Supine PCNL is the way to go!

The fact that operating a patient in the supine position is easier than in a prone position is rather intuitive: apart from PCNL and, obviously, spinal surgery, there is no surgery of retroperitoneal organs performed in the prone position. So, why is it that nowadays PCNL is performed in the supine position only in 20% of cases worldwide? [1]. Indeed, the prone position was adopted in the pioneering era of PCNL only on an intuitive basis with the thought that in the supine position no window for puncture was present because of colon interposition. This was assumed as a postulate. As a consequence, this approach was supposed to be the only one able to prevent colonic perforation which was, and still is, considered one of the most frightening complications of PCNL. And probably at that time it really was, neither CT nor US scans were available and no chance to detect organs that lied in between the skin and kidney was possible. For decades, this concept never came into question and it was unquestionably adopted by the following generations. But at this moment in time in which no patients undergo a PCNL without a preoperative CT scan, perseverance in this attitude is meaningless. Also because, as already demonstrated, the incidence of a retrorenal colon is higher in the prone than in the supine position (10 vs. 1.9%) [2]. Moreover, we also have to consider that, as done by the majority of urologists, the fact that the preoperative CT scan is mostly carried out in the supine position, can be misleading when planning a prone PCNL [3]. As such, only in these anecdotal cases of retrorenal colon, the surgeon can decide to go back to the prone position. On the other hand, the supine position certainly offers several advantages, as listed in detail in this interesting paper [4–7]. So then, what is still preventing the worldwide propagation of the supine Supine PCNL is the way to go!