Editorial Comment for Yuan et al.

Since the introduction of percutaneous nephrolithotomy (PCNL), the prone position has been the preferred approach. Although it seems that the prone position enables a safer access to a variety of different calices, it has also several disadvantages as were already described. The supine position is a competitive approach that is currently gaining increasing popularity, ¹ but still has several drawbacks. These include the necessity of more puncture sites to clean the collecting system from stones with apparently a greater risk, mainly because of the higher chance of intrarenal vascular injury and damage to adjacent organs.

In this important article, the authors conducted a meta-analysis of a robust number of patients to evaluate the efficacy and safety of PCNL in supine and prone positions. Their results indicate that there were no differences in patient's complications, including postoperative bleeding. However, the stone-free rate was significantly lower. We must remember that the main goal of this surgery is gaining the patient to be stone free. Unfortunately, considering stone-free rate, the supine position was found to be inferior to the prone position as was previously published by the CROES study group as well. ² Other approaches such as the lateral decubitus position ³ might overcome this drawback and still keep most of the advantages of the supine position. In such a position, the surgeon can still use all familiar potential puncture sites but avoid the main drawbacks of the prone position. In this position, the respiratory pressure is not elevated, there is no need for positional change after retrograde ureteral catheterization, and the surgeon can combine antegrade and retrograde stone handling.

In conclusion, there is no right or wrong position for PCNL. In choosing the correct position, the surgeon has to rely on his surgical experience while seeing the main goals: gaining the best success rates with the lowest complication rates.