Supine Percutaneous Nephrolithotomy (PCNL): Current Status

Background: Percutaneous nephrolithotomy (PCNL) remains the standard treatment for large (>20 mm), staghorn, and complex renal calculi. Although the prone position has traditionally been preferred, it is associated with anaesthetic challenges, longer operative times due to repositioning, and ergonomic limitations. Supine PCNL, particularly in the Galdakao-modified supine Valdivia position, has re-emerged as an alternative that may improve perioperative safety, workflow efficiency, and facilitate combined antegrade–retrograde intrarenal surgery (ECIRS). Objective: To review the current status of supine PCNL, focusing on its procedural principles, indications, outcomes, complications, and comparative effectiveness relative to prone PCNL. Methods: A narrative review was performed synthesising evidence from comparative studies, randomised trials, meta-analyses, and large observational series evaluating supine PCNL. Key aspects analysed included patient selection, positioning techniques, access and tract creation, intraoperative workflow, adjunctive ECIRS, anaesthetic and ergonomic considerations, postoperative strategies, and reported clinical outcomes. Results: Across most indications, supine PCNL demonstrates stone-free and complication rates comparable to prone PCNL. Supine positioning consistently reduces operative and anaesthesia time by eliminating intraoperative repositioning and improves airway access and hemodynamic stability, particularly in obese and high-risk patients. ECIRS is more readily feasible in the supine position, narrowing any potential disadvantage in complete staghorn calculi. Bleeding, infection, and visceral injury rates are similar between positions when appropriate patient selection and imaging-guided access are employed. Conclusion: Supine PCNL is a safe, efficient, and versatile alternative to prone PCNL that aligns with contemporary goals of patient-centred care, anaesthetic safety, and surgical ergonomics. With appropriate training and case selection, it achieves outcomes equivalent to the prone approach while offering distinct workflow and physiologic advantages.