Supine percutaneous nephrolithotomy (PCNL): 'in vogue' but in which position?

OBJECTIVE To discuss the relative merits of the different described supine positions for percutaneous nephrolithotomy (PCNL) and highlight the new 'Barts flank-free modified supine position', as the last decade has seen the emergence of various supine positions for PCNL. MATERIALS AND METHODS We reviewed English publications on supine PCNL to look at the different positions being used to carry out PCNL and their relative merits. We describe the new 'Barts flank-free modified supine position', which we think will add significantly to the armamentarium of the endourologist. RESULTS Five different supine positions are discussed. These include the complete supine, the Valdivia, the Galdakao modified Valdivia, the Barts modified Valdivia and the herein described Barts flank-free modified supine position These positions all differ in regard to ease of puncture under image guidance, operative field availability, ability to make multiple tracts and the ease of combining retrograde intra-renal surgery. CONCLUSIONS All of the supine positions decrease operative duration, as there is no need for repositioning and allow quick access to the airway for the anaesthetist. However, one supine position does not fit all and the right one must be chosen for the right patient with the right stone burden. It is important for endourologists of today to familiarise themselves with these positions to be able to make these judgements.