Abstract
Percutaneous nephrolithotomy (PCNL) has been the mainstay of surgical treatment of large and complex renal calculi for more than four decades. There has been an ongoing debate about whether the prone or supine position is better for PCNL. It is believed that the journey of PCNL started with prone PCNL, and supine PCNL was later introduced as a modification. Interestingly, the historical evidence is contrary to this belief.
The first nephroscopy for removal of calculus from the kidney using a cystoscope through a surgically created nephrostomy tract was performed by Rupel and Brown in 1941. 1 Goodwin, Casey, and Woolf (1955) are credited with the first description of the creation of a percutaneous nephrostomy in the prone position. 2
First PCNL, where a percutaneous tract was intentionally created for removing renal calculi, was reported by Fernstrom and Johansson in 1976. 3 In this three-case series, the authors report their experience with a tract created under radiology guide. This seminal work gave birth to PCNL and to the endourology subspeciality. The first PCNL described by Fernstrom and Johansson was actually a supine PCNL. They took renal access using a technique described by Almgård and Fernström in 1974. 4 To our knowledge, this aspect has received little attention in subsequent historical accounts of PCNL. They visualized the kidney by intravenous contrast or on an image intensifier, depending on kidney function. Then they marked the external puncture site in the axillary line or more dorsally. The initial renal puncture was done under local anesthesia with the patient in supine position using a 9 cm long needle passed horizontally at the level of the center of the kidney. To monitor the entry of the needle and to prevent entry into the peritoneum, they injected contrast intermittently. After satisfactory puncture, they injected contrast into the kidney and withdrew the needle, noting the direction of entry. Through this needle tract, they passed a specially prepared nephrostomy tube over a stylet. They reported 51 cases of percutaneous nephrostomy (PCN) done with this technique. 4 The first PCNL reported by Fernström and Johansson 3 used this technique for the initial nephrostomy. Then they dilated the tract daily by increments of 0.5 mm in diameter. After achieving the adequate tract size percutaneous tract, the PCN tube was kept for 14 days before stone extraction. They used Dormia basket or forceps for stone removal under image intensifier guide without visualization by endoscope.
It is interesting to note that this procedure was done in the supine position. Subsequent developments in PCNL were mainly in prone PCNL, largely because of the retroperitoneal position of the kidney, the ease of renal puncture in the prone position, and the fear of colonic injury in the supine position. For most of the time, PCNL meant a prone PCNL, before Valdivia described supine PCNL in 1987. 5
We intend to correct the common myth that PCNL started as prone PCNL and bring to notice that the first reported PCNL by Fernstrom and Johansson was indeed a supine PCNL. Valdivia and colleagues should be credited for later popularizing supine PCNL, demonstrating its safety and highlighting the advantages of this position.
Dr. Prashant Motiram Mulawkar
Dr. Gyanendra Sharma
Dr. Pankaj N. Maheshwari
Dr. Venkat Gite