Amón Sesmero J H, Del Valle González N, Conde Redondo C, Rodriguez Toves A, Cepeda Delgado M, Martínez-Sagarra Oceja J M
Servicio de Urología, Hospital Rio Hortega, Valladolid.
Actas Urol Esp. 2008 Apr;32(4):424-9. doi: 10.1016/s0210-4806(08)73857-9.
Although the supine position created by Dr. Valdivia two decades ago to perform the procedure known as percutaneous nephrolitectomy (PNL) presents advantages against the prone position in some aspects concerning anesthesia and surgical ergonomy, its use has failed to spread widely among the urology community due to certain technical difficulties, a lower rate of calculi clearing and a higher rate of complications, in spite of the fact that the scarce comparative studies do not show enough data to support this opinion. The present study compares both positions considering the technical difficulties encountered, their effectiveness and their results and complications.
A series of 50 patients that underwent PCNL by prone position is compared retrospectively with another series of 54 patients that underwent consecutively PCNL by prone position. All procedures were performed under general anesthesia, the inferior calyx approach was the one used the most over the supracostal approach, and the sole tract over the multi-tract approach was predominant. Dilatation of the nephrostomy tract was done, in most of the cases, with a high-pressure balloon catheter. The stone surface treated was 399.93+/-58.2 mm2 for the supine group, and 416.36+/-46.54 mm2 for the prone one (p=0.456). The management of the stones was carried out by ultrasonic or ballistic fragmentation, and a small group of patients underwent direct stone removal.
As far as demographic parameters and operative variables such as number of tracts performed, calyx election, type of tract dilatation and kind of energy used for fragmentation, both groups were homogeneous. In 3 cases of each group there was a failure to access the kidney. The rate of failure was 6%, and 5.56%, for the supine and prone groups, respectively (p=0.716). Average operating time was 74.55+/-25.54 and 91.82+/-24.82 minutes, respectively, p=0.123. A postoperative x-ray showed a stone-free rate of 76% for the supine group and 74% for the prone group, p=0.308. ESWL was the supplementary treatment for 12% of the patients in the supine group, and for 12.96% of the patients in the prone group p= 0.478, and a second procedure was performed on 4 (8%) patients in the supine group and on 3 (5.56%) in the prone one, p=0.697. Hospital stay was the same for both groups (5.89+/-4.7 for the supine group, and 5.5+/-4.09 for the prone one, p=0.694). As far as analgesia required, 6.89+/-4.87 was administered for the supine against 6.18+/-4.09 for the prone, p=0.580. The complications rate was very low for both groups and also very similar; one of the patients in the supine group suffered a lesion to the colon.
Valdivia position is as feasible as the prone position for PCNL. Success rates, as far as stone clearing, and complications are similar for both positions.
尽管瓦尔迪维亚医生在二十年前开创的仰卧位用于经皮肾镜取石术（PNL），在麻醉和手术人体工程学的某些方面相较于俯卧位具有优势，但其应用在泌尿外科界并未广泛传播，原因在于存在某些技术难题、结石清除率较低以及并发症发生率较高，尽管为数不多的比较研究并未提供足够数据支持这一观点。本研究从所遇到的技术难题、有效性以及结果和并发症方面对两种体位进行比较。
将一系列50例采用俯卧位进行经皮肾镜取石术的患者与另一组54例连续采用仰卧位进行经皮肾镜取石术的患者进行回顾性比较。所有手术均在全身麻醉下进行，下盏入路是比肋上入路使用最多的方法，单通道入路在多通道入路中占主导地位。在大多数情况下，使用高压球囊导管进行肾造瘘通道扩张。仰卧组治疗的结石表面积为399.93±58.2平方毫米，俯卧组为416.36±46.54平方毫米（p = 0.456）。结石处理采用超声或弹道碎石术，一小部分患者进行了直接取石。
就人口统计学参数和手术变量而言，如通道数量、肾盏选择、通道扩张类型以及用于碎石的能量类型，两组具有同质性。每组各有3例未能进入肾脏。仰卧组和俯卧组的失败率分别为6%和5.56%（p = 0.716）。平均手术时间分别为74.55±25.54分钟和91.82±24.82分钟，p = 0.123。术后X线显示仰卧组结石清除率为76%，俯卧组为74%，p = 0.308。仰卧组12%的患者接受了体外冲击波碎石术（ESWL）作为辅助治疗，俯卧组为12.96%的患者，p = 0.478，仰卧组有4例（8%）患者进行了二次手术，俯卧组有3例（5.56%）患者进行了二次手术，p = 0.697。两组的住院时间相同（仰卧组为5.89±4.7天，俯卧组为5.5±4.09天，p = 0.694）。就所需镇痛而言,仰卧组为6.89±4.87，俯卧组为6.18±4.09，p = 0.580。两组的并发症发生率都很低且非常相似；仰卧组有一名患者结肠受损。
对于经皮肾镜取石术，瓦尔迪维亚体位与俯卧位一样可行。在结石清除成功率以及并发症方面，两种体位相似。
