertained between the two groups in terms of stone-free rate (group A, 88.7% vs. group B, 91.6%, p=0.12), mean blood loss (group A, Delta hemoglobin -2.3g/dl vs. group B, -2.2g/dl, p=0.23), and mean hospital stay (group A, 4.3 d vs. group B, 4.1 d, p=0.18). The only significant difference reported was mean operative time (group A, 43min vs. group B, 68min, p<0.001). No blood transfusions were needed and no organ injuries were reported. CONCLUSIONS: In this carefully selected patient population with uncomplicated renal stones, the supine position was similar to the prone position for percutaneous stone removal.     

Emergence from anesthesia in the prone versus supine position in patients undergoing lumbar surgery

BACKGROUND: Conventional supine emergence in patients undergoing prone lumbar surgery frequently results in tachycardia, hypertension, coughing, and loss of monitoring as the patient is rolled supine. The prone position might facilitate a smoother emergence because the patient is not disturbed. No data describe this technique. METHODS: Fifty patients were anesthetized with fentanyl, nitrous oxide, isoflurane, and rocuronium. By the conclusion of surgery, all patients achieved spontaneous ventilation and full reversal of neuromuscular blockade in the prone position, as the volatile anesthetic level was reduced. Baseline heart rate and mean arterial pressure were recorded. Patients were then randomized at time 0 to the supine (n = 24) or prone (n = 21) position as 100% oxygen was administered. Patients in the supine position were then rolled over, while those in the prone position remained undisturbed. Heart rate, mean arterial pressure, and coughs were recorded until extubation. Tracheas were extubated on eye opening or purposeful behavior. RESULTS: When compared with the supine group, prone patients had significantly less increase in heart rate (P = 0.0003, maximum increase 9.3 vs. 25 beats/min), less increase in mean arterial pressure (P = 0.0063, maximum increase 4.8 vs. 19 mmHg), less coughing (P = 0.0004, 7.0 vs. 23 coughs), and fewer monitor disconnections (P < 0.0001). Time to extubation from time 0 was similar (4.0 vs. 3.7 min, prone vs. supine). No one required airway rescue. There was no significant difference in need for restraint (three prone, four supine). CONCLUSIONS: Prone emergence and extubation is associated with less hemodynamic stimulation, less coughing, and less disruption of monitors, without specifically observed adverse effects, when compared with conventional supine techniques.     

Effect of prone versus supine position in COVID-19 patients: A systematic review and meta-analysis

Study objectiveTo review the effects of prone position and supine position on oxygenation parameters in patients with Coronavirus Disease 2019 (COVID-19).DesignSystematic review and meta-analysis of non-randomized trials.PatientsDatabases of EMBASE, MEDLINE and CENTRAL were systematically searched from its inception until March 2021.InterventionsCOVID-19 patients being positioned in the prone position either whilst awake or mechanically ventilated.MeasurementsPrimary outcomes were oxygenation parameters (PaO₂/FiO₂ ratio, PaCO₂, SpO₂). Secondary outcomes included the rate of intubation and mortality rate.ResultsThirty-five studies (n = 1712 patients) were included in this review. In comparison to the supine group, prone position significantly improved the PaO₂/FiO₂ ratio (study = 13, patients = 1002, Mean difference, MD 52.15, 95% CI 37.08 to 67.22; p < 0.00001) and SpO₂ (study = 11, patients = 998, MD 4.17, 95% CI 2.53 to 5.81; p ≤0.00001). Patients received prone position were associated with lower incidence of mortality (study = 5, patients = 688, Odd ratio, OR 0.44, 95% CI 0.24 to 0.80; p = 0.007). No significant difference was noted in the incidence of intubation rate (study = 5, patients = 626, OR 1.20, 95% CI 0.77 to 1.86; p = 0.42) between the supine and prone groups.ConclusionOur meta-analysis demonstrated that prone position improved PaO₂/FiO₂ ratio with better SpO₂ than supine position in COVID-19 patients. Given the limited number of studies with small sample size and substantial heterogeneity of measured outcomes, further studies are warranted to standardize the regime of prone position to improve the certainty of evidence.PROSPERO Registration: CRD42021234050     

经皮肾镜取石术在复发性肾结石二次手术中的治疗效果

目的：评价经皮肾镜取石术在复发性肾结石二次手术中的临床效果及安全性。方法：回顾分析我院2010年6月至2013年7月间经皮肾镜取石术治疗24例复发性肾结石二次手术病例的临床资料。 结果：24例患者均行一期PCNL手术,术后腹部平片显示,21例结石清除干净,净石率为87.5%;3例术后有残石者,1例患者系术中取石失败,术后行体外冲击被碎石术,1例行经输尿管镜碎石取石术,1例行第二次经皮肾镜取石术并术后辅以体外冲击被碎石术。手术时间40～110min,平均80min。术后无严重并发症发生。结论：经皮肾镜取石术是复发性肾结石二次手术治疗安全、有效的方法。     

Percutaneous access to upper pole renal stones: role of prone 3-dimensional computerized tomography in inspiratory and expiratory phases

PURPOSE: We evaluated the role of noncontrast, prone position, inspiratory and expiratory 3-dimensional spiral computerized tomography (PIE-CT) for preoperative planning of percutaneous treatment in patients with complex upper pole renal calculi. MATERIALS AND METHODS: In this pilot study a total of 6 renal units in 4 women and 1 man with complex upper pole calculi who were candidates for percutaneous nephrolithotomy were evaluated with thin section PIE-CT. With the patient imaged in the prone position percutaneous access was simulated under 4 potential access conditions, including subcostal and intercostal, in inspiration and expiration. Each potential access was then deemed transpleural or extrapleural and minimally angulated or severely angulated cephalad. RESULTS: PIE-CT was performed uneventfully in all patients. Ideal nonangulated extrapleural percutaneous access was deemed possible in 5 of 6 renal units. However, inspiratory plus expiratory phases were necessary to identify the most suitable access site. In 2 renal units only 1 safe access site was identified. No pulmonary complications were noted in any of these patients. In 1 renal unit no suitable access could be identified and this patient was treated with laparoscopic caliceal diverticulectomy. CONCLUSIONS: Thin section PIE-CT offers 3-dimensionally rendered images that clearly demonstrate anatomical relationships among the kidney, calculi, pleura, diaphragm, ribs and surrounding organs. In this pilot study PIE-CT provided useful data for planning urological intervention for complex upper pole renal stones. This study also suggests that generalizations regarding the safety of upper pole access in the inspiratory or expiratory phase are not warranted.     

Lower intracuff pressure of laryngeal mask airway in the lateral and prone positions compared with that in the supine position

We compared the intracuff pressure (ICP) of a laryngeal mask airway (LMA) in the lateral and prone positions with that in the supine position. One hundred and eight patients, weighing 50-70 kg, scheduled for elective orthopedic and plastic surgery, were assigned to three groups, based on their body position during surgery. General anesthesia was induced and then a size 4 deflated LMA was inserted in each patient in the supine (group 1; n = 42), lateral (group 2; n = 45), or prone position (group 3; n = 21). The LMA cuff was inflated with 15 ml of air. Anesthesia was maintained without nitrous oxide, and the ICP was measured until LMA removal in the supine position. ICP in groups 2 and 3 was significantly lower than that in group 1 from immediately after insertion to the end of surgery. After surgery, turning from the lateral (group 2) or prone (group 3) position to the supine position significantly raised the ICP. Because the ICP is related to the seal pressure of the LMA and postoperative pharyngolaryngeal morbidity, we recommend evaluating and adjusting the ICP appropriately in each body position.     

Endoscopic combined intrarenal surgery in prone split-leg and inclined supine positions to treat renal cast and multiple calyx stones: An invited commentary

This Invited Commentary discusses the following article:Mulay A, Mane D, Mhaske S, Shah AS, Krishnappa D, Sabale V. Supine versus prone percutaneous nephrolithotomy for renal calculi: Our experience. Curr Urol 2022;16 (1):25-29. doi: 10.1097/CU9.0000000000000076.

Urolithiasis is a common disease encountered in urology. Its incidence is 0.1%-14.8% in Western countries and 5.94%-9.15% in China, with a significantly higher incidence in South China than in North China. In some areas of South China, the incidence of calculi exceeds 20%.^[1] Currently, percutaneous nephrolithotomy (PCNL) is the preferred treatment option for patients with multiple complex, renal cast, and multiple calyx stones.^[2] Complex multiple stones are associated with a lower stone clearance rate and a higher complication rate.^[3] Multichannel lithotripsy and endoscopic combined intrarenal surgery (ECIRS) in prone split-leg and inclined supine positions can improve the stone clearance rate.^[4] The 2016 American Urological Association guidelines established multi-channel PCNL as a safe and effective treatment for complex stones. In a previous study, the stone-free rate in a single operation was 79%, but the size and number of channels increased, followed by an increased risk of bleeding.^[5]In the article “Supine versus prone percutaneous nephrolithotomy for renal calculi—Our experience,” Mulay et al. evaluated the efficacy and safety of PCNL in modified supine and prone positions and showed that PCNL and ECIRS can be performed simultaneously in the supine position. In 1992, Ibarluzea et al. introduced ECIRS in the modified supine position.^[6] With the improvement and development of various urological surgical techniques and instruments, retrograde intrarenal surgery (RIRS) is no longer just an adjunctive or alternative surgery but an important part of clinical treatment. Better clinical outcomes and minimization of surgery-related complications can be achieved by combining RIRS with PCNL. A systematic review of 14 ECIRS cases showed that ECIRS had a stone-free rate of 61%-97%, a complication rate of 5.8%-42%, and a reduced risk of bleeding. Moreover, the bleeding risk was not correlated with the PCNL puncture channel size.^[7] Modified supine ECIRS has the following advantages over multichannel PCNL:

1. No position adjustment is required after anesthesia.
2. Direct vision puncture can be performed, and the puncture needle and dilator can enter the collecting system without being too deep under the direct vision of the transurethral ureteroscope, ensuring the safety and effectiveness of the puncture and reducing the incidence of complications when the channel is established.
3. The first choice for percutaneous renal puncture in ECIRS is the inferior calyx approach, and flexible ureteroscopy is performed to treat stones in the middle and upper calyces, which are relatively easy to access. Simultaneously, the advantages of flexible ureteroscopy for exploration include treating parallel calyx stones. For lower parallel calyx stones, the stone basket under the flexible scope can be used to move the stone to a position that can be treated with nephroscopy, after which the stone can be crushed and extracted.
4. Stone fragments entering the ureter can be treated without position adjustment, thereby reducing the rate of reoperation.
5. Combined PCNL and RIRS can treat ureteral and kidney stones simultaneously.
6. The stone clearance rate improves without increasing the risk of bleeding.
7. Combined with ureteral twisting and stenosis, it is difficult to insert the double J stent tube from the PCNL channel after lithotripsy. The double J stent tube can be placed retrogradely through the urethra using the ECIRS without position adjustment.

ECIRS can also be performed in the prone split-leg position, which has several advantages compared to the modified supine position as follows:

1. The prone split-leg position fully exposes the percutaneous renal puncture area of the affected kidney at the waist.
2. This position is simpler than the modified supine position and effectively reduces the workload of medical staff.
3. The peripheral organs, such as the intestines, are lowered by gravity, reducing the risk of organ damage.
4. The intrarenal perfusion effect is better in the prone position; therefore, the operative field of view is unaffected.
5. The modified supine position typically has a longer PCNL tract, particularly in patients with obesity, with decreased nephroscopic mobility and greater renal parenchymal mobility; thus, the bleeding risk is high, and extra-long devices should be provided.

However, the prone split-leg or inclined supine position is not significantly superior in terms of urological parameters, such as the stone clearance or complication rate.^[8]PCNL technology has evolved mainly owing to improvements in puncture technology, endoscopic instruments, lithotripsy devices, and drainage management. The introduction of the split-leg prone and improved supine positions is also part of the development. The development of ECIRS reflects the individualized management of patients with stones. ECIRS in split prone and modified supine positions is associated with a higher stone clearance rate, less blood loss, shorter operative time, and reduced perioperative complications when treating renal cast and multiple calyx stones. This is a new, safe, and effective procedure for PCNL.     

Comparison of different extubation techniques in lumbar surgery: prone extubation versus supine extubation with or without prior injection of intravenous lidocaine

The aim of this study was to evaluate the incidence of coughing and breath holding in patients undergoing lumbar surgery extubated in prone position, supine position, or supine position with intravenous lidocaine before extubation. About 105 ASA I to II patients undergoing lumbar surgery were extubated in prone position in group P (n = 35), in supine position in group S (n = 35) and in supine position with intravenous 1.5 mg/kg lidocaine 10 minutes before extubation in group SL (n = 35). The number of patients who coughed and demonstrated breath holding was noted at emergence period. The time of loss of monitoring while repositioning the patient was recorded. The frequency of cough in group S was higher compared with group P at 1 minute after extubation (P = 0.008). Two and three minutes after extubation, the patients in group S demonstrated higher cough incidence compared with groups P and SL (P < 0.05). The incidence of breath holding in the first 6 minutes was lower in group P (n = 11) compared with groups S (n = 29) and SL (n = 25)(P = 0.001). The loss of monitoring time was longer in groups S (62 +/- 40 s) and SL (53 +/- 39 s) when compared with group P (0 s) (P < 0.01). Prone emergence and supine emergence with intravenous lidocaine provides an alternative approach to conventional supine emergence and prone extubation offers less cough and breath holding and continuation of monitoring.