Split-leg percutaneous nephrolithotomy: A safe and versatile technique

Objectives: Percutaneos nephrolithotomy (PCNL) is the gold standard for treatment of urinary stones larger than 2 cm and refractory to ESWL. Nowadays most debate about surgical technique is related to the positioning of patients. We report our expe- rience on prone PCNL with split-leg variant (SL-PCNL) Materials and methods: 30 consecutive patients underwent prone SL-PCNL. Preoperative stone size was deter- mined by measuring stones longest diameter on CT scan. In cases with multiple stones, stone size was determined by the sum of each stone diameter on CT scan. Patients evaluated con- sisted of 20 females and 10 males and median age was 55 (20-72). The average BMI was 27 (24-35). 15 patients had multiple stones, 10 pyelocalicial, 10 pelvic larger than 2 cm, 2 in horseshoe kidneys and 3 staghorn stones. Results: Stone free rate was 87% after first look and 97% after second look. In 2 cases, we used a flexible ureteroscopy 7.5 Fr (Flex 2 - Storz) to treat a calculus in ureter or for a contemporary double access (Endoscopic combined Retrograde Intrarenal Surgery ECIRS). In 28 cases we placed a 20 fr nephrostomy while in two cases procedure was tubeless. In 20 cases we placed a double-J catheter. In 2 cases we performed two tract and in 2 horseshoe kidneys access was close to spine. The average surgical time was about 90 minutes (range 30-120 minutes). Hemoglobin drop was about 1.5 mg/dl (range 1-3 .4 mg/dl) and no major complications were reported. Conclusions: In our experience PCNL in prone with spread-legs variant is a versatile technique and allows to match the advantages you have with same technique in supine, providing at the same time benefits in cases of anatomical abnormalities, challenging cases, or when multi-tract accesses are required.