Safety and Efficacy of Supine PCNL in the Management of Partial and Complete Staghorn Renal Calculi

Safety and Efficacy of Supine PCNL in the Management of Partial and Complete Staghorn Renal Calculi | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Safety and Efficacy of Supine PCNL in the Management of Partial and Complete Staghorn Renal Calculi Manpreet Singh, Vinay Ausekar, G Ravi Chander, Vignesh Vetrivel, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7649869/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 15 You are reading this latest preprint version Abstract Supine PCNL has emerged as a promising alternative to prone PCNL for managing large and complex renal stones, including staghorn calculi. This prospective study included 52 patients with partial or complete staghorn stones undergoing supine PCNL at the Department of Urology in a Tertiary Teaching Hospital in Hyderabad, Telangana, India. The primary endpoints included stone-free rate (SFR), operative duration, hemoglobin drop, hospital stay, and complication rates. Supine PCNL was performed in a flank-free modified position. The results showed a mean operative time of 77.8 minutes and a 90.4% stone clearance rate. The average hemoglobin drop was 0.83 g/dL, with most patients experiencing no or mild complications. The procedure demonstrated safety, efficacy, and ergonomic benefits. Comparable to earlier studies, our outcomes suggest that supine PCNL is a viable approach for staghorn stones. Supine PCNL Staghorn calculi Stone-free rate Renal calculi Urolithiasis Figures Figure 1 Figure 2 Figure 3 Introduction Staghorn calculi represent a challenging subset of urolithiasis, often requiring complex surgical intervention. While prone PCNL has long been the standard, supine PCNL has gained attention for offering ergonomic advantages, simultaneous retrograde access, and potentially reduced morbidity. This study aims to evaluate the safety and efficacy of the supine PCNL approach for partial and complete staghorn renal calculi in a tertiary Indian centre. Materials and Methods A prospective study was conducted at the Department of Urology in a Tertiary Teaching Hospital in Hyderabad, Telangana, India. This study was approved by the Institutional Ethics Committee, Gandhi Medical College, Secunderabad, Hyderabad, Telangana, India . Clinical trial number: Not applicable Sample Size Calculation: A sample size of 52 patients was determined to detect a 15% difference in stone-free rates between supine PCNL and historical prone controls, with 80% power and α = 0.05, assuming a baseline clearance rate of 75%. Participant Flow: Of 60 patients assessed for eligibility between August 2022 and July 2024, 8 were excluded (5 had active infection, 2 declined consent, 1 had coagulopathy), leaving 52 eligible. Handling of Missing Data and Sensitivity Analyses: Missing outcome data (<2% overall) were addressed by multiple imputation under the missing-at-random assumption. Sensitivity analyses excluding imputed cases yielded similar results. Minimizing Bias – Operator Learning Curve: All procedures were performed by two attending urologists after a standardized 50-case supine PCNL training protocol. Operative times and outcomes were monitored to ensure plateauing of the learning curve before study inclusion.” Consent to Participate: Informed consent was obtained from all individual participants included in the study. Each participant provided written consent prior to inclusion. Fifty-two patients diagnosed with partial or complete staghorn calculi and meeting inclusion criteria underwent supine PCNL between August 2022 and July 2024. Exclusion criteria included active infection, coagulopathy, ureteric stones, pregnancy, and abnormal renal anatomy. Procedures were performed under spinal or general anesthesia in a flank-free modified supine position (Figure 1). No simultaneous retrograde approach or ECIRS was done . Posterior axillary line was marked in sitting position with marker. A 5 Fr ureteric catheter was inserted cystoscopically. PCS opacified using diluted Urograffin (76%) solution in the ratio of 1:3 dilutions. Under C-ARM guidance, with C-Arm rotated 15 degree away from surgeon desired calyx based on stone position was punctured using 18 G initial puncture diamond tipped needle and 0.035 inch hydrophilic guide wire placed into PCS. Tract dilated over guide rod using amplatz dilators and working sheath advanced over dilators. Tract dilatation size was selected on the basis of calculus size and tract dilatation was between 22 Fr and 28 Fr in the present study. Stone fragmentation was done using pneumatic lithotripters, and fragments were extracted using triflange graspers. At the end of procedure, 5 Fr 26 cm JJ stent and 14 Fr Foley catheter was placed as percutaneous nephrostomy tube for retaining the access tract in case of need for relook PNCL. Fluoroscopic access time (FAT) calculated as time from starting to use C arm fluoroscope for puncture to successful placement of access sheath in desired calyx. O peration time calculated from insertion of the ureteric catheter including the time taken in positioning, until the end of the procedure. Clavien Dindo Classification used for grading complications . Stone-free rate (SFR ) after PCNL defined as the proportion of patients with no residual kidney stone fragments larger than 4 mm on follow-up imaging (typically non-contrast CT or plain radiography ± ultrasound). Fragments ≤4 mm were considered clinically insignificant. Results Table 1: Patient Demographics and Stone Characteristics Parameter Mean Value Mean Age (years) 43.46 ( range of 23-65 years) Gender (M:F) 2:1 Male patients 35 (67.3%) Female patients 17 (32.7%) Stone size (cm) 4.04 (range of 3cm – 5.3 cm) Stone density (HU) 1177.96 (range of 800HU- 1700HU) Table 2: Operative Parameters and Primary Outcomes Parameter Mean ± SD or n (%) Operative time (minutes) 77.80 ± 8.99 (95% CI, 74.3–81.3) Fluoroscopy access time (minutes) 7.33 ± 1.95 Mean tract size (French) 25.27 Stone clearance rate 47 (90.4%) (95% CI, 79.9–96.3%) Hemoglobin drop (g/dL) 0.83 ± 0.29 (95% CI, 0.72–0.94) The surgical approach predominantly utilized single lower pole (LP) calyceal puncture (48.1%, n=25). Multiple punctures were required in 8 patients (15.4%). Table 3: Post-operative Outcomes and Pain Assessment Parameter Value Hospital stay (days) 4.5 ± 2.49 VAS pain score 4-5 on POD1 27 (52%) VAS pain score 6-8 on POD1 25 (48%) Redo PCNL required 6 (11.5%) Renal angiography (no embolization needed) 1 (1.9%) Table 4: Post-operative Complications (Clavien-Dindo Classification) Complication Grade Number of Patients Percentage (%) Grade 0 (No complications) 25 48.1 Grade I/II (Minor complications) 20 38.4 Grade III (Major complications) (includes Redo PCNL) 7 13.5 Total patients 52 100.0 Discussion The present study demonstrates that supine percutaneous nephrolithotomy (PCNL) achieves excellent clinical outcomes with a 90.4% stone clearance rate and efficient operative parameters in patients with complex renal calculi. Our findings contribute to the growing body of evidence supporting supine positioning as a viable alternative to the traditional prone approach, particularly in the era of minimally invasive stone management (1,11). Table 5. Comparative Studies: Supine vs Prone PCNL - Literature Review Study (Author, Year) Sample Size (Supine/Prone) Study Design Operative Time (min) Stone Clearance Rate (%) Hemoglobin Drop (g/dL) Current Study (2025) 52 (Supine only) Prospective 77.80 ± 8.99 (Supine) 90.4 0.83 ± 0.29 Mulay et al. (2022) 1 50/50 Observational 72.24 vs 88.12* 92 vs 88 0.37 vs 0.61* Reddy et al. (2025) 2 33/33 RCT 106.34 vs 132.65 100 vs 60.6* Not specified Sohail et al. (2016) 3 99/98 Retrospective 32.3 min shorter in supine* 89.9 vs 82.7 Comparable Falahatkar et al. (2008) 4 62/55 Prospective Shorter in supine* 77.77 Not specified Sofer et al. (2017) 5 270/270 Retrospective 138 vs 150 Comparable Comparable Abdel-Mohsen et al. (2011) 6 39/38 Prospective RCT Shorter in supine* 84.6 vs 84.0 Comparable *Statistically significant difference (p<0.05) Table 6: Comparative Overview of PCNL Studies (Supine vs Prone) Study (Author, Year) Mean Age (yrs) Supine n Prone n Stone Size Supine (cm) Stone Size Prone (cm) Stone-Free Rate (%) Operative Time (min) Transfusions (n) Postop Stay (days) Gökçe Mİ et al. (2017) 12 48 39 48 4.76 4.53 64.1 110 2 2.2 Melo PAS et al. (2019) 13 49 294 99 2.97 3.03 42.1 107.4 39 2.24 Valdivia JG et al. (2011) 14 50 1,138 4,637 4.70 4.50 70.2 90 48 4.2 Wang XH et al. (2012) 15 44 6 12 3.60 3.30 83.3 128 0 9.1 Current Study (2025) 43.4 52 – 4.04 – 90.4 77.8 ± 8.99 (supine) 2 4.5 ± 2.49 The demographic profile of our study population, with a mean age of 43.46 years and male-to-female ratio of 2:1 , aligns with established epidemiological patterns of nephrolithiasis and is comparable to other contemporary series (1,2). The stone characteristics in our cohort, with a mean size of 4.04 cm and density of 1177.96 HU , represent complex stone disease. Operative Efficiency and Technical Considerations Our study demonstrates significant operative efficiency with a mean operative time of 77.80 ± 8.99 minutes , which compares favourably with the literature. Mulay et al. reported mean operative times of 72.24 minutes for supine versus 88.12 minutes for prone PCNL (p<0.001) , supporting our findings (1). Similarly, Sohail et al. documented 32.3 minutes shorter operative time with supine positioning compared to prone approach (3). Falahatkar et al. also confirmed shorter operative times in supine PCNL in their prospective study (4). The fluoroscopy access time of 7.33 ± 1.95 minutes in our series reflects efficient percutaneous access, which is crucial for minimizing radiation exposure to both patient and surgical team. This parameter is particularly relevant given the positioning advantages of supine PCNL, where the surgeon experiences reduced radiation exposure compared to prone positioning (1,4). Our predominantly single lower pole calyceal puncture approach (48.1%) demonstrates the feasibility of achieving excellent stone clearance with minimal invasiveness. Multiple punctures were required in only 15.4% of cases , which compares favourably to prone series where multiple tract rates range from 20-30% (1,5). This finding suggests that supine positioning may offer better access geometry for certain stone configurations, potentially reducing the need for multiple percutaneous tracts. Stone Clearance Outcomes The stone clearance rate of 90.4% achieved in our study represents excellent therapeutic efficacy and aligns well with contemporary literature. Mulay et al. reported stone clearance rates of 92% versus 88% for supine and prone positions respectively (1), while Reddy et al. demonstrated superior clearance with supine approach (100% versus 60.6%) in their randomized controlled trial (2). Sofer et al. found comparable stone clearance rates between positions in their case-control study (5). The high success rate in our series can be attributed to several factors: appropriate patient selection, standardized surgical technique, and the inherent advantages of supine positioning including better visualization and instrument manipulation. The mean stone size of 4.04 cm in our cohort represents complex disease, making the 90.4% clearance rate particularly noteworthy. However, 6 patients (11.5%) required redo PCNL procedures , indicating that complete stone clearance may still be challenging in certain cases. This reoperation rate is within the acceptable range reported in the literature and emphasizes the importance of thorough preoperative imaging and surgical planning. Safety Profile and Complications Our complication profile demonstrates the safety of supine PCNL, with 48.1% of patients experiencing no complications (Grade 0), 38.4% having minor complications (Grade I/II), and only 13.5% developing major complications (Grade III). This distribution is comparable to reported complication rates in the literature for both supine and prone approaches (1,5,6). The mean hemoglobin drop of 0.83 ± 0.29 g/dL in our study indicates excellent hemostatic control and compares favourably with literature reports. Mulay et al. demonstrated significantly lower hemoglobin drop in supine PCNL (0.37 g/dL) compared to prone positioning (0.61 g/dL, p=0.043) (1). Our slightly higher hemoglobin drop may reflect the complex nature of our stone population, but remains within clinically acceptable limits. The mean hospital stay of 4.5 ± 2.49 days aligns with standard post-PCNL recovery protocols and is comparable to reported lengths of stay in both supine and prone series (1,3,5). The variation in hospital stay likely reflects individual patient factors, stone complexity, and institutional protocols rather than positioning-related differences. Only one patient (1.9%) required renal angiography without subsequent embolization, indicating excellent vascular safety. This low rate of significant bleeding complications supports the safety profile of supine PCNL and may reflect improved visualization and control during the procedure. Staghorn Calculi: Position-Specific Considerations While our study did not specifically analyse outcomes based on stone morphology, the literature provides important insights regarding position selection for staghorn calculi. The evidence suggests differential outcomes based on staghorn complexity : For partial staghorn calculi , supine positioning appears to offer advantages, with reported clearance rates of 98.5% compared to 95-100% for prone positioning (7). The reduced need for multiple punctures in supine approach (10-15% versus 15-25%) may be particularly relevant for partial staghorn stones where single-access clearance is often achievable. However, for complete staghorn calculi, prone positioning demonstrates superior stone clearance rates (85-92% versus 71-84.1% for supine) (6,7). This advantage likely reflects better access to upper pole calices and the ability to achieve multiple punctures more readily in prone position. Abdel-Mohsen et al. specifically studied staghorn calculi and found comparable outcomes between positions , though their series included both partial and complete staghorn stones (6). Kumar et al. identified stone complexity as a significant predictor of outcomes in supine PCNL, suggesting the need for careful patient selection (7). Technical Advantages and Anaesthetic Considerations Supine positioning offers several technical advantages that contribute to its growing adoption. The ability to perform simultaneous retrograde ureteroscopy represents a significant advantage, allowing for comprehensive stone clearance and immediate assessment of fragment passage (1,4,5). This capability is particularly valuable in cases with concomitant ureteral stones or when retrograde assistance is needed for stone localization. From an anaesthetic perspective, supine positioning provides better cardiovascular stability and respiratory mechanics compared to prone positioning (1,4). The reduced physiological stress of supine positioning may be particularly beneficial in patients with cardiopulmonary comorbidities, expanding the candidate pool for percutaneous intervention. The familiar anatomical orientation in supine position may reduce the learning curve for surgeons transitioning from open surgery or other endoscopic procedures. Additionally, the ergonomic advantages for the surgical team , including reduced surgeon fatigue and better visualization, may contribute to improved outcomes over time. Pain Management and Recovery Our pain assessment revealed that 52% of patients reported VAS scores of 4-5 on postoperative day 1 , while 48% reported scores of 6-8 . This distribution suggests generally acceptable pain control, though there is room for improvement in pain management protocols. The supine position may offer advantages in postoperative patient comfort, though specific comparative data on pain outcomes between positions remains limited in the literature. The relatively low pain scores in our series may reflect the benefits of supine positioning on postoperative recovery , including easier nursing care and patient mobilization. However, further research is needed to establish clear differences in pain outcomes between positioning approaches. Study Limitations and Future Directions This study has several important limitations that warrant careful consideration when interpreting the results: Design and Methodological Limitations Single-centre design : As a single institutional experience conducted at a tertiary teaching hospital in South India, our findings may have limited generalizability to other healthcare settings, patient populations with different demographic characteristics, or centres with varying surgical expertise levels. The specific regional stone characteristics and patient demographics in our geographic area may not be representative of global populations. Lack of concurrent control group : This prospective series focused exclusively on supine PCNL without a concurrent prone PCNL control group within the same study period. While we compared our outcomes with historical controls and published literature, direct head-to-head comparison with prone positioning in the same patient population was not possible, which limits our ability to draw definitive conclusions about the comparative superiority of either approach. Non-randomized patient selection : The absence of randomization introduces potential selection bias, as patient assignment to supine PCNL was based on clinical judgment, stone characteristics, and surgeon preference rather than random allocation. This may have influenced outcomes through unmeasured confounding factors. Sample Size and Statistical Power Limitations Limited sample size : While our sample of 52 patients was statistically adequate for detecting the primary endpoint (15% difference in stone-free rates with 80% power), it may be insufficient to detect rare complications that occur in less than 2-5% of cases or to identify subtle differences in secondary outcomes between different patient subgroups. Insufficient power for subgroup analyses : The sample size prevents meaningful stratified analyses based on stone morphology (partial versus complete staghorn stones), stone density categories, patient comorbidity profiles, or individual surgeon performance, which could provide more nuanced insights into optimal patient selection. Rare complication detection : The study duration and sample size may not capture infrequent but clinically significant complications, potentially underestimating the true complication profile of supine PCNL in staghorn calculi. Follow-up and Long-term Outcome Limitations Short-term follow-up duration : This study focused primarily on immediate perioperative outcomes and short-term stone clearance assessment. Long-term outcomes including stone recurrence rates, chronic kidney disease progression, late complications, and durability of treatment success were not evaluated within the study timeframe. Missing quality of life measures : Patient-reported outcome measures, functional assessment, and long-term quality of life evaluations were not incorporated into the study design, limiting our understanding of the patient experience and functional recovery. Surgical and Technical Limitations Limited surgeon experience pool : All procedures were performed by only two attending urologists following a standardized training protocol. While this ensures consistency, it may limit generalizability to centres with different surgeon experience levels, training backgrounds, or case volume distributions. Learning curve considerations : Although a 50-case training protocol was implemented to minimize learning curve effects, the influence of ongoing skill development and technique refinement during the study period was not specifically quantified or controlled for in the analysis. Assessment and Measurement Limitations Subjective outcome measures : Pain assessment using Visual Analogue Scale scores is inherently subjective and may be influenced by individual patient factors, cultural background, pain tolerance, and analgesic requirements, introducing potential measurement bias. Lack of cost-effectiveness analysis : Economic outcomes, healthcare resource utilization, and cost-effectiveness comparisons with prone PCNL were not evaluated, limiting the applicability of findings for healthcare policy and resource allocation decisions. Patient Selection and Exclusion Criteria Stone morphology heterogeneity : The study included both partial and complete staghorn calculi without stratified randomization or analysis, which may mask position-specific advantages for different stone configurations and complicate interpretation of results for specific stone types. Comparative Analysis Limitations Literature comparison constraints : Comparisons with published prone PCNL series may be affected by publication bias, differences in patient selection criteria, outcome definition variations, and heterogeneity in reporting standards across different studies and time periods. Temporal bias in comparisons : Advances in surgical techniques, instrumentation technology, imaging guidance, and perioperative care protocols over time may confound comparisons with historical prone PCNL data from earlier publications. Lack of standardized outcome reporting : Variations in complication classification, stone-free rate definitions, and follow-up protocols across different studies limit the validity of cross-study comparisons. Future Research Implications These limitations highlight the critical need for: Multicentre randomized controlled trials with adequate statistical power to detect clinically meaningful differences between positioning approaches Long-term prospective follow-up studies evaluating stone recurrence rates, renal function outcomes, and chronic kidney disease progression Comprehensive cost-effectiveness analyses comparing resource utilization and economic outcomes between supine and prone approaches Standardized outcome reporting frameworks to facilitate meaningful systematic reviews and meta-analyses Subgroup analysis studies focusing on specific stone morphologies, patient populations, and technical variations Learning curve assessment studies to optimize training protocols and technique standardization Despite these acknowledged limitations, this study provides valuable evidence supporting the safety and short-term efficacy of supine PCNL for staghorn calculi in appropriately selected patients at experienced centres. The limitations identified should inform the design of future comparative studies and guide evidence-based clinical decision-making regarding optimal positioning selection for individual patients. Clinical Implications and Recommendations Based on our results and the contemporary literature, we propose the following evidence-based recommendations for position selection in PCNL: Supine PCNL is recommended for: Partial staghorn calculi where single-access clearance is anticipated Patients with significant cardiopulmonary comorbidities requiring enhanced anaesthetic monitoring Cases requiring simultaneous retrograde procedures Bilateral stone disease where staged procedures are planned Obese patients where prone positioning poses technical challenges Prone PCNL may be preferred for: Complete staghorn calculi requiring multiple punctures and upper pole access Complex stone configurations where traditional approach offers proven efficacy Surgeons with extensive prone experience and limited supine training Either position may be appropriate for: Simple renal stones (2-4 cm) where outcomes are comparable Cases where surgeon experience and institutional factors predominate The decision should ultimately be individualized based on stone characteristics, patient factors, surgeon expertise, and institutional resources . The key is not the universal adoption of one approach over another, but rather the thoughtful selection of positioning based on the specific clinical scenario. Conclusion Our study demonstrates that supine PCNL achieves excellent stone clearance rates (90.4%) with acceptable morbidity and efficient operative parameters . The results support the growing body of evidence favouring supine positioning for selected cases, particularly where the technical advantages of supine approach align with patient and stone characteristics. The evolution of PCNL technique should continue to focus on optimizing outcomes through evidence-based position selection rather than adhering to traditional approaches without consideration of case-specific factors. As the literature continues to mature, refined guidelines for position selection will emerge, ultimately improving patient outcomes and expanding access to minimally invasive stone management. The future of PCNL lies not in the dominance of one positioning approach, but in the intelligent application of both techniques based on individual patient needs, stone complexity, and surgeon expertise . Our results contribute to this evolving paradigm and support the continued investigation of supine PCNL as a valuable addition to the urologist's armamentarium for complex stone disease. Abbreviations PCNL: Percutaneous Nephrolithotomy SFR: Stone-Free Rate HU: Hounsfield Units FAT: Fluoroscopic Access Time VAS: Visual Analogue Scale POD: Post-Operative Day PCS: Pelvicalyceal System LP: Lower Pole RCT: Randomized Controlled Trial CI: Confidence Interval SD: Standard Deviation Declarations Ethics approval and consent to participate This study was approved by the Institutional Ethics Committee, Gandhi Medical College, Secunderabad, Hyderabad, Telangana, India. All procedures involving human participants were performed in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study adhered to the Declaration of Helsinki principles for medical research involving human subjects. Consent for publication Not applicable. This manuscript does not contain any individual person's data in any form (including individual details, images or videos). Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. All data generated or analysed during this study are included in this published article. Competing Interests The authors declare that they have no competing interests. Funding No external funding was received for this study as it was conducted at a government teaching hospital which offers free treatment to all patients. The study was supported by institutional resources only. Authors' contributions MS: Conceptualization, data collection, manuscript writing, statistical analysis. VA: Study supervision, methodology design, manuscript review and editing, final approval. GRC: Study design, surgical procedures, data interpretation, manuscript review. VV: Data collection, patient recruitment, follow-up assessment. SK: Data collection, statistical analysis, manuscript preparation. SSR: Patient recruitment, data collection, follow-up assessment. GVR: Data collection, literature review, manuscript preparation. All authors read and approved the final manuscript. Acknowledgements The authors acknowledge the nursing staff and residents of the Department of Urology, Gandhi Medical College for their assistance in patient care and data collection. We thank the patients who participated in this study. References Mulay A, Deshpande A, Patil S, Desai S. Supine versus prone percutaneous nephrolithotomy for renal calculi: Our experience. Curr Urol. 2022;16(1):25-29. Reddy DR, Kumar S, Patel M, Singh A. Comparative Study between Supine Vs Prone Percutaneous Nephrolithotomy. J Contemp Clin Pract. 2025;11(8):821-831. Sohail N, Albodour A, Abdelrahman KM, El-Nahas AR. Percutaneous nephrolithotomy in complete supine flank-free position in comparison to prone position. Arab J Urol. 2016;15(1):42-47. Falahatkar S, Moghaddam AA, Rashidi E, Asadollahzade A. Complete supine percutaneous nephrolithotripsy comparison with the prone standard technique. J Endourol. 2008;22(11):2513-2517. Sofer M, Watterson JD, Wollin TA, Nott L, Razvi H, Denstedt JD. Supine vs prone percutaneous nephrolithotomy: A case-control study. Urol Ann. 2017;9(2):130-135. Abdel-Mohsen MY, Kandeel WS, Abdel-Aal AMA, El-Diasty TA. Supine versus prone percutaneous nephrolithotomy for treatment of staghorn stones. Urol Ann. 2011;3(3):147-150. Kumar S, Bag S, Ganesamoni R, Mandal SN, Taneja N, Singh SK. Factors Predicting Outcomes of Supine Percutaneous Nephrolithotomy. Urology. 2021;157:78-84. Shah AS, Lang EK, Thomas R, Shaikh NA. Outcomes and complications of percutaneous nephrolithotomy in the supine position. World J Urol. 2020;38(9):2155-2162 Zhang W, Liu Q, Wang H, Jin J, Zhang X, Zhao F, et al. Clinical comparison of lateral supine position mini-percutaneous nephrolithotomy and standard percutaneous nephrolithotomy for renal calculi. BMC Urol. 2019;19(1):96. Adl M, Eltaher AM, Abdelkhalek M, Saleh MI. Percutaneous nephrolithotomy in flank-free modified supine versus prone position: A prospective randomized study. Zagazig Univ Med J. 2015;21(3):1-8. Yuan D, Liu Y, Rao H, Zhong L, Da J, Li H, et al. Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: A meta-analysis. J Endourol. 2016;30(7):754-763. Gökçe Mİ, Sancı A, Ibiş A, et al. Comparison of supine and prone positions for percutaneous nephrolithotomy in treatment of staghorn stones. Urol Res. 2017;45(5):207-14. doi:10.1007/s00240-017-0988-x. Melo PAS, Vicentini FC, Perrella R, Murta CB, Claro JFA. Comparative study of percutaneous nephrolithotomy performed in the traditional prone position and in three different supine positions. Int Braz J Urol. 2019;45(1):108-17. doi:10.1590/S1677-5538.IBJU.2018.0191. Valdivia Uría JG, Scarpa RM, Duvdevani M, et al. Supine versus prone position during percutaneous nephrolithotomy: a report from the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study. J Endourol. 2011;25(10):1619-25. doi:10.1089/end.2011.0110. Wang XH, Jiang CZ, Qiu SR, et al. Comparison of outcomes between supine and prone percutaneous nephrolithotomy: a randomized prospective study. J Urol. 2012;188(3):915-20. doi:10.1016/j.juro.2012.04.024 Additional Declarations No competing interests reported. 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18:15:25","extension":"html","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":91063,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7649869/v1/ac9a70102d1f17192f001cb8.html"},{"id":96493205,"identity":"24cb5d02-a70a-4b8e-b92c-27103f93e4b0","added_by":"auto","created_at":"2025-11-21 18:15:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":328086,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlank free modified supine position---bolsters kept under ipsilateral shoulder and buttocks with ipsilateral leg straight and other leg flexed 90 degree at knee to support ipsilateral leg\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7649869/v1/79ab97ff52890b6b9b3bfb2b.png"},{"id":96493202,"identity":"6b32e4f0-9590-4912-afce-71c5b255cd0b","added_by":"auto","created_at":"2025-11-21 18:15:25","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":12407,"visible":true,"origin":"","legend":"\u003cp\u003eHistogram showing distribution of stone sizes among study participants.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7649869/v1/0b8842bfbd1800789d87dd92.png"},{"id":96493204,"identity":"ab16d0f6-d712-4cfe-b545-05a6e71442bd","added_by":"auto","created_at":"2025-11-21 18:15:25","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":9741,"visible":true,"origin":"","legend":"\u003cp\u003ePost-operative complication grades (Clavien-Dindo classification)\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7649869/v1/fae046955c66cc485dbc5db1.png"},{"id":96912967,"identity":"16bc7680-b53c-4c60-be76-2ac9929cb0f2","added_by":"auto","created_at":"2025-11-27 13:46:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3547405,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7649869/v1/abb9c16a-b7ec-4332-be88-392e9e1e6545.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Safety and Efficacy of Supine PCNL in the Management of Partial and Complete Staghorn Renal Calculi","fulltext":[{"header":"Introduction","content":"\u003cp\u003eStaghorn calculi represent a challenging subset of urolithiasis, often requiring complex surgical intervention. While prone PCNL has long been the standard, supine PCNL has gained attention for offering ergonomic advantages, simultaneous retrograde access, and potentially reduced morbidity. This study aims to evaluate the safety and efficacy of the supine PCNL approach for partial and complete staghorn renal calculi in a tertiary Indian centre.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eA prospective study was conducted at the Department of Urology in a Tertiary Teaching Hospital in Hyderabad, Telangana, India.\u003c/p\u003e\n\u003cp\u003eThis study was approved by the \u003cstrong\u003eInstitutional Ethics Committee, Gandhi Medical College, Secunderabad, Hyderabad, Telangana, India\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample Size Calculation:\u003c/strong\u003e A sample size of 52 patients was determined to detect a 15% difference in stone-free rates between supine PCNL and historical prone controls, with 80% power and \u0026alpha; = 0.05, assuming a baseline clearance rate of 75%.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipant Flow:\u003c/strong\u003e Of 60 patients assessed for eligibility between August 2022 and July 2024, 8 were excluded (5 had active infection, 2 declined consent, 1 had coagulopathy), leaving 52 eligible.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHandling of Missing Data and Sensitivity Analyses:\u003c/strong\u003e Missing outcome data (\u0026lt;2% overall) were addressed by multiple imputation under the missing-at-random assumption. Sensitivity analyses excluding imputed cases yielded similar results.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMinimizing Bias \u0026ndash; Operator Learning Curve:\u003c/strong\u003e All procedures were performed by two attending urologists after a standardized 50-case supine PCNL training protocol. Operative times and outcomes were monitored to ensure plateauing of the learning curve before study inclusion.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Informed consent was obtained from all individual participants included in the study. Each participant provided written consent prior to inclusion.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Fifty-two patients diagnosed with partial or complete staghorn calculi and meeting inclusion criteria underwent supine PCNL between August 2022 and July 2024.\u003c/p\u003e\n\u003cp\u003eExclusion criteria included active infection, coagulopathy, ureteric stones, pregnancy, and abnormal renal anatomy.\u003c/p\u003e\n\u003cp\u003eProcedures were performed under spinal or general anesthesia in a \u003cstrong\u003eflank-free modified supine position\u003c/strong\u003e (Figure 1). \u003cstrong\u003eNo simultaneous retrograde approach or ECIRS was done\u003c/strong\u003e. Posterior axillary line was marked in sitting position with marker. A 5 Fr ureteric catheter was inserted cystoscopically. PCS opacified using diluted Urograffin (76%) solution in the ratio of 1:3 dilutions. Under C-ARM guidance, with C-Arm rotated 15 degree away from surgeon desired calyx based on stone position was punctured using 18 G initial puncture diamond tipped needle and 0.035 inch hydrophilic guide wire placed into PCS. Tract dilated over guide rod using amplatz dilators and working sheath advanced over dilators. Tract dilatation size was selected on the basis of calculus size and tract dilatation was between 22 Fr and 28 Fr in the present study. Stone fragmentation was done using pneumatic lithotripters, and fragments were extracted using triflange graspers. At the end of procedure, 5 Fr 26 cm JJ stent and 14 Fr Foley catheter was placed as percutaneous nephrostomy tube for retaining the access tract in case of need for relook PNCL.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFluoroscopic access time\u003c/strong\u003e \u003cstrong\u003e(FAT)\u003c/strong\u003e calculated as time from starting to use C arm fluoroscope for puncture to successful placement of access sheath in desired calyx. \u003cstrong\u003eO\u003c/strong\u003e\u003cstrong\u003eperation time\u003c/strong\u003e calculated from insertion of the ureteric catheter including the time taken in positioning, until the end of the procedure. \u003cstrong\u003eClavien Dindo Classification used for grading complications\u003c/strong\u003e. \u003cstrong\u003eStone-free rate (SFR\u003c/strong\u003e) after PCNL defined as the proportion of patients with no residual kidney stone fragments larger than 4 mm on follow-up imaging (typically non-contrast CT or plain radiography \u0026plusmn; ultrasound). Fragments \u0026le;4 mm were considered clinically insignificant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eTable 1: Patient Demographics and Stone Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" width=\"740\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eMean Age (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e43.46 \u0026nbsp;( range of 23-65 years)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Gender (M:F)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2:1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eMale patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e35 (67.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eFemale patients\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e17 (32.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eStone size (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e4.04 \u0026nbsp; (range of 3cm \u0026ndash; 5.3 cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eStone density (HU)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1177.96 \u0026nbsp;(range of 800HU- 1700HU)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Operative Parameters and Primary Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" width=\"740\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD or n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eOperative time (minutes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e77.80 \u0026plusmn; 8.99 \u003cstrong\u003e(95% CI, 74.3\u0026ndash;81.3)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eFluoroscopy access time (minutes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e7.33 \u0026plusmn; 1.95\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eMean tract size (French)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e25.27\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eStone clearance rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e47 (90.4%) \u003cstrong\u003e\u0026nbsp;(95% CI, 79.9\u0026ndash;96.3%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eHemoglobin drop (g/dL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.83 \u0026plusmn; 0.29 \u003cstrong\u003e(95% CI, 0.72\u0026ndash;0.94)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe surgical approach predominantly utilized single lower pole (LP) calyceal puncture (48.1%, n=25). Multiple punctures were required in 8 patients (15.4%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Post-operative Outcomes and Pain Assessment\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" width=\"740\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eParameter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eValue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eHospital stay (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e4.5 \u0026plusmn; 2.49\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eVAS pain score 4-5 on POD1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e27 (52%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eVAS pain score 6-8 on POD1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e25 (48%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eRedo PCNL required\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e6 (11.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eRenal angiography (no embolization needed)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1 (1.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u003c/strong\u003e\u003cstrong\u003eTable 4: Post-operative Complications (Clavien-Dindo Classification)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" width=\"740\" class=\"fr-table-selection-hover\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eComplication Grade\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of Patients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 0 (No complications)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e25\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e48.1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade I/II (Minor complications)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e20\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e38.4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade III (Major complications)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(includes Redo PCNL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e13.5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal patients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e52\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e100.0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study demonstrates that supine percutaneous nephrolithotomy (PCNL) achieves \u003cstrong\u003eexcellent clinical outcomes with a 90.4% stone clearance rate\u003c/strong\u003e and efficient operative parameters in patients with complex renal calculi. Our findings contribute to the growing body of evidence supporting supine positioning as a viable alternative to the traditional prone approach, particularly in the era of minimally invasive stone management (1,11).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5. Comparative Studies: Supine vs Prone PCNL - Literature Review\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" width=\"740\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy (Author, Year)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSample Size (Supine/Prone)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOperative Time (min)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStone Clearance Rate (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHemoglobin Drop (g/dL)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eCurrent Study (2025)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e52 (Supine only)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eProspective\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e77.80 \u0026plusmn; 8.99 (Supine)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e90.4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.83 \u0026plusmn; 0.29\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eMulay et al. (2022)\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e50/50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eObservational\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e72.24 vs 88.12*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e92 vs 88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.37 vs 0.61*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eReddy et al. (2025)\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e33/33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e106.34 vs 132.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e100 vs 60.6*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eNot specified\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eSohail et al. (2016)\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e99/98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eRetrospective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e32.3 min shorter in supine*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e89.9 vs 82.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eComparable\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eFalahatkar et al. (2008)\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e62/55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eProspective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eShorter in supine*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e77.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eNot specified\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eSofer et al. (2017)\u003csup\u003e5\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e270/270\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eRetrospective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e138 vs 150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eComparable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eComparable\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eAbdel-Mohsen et al. (2011)\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e39/38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eProspective RCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eShorter in supine*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e84.6 vs 84.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eComparable\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Statistically significant difference (p\u0026lt;0.05)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6: Comparative Overview of PCNL Studies (Supine vs Prone)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" width=\"740\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy (Author, Year)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean Age (yrs)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSupine n\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eProne n\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStone Size Supine (cm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStone Size Prone (cm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStone-Free Rate (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOperative Time (min)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTransfusions (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostop Stay (days)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eG\u0026ouml;k\u0026ccedil;e Mİ et al. (2017)\u003csup\u003e12\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e4.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e4.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e64.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e110\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eMelo PAS et al. (2019)\u003csup\u003e13\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e294\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e3.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e42.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e107.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eValdivia JG et al. (2011)\u003csup\u003e14\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1,138\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e4,637\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e4.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e4.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e70.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eWang XH et al. (2012)\u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e3.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e3.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e83.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e9.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eCurrent Study (2025)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e43.4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e52\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026ndash;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.04\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026ndash;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e90.4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e77.8 \u0026plusmn; 8.99\u0026nbsp;(supine)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.5 \u0026plusmn; 2.49\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;The demographic profile of our study population, with a \u003cstrong\u003emean age of 43.46 years and male-to-female ratio of 2:1\u003c/strong\u003e, aligns with established epidemiological patterns of nephrolithiasis and is comparable to other contemporary series (1,2). The stone characteristics in our cohort, with a \u003cstrong\u003emean size of 4.04 cm and density of 1177.96 HU\u003c/strong\u003e, represent complex stone disease.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOperative Efficiency and Technical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur study demonstrates \u003cstrong\u003esignificant operative efficiency with a mean operative time of 77.80 \u0026plusmn; 8.99 minutes\u003c/strong\u003e, which compares favourably with the literature. Mulay et al. reported mean operative times of \u003cstrong\u003e72.24 minutes for supine versus 88.12 minutes for prone PCNL (p\u0026lt;0.001)\u003c/strong\u003e, supporting our findings (1). Similarly, Sohail et al. documented \u003cstrong\u003e32.3 minutes shorter operative time\u003c/strong\u003e with supine positioning compared to prone approach (3). Falahatkar et al. also confirmed shorter operative times in supine PCNL in their prospective study (4).\u003c/p\u003e\n\u003cp\u003eThe \u003cstrong\u003efluoroscopy access time of 7.33 \u0026plusmn; 1.95 minutes\u003c/strong\u003e in our series reflects efficient percutaneous access, which is crucial for minimizing radiation exposure to both patient and surgical team. This parameter is particularly relevant given the positioning advantages of supine PCNL, where the surgeon experiences \u003cstrong\u003ereduced radiation exposure\u003c/strong\u003e compared to prone positioning (1,4).\u003c/p\u003e\n\u003cp\u003eOur predominantly \u003cstrong\u003esingle lower pole calyceal puncture approach (48.1%)\u003c/strong\u003e demonstrates the feasibility of achieving excellent stone clearance with minimal invasiveness. Multiple punctures were required in only \u003cstrong\u003e15.4% of cases\u003c/strong\u003e, which compares favourably to prone series where multiple tract rates range from \u003cstrong\u003e20-30%\u003c/strong\u003e (1,5). This finding suggests that supine positioning may offer \u003cstrong\u003ebetter access geometry\u003c/strong\u003e for certain stone configurations, potentially reducing the need for multiple percutaneous tracts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStone Clearance Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe \u003cstrong\u003estone clearance rate of 90.4%\u003c/strong\u003e achieved in our study represents excellent therapeutic efficacy and aligns well with contemporary literature. Mulay et al. reported stone clearance rates of \u003cstrong\u003e92% versus 88%\u003c/strong\u003e for supine and prone positions respectively (1), while Reddy et al. demonstrated \u003cstrong\u003esuperior clearance with supine approach (100% versus 60.6%)\u003c/strong\u003e in their randomized controlled trial (2). Sofer et al. found \u003cstrong\u003ecomparable stone clearance rates\u003c/strong\u003e between positions in their case-control study (5).\u003c/p\u003e\n\u003cp\u003eThe high success rate in our series can be attributed to several factors: \u003cstrong\u003eappropriate patient selection, standardized surgical technique, and the inherent advantages of supine positioning\u003c/strong\u003e including better visualization and instrument manipulation. The mean stone size of 4.04 cm in our cohort represents complex disease, making the 90.4% clearance rate particularly noteworthy.\u003c/p\u003e\n\u003cp\u003eHowever, \u003cstrong\u003e6 patients (11.5%) required redo PCNL procedures\u003c/strong\u003e, indicating that complete stone clearance may still be challenging in certain cases. This reoperation rate is within the acceptable range reported in the literature and emphasizes the importance of thorough preoperative imaging and surgical planning.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSafety Profile and Complications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur complication profile demonstrates the \u003cstrong\u003esafety of supine PCNL, with 48.1% of patients experiencing no complications\u003c/strong\u003e (Grade 0), 38.4% having minor complications (Grade I/II), and only \u003cstrong\u003e13.5% developing major complications\u003c/strong\u003e (Grade III). This distribution is comparable to reported complication rates in the literature for both supine and prone approaches (1,5,6).\u003c/p\u003e\n\u003cp\u003eThe \u003cstrong\u003emean hemoglobin drop of 0.83 \u0026plusmn; 0.29 g/dL\u003c/strong\u003e in our study indicates excellent hemostatic control and compares favourably with literature reports. Mulay et al. demonstrated \u003cstrong\u003esignificantly lower hemoglobin drop in supine PCNL (0.37 g/dL) compared to prone positioning (0.61 g/dL, p=0.043)\u003c/strong\u003e (1). Our slightly higher hemoglobin drop may reflect the complex nature of our stone population, but remains within clinically acceptable limits.\u003c/p\u003e\n\u003cp\u003eThe \u003cstrong\u003emean hospital stay of 4.5 \u0026plusmn; 2.49 days\u003c/strong\u003e aligns with standard post-PCNL recovery protocols and is comparable to reported lengths of stay in both supine and prone series (1,3,5). The variation in hospital stay likely reflects individual patient factors, stone complexity, and institutional protocols rather than positioning-related differences.\u003c/p\u003e\n\u003cp\u003eOnly \u003cstrong\u003eone patient (1.9%) required renal angiography\u003c/strong\u003e without subsequent embolization, indicating excellent vascular safety. This low rate of significant bleeding complications supports the safety profile of supine PCNL and may reflect improved visualization and control during the procedure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStaghorn Calculi: Position-Specific Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhile our study did not specifically analyse outcomes based on stone morphology, the literature provides important insights regarding position selection for staghorn calculi. The evidence suggests \u003cstrong\u003edifferential outcomes based on staghorn complexity\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFor partial staghorn calculi\u003c/strong\u003e, supine positioning appears to offer advantages, with reported \u003cstrong\u003eclearance rates of 98.5%\u003c/strong\u003e compared to 95-100% for prone positioning (7). The \u003cstrong\u003ereduced need for multiple punctures in supine approach (10-15% versus 15-25%)\u003c/strong\u003e may be particularly relevant for partial staghorn stones where single-access clearance is often achievable.\u003c/p\u003e\n\u003cp\u003eHowever, \u003cstrong\u003efor complete staghorn calculi, prone positioning demonstrates superior stone clearance rates (85-92% versus 71-84.1% for supine)\u003c/strong\u003e (6,7). This advantage likely reflects \u003cstrong\u003ebetter access to upper pole calices\u003c/strong\u003e and the ability to achieve multiple punctures more readily in prone position.\u003c/p\u003e\n\u003cp\u003eAbdel-Mohsen et al. specifically studied staghorn calculi and found \u003cstrong\u003ecomparable outcomes between positions\u003c/strong\u003e, though their series included both partial and complete staghorn stones (6). Kumar et al. identified \u003cstrong\u003estone complexity as a significant predictor of outcomes\u003c/strong\u003e in supine PCNL, suggesting the need for careful patient selection (7).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTechnical Advantages and Anaesthetic Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSupine positioning offers several technical advantages that contribute to its growing adoption. The \u003cstrong\u003eability to perform simultaneous retrograde ureteroscopy\u003c/strong\u003e represents a significant advantage, allowing for comprehensive stone clearance and immediate assessment of fragment passage (1,4,5). This capability is particularly valuable in cases with concomitant ureteral stones or when retrograde assistance is needed for stone localization.\u003c/p\u003e\n\u003cp\u003eFrom an anaesthetic perspective, supine positioning provides \u003cstrong\u003ebetter cardiovascular stability and respiratory mechanics\u003c/strong\u003e compared to prone positioning (1,4). The reduced physiological stress of supine positioning may be particularly beneficial in patients with cardiopulmonary comorbidities, expanding the candidate pool for percutaneous intervention.\u003c/p\u003e\n\u003cp\u003eThe \u003cstrong\u003efamiliar anatomical orientation in supine position\u003c/strong\u003e may reduce the learning curve for surgeons transitioning from open surgery or other endoscopic procedures. Additionally, the \u003cstrong\u003eergonomic advantages for the surgical team\u003c/strong\u003e, including reduced surgeon fatigue and better visualization, may contribute to improved outcomes over time.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePain Management and Recovery\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur pain assessment revealed that \u003cstrong\u003e52% of patients reported VAS scores of 4-5 on postoperative day 1\u003c/strong\u003e, while \u003cstrong\u003e48% reported scores of 6-8\u003c/strong\u003e. This distribution suggests generally acceptable pain control, though there is room for improvement in pain management protocols. The supine position may offer advantages in postoperative patient comfort, though specific comparative data on pain outcomes between positions remains limited in the literature.\u003c/p\u003e\n\u003cp\u003eThe relatively low pain scores in our series may reflect the \u003cstrong\u003ebenefits of supine positioning on postoperative recovery\u003c/strong\u003e, including easier nursing care and patient mobilization. However, further research is needed to establish clear differences in pain outcomes between positioning approaches.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Limitations and Future Directions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has several important limitations that warrant careful consideration when interpreting the results:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDesign and Methodological Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSingle-centre design\u003c/strong\u003e: As a single institutional experience conducted at a tertiary teaching hospital in South India, our findings may have limited generalizability to other healthcare settings, patient populations with different demographic characteristics, or centres with varying surgical expertise levels. The specific regional stone characteristics and patient demographics in our geographic area may not be representative of global populations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLack of concurrent control group\u003c/strong\u003e: This prospective series focused exclusively on supine PCNL without a concurrent prone PCNL control group within the same study period. While we compared our outcomes with historical controls and published literature, direct head-to-head comparison with prone positioning in the same patient population was not possible, which limits our ability to draw definitive conclusions about the comparative superiority of either approach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNon-randomized patient selection\u003c/strong\u003e: The absence of randomization introduces potential selection bias, as patient assignment to supine PCNL was based on clinical judgment, stone characteristics, and surgeon preference rather than random allocation. This may have influenced outcomes through unmeasured confounding factors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample Size and Statistical Power Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimited sample size\u003c/strong\u003e: While our sample of 52 patients was statistically adequate for detecting the primary endpoint (15% difference in stone-free rates with 80% power), it may be insufficient to detect rare complications that occur in less than 2-5% of cases or to identify subtle differences in secondary outcomes between different patient subgroups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInsufficient power for subgroup analyses\u003c/strong\u003e: The sample size prevents meaningful stratified analyses based on stone morphology (partial versus complete staghorn stones), stone density categories, patient comorbidity profiles, or individual surgeon performance, which could provide more nuanced insights into optimal patient selection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRare complication detection\u003c/strong\u003e: The study duration and sample size may not capture infrequent but clinically significant complications, potentially underestimating the true complication profile of supine PCNL in staghorn calculi.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFollow-up and Long-term Outcome Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eShort-term follow-up duration\u003c/strong\u003e: This study focused primarily on immediate perioperative outcomes and short-term stone clearance assessment. Long-term outcomes including stone recurrence rates, chronic kidney disease progression, late complications, and durability of treatment success were not evaluated within the study timeframe.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMissing quality of life measures\u003c/strong\u003e: Patient-reported outcome measures, functional assessment, and long-term quality of life evaluations were not incorporated into the study design, limiting our understanding of the patient experience and functional recovery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical and Technical Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimited surgeon experience pool\u003c/strong\u003e: All procedures were performed by only two attending urologists following a standardized training protocol. While this ensures consistency, it may limit generalizability to centres with different surgeon experience levels, training backgrounds, or case volume distributions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLearning curve considerations\u003c/strong\u003e: Although a 50-case training protocol was implemented to minimize learning curve effects, the influence of ongoing skill development and technique refinement during the study period was not specifically quantified or controlled for in the analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssessment and Measurement Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubjective outcome measures\u003c/strong\u003e: Pain assessment using Visual Analogue Scale scores is inherently subjective and may be influenced by individual patient factors, cultural background, pain tolerance, and analgesic requirements, introducing potential measurement bias.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLack of cost-effectiveness analysis\u003c/strong\u003e: Economic outcomes, healthcare resource utilization, and cost-effectiveness comparisons with prone PCNL were not evaluated, limiting the applicability of findings for healthcare policy and resource allocation decisions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Selection and Exclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStone morphology heterogeneity\u003c/strong\u003e: The study included both partial and complete staghorn calculi without stratified randomization or analysis, which may mask position-specific advantages for different stone configurations and complicate interpretation of results for specific stone types.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparative Analysis Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLiterature comparison constraints\u003c/strong\u003e: Comparisons with published prone PCNL series may be affected by publication bias, differences in patient selection criteria, outcome definition variations, and heterogeneity in reporting standards across different studies and time periods.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTemporal bias in comparisons\u003c/strong\u003e: Advances in surgical techniques, instrumentation technology, imaging guidance, and perioperative care protocols over time may confound comparisons with historical prone PCNL data from earlier publications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLack of standardized outcome reporting\u003c/strong\u003e: Variations in complication classification, stone-free rate definitions, and follow-up protocols across different studies limit the validity of cross-study comparisons.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFuture Research Implications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThese limitations highlight the critical need for:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eMulticentre randomized controlled trials\u003c/strong\u003e with adequate statistical power to detect clinically meaningful differences between positioning approaches\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eLong-term prospective follow-up studies\u003c/strong\u003e evaluating stone recurrence rates, renal function outcomes, and chronic kidney disease progression\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eComprehensive cost-effectiveness analyses\u003c/strong\u003e comparing resource utilization and economic outcomes between supine and prone approaches\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eStandardized outcome reporting frameworks\u003c/strong\u003e to facilitate meaningful systematic reviews and meta-analyses\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSubgroup analysis studies\u003c/strong\u003e focusing on specific stone morphologies, patient populations, and technical variations\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eLearning curve assessment studies\u003c/strong\u003e to optimize training protocols and technique standardization\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eDespite these acknowledged limitations, this study provides valuable evidence supporting the safety and short-term efficacy of supine PCNL for staghorn calculi in appropriately selected patients at experienced centres. The limitations identified should inform the design of future comparative studies and guide evidence-based clinical decision-making regarding optimal positioning selection for individual patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Implications and Recommendations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on our results and the contemporary literature, we propose the following \u003cstrong\u003eevidence-based recommendations for position selection\u003c/strong\u003e in PCNL:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupine PCNL is recommended for:\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003ePartial staghorn calculi\u003c/strong\u003e where single-access clearance is anticipated\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003ePatients with significant cardiopulmonary comorbidities\u003c/strong\u003e requiring enhanced anaesthetic monitoring\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCases requiring simultaneous retrograde procedures\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eBilateral stone disease\u003c/strong\u003e where staged procedures are planned\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eObese patients\u003c/strong\u003e where prone positioning poses technical challenges\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eProne PCNL may be preferred for:\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eComplete staghorn calculi\u003c/strong\u003e requiring multiple punctures and upper pole access\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eComplex stone configurations\u003c/strong\u003e where traditional approach offers proven efficacy\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eSurgeons with extensive prone experience\u003c/strong\u003e and limited supine training\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eEither position may be appropriate for:\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eSimple renal stones (2-4 cm)\u003c/strong\u003e where outcomes are comparable\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCases where surgeon experience and institutional factors\u003c/strong\u003e predominate\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe decision should ultimately be \u003cstrong\u003eindividualized based on stone characteristics, patient factors, surgeon expertise, and institutional resources\u003c/strong\u003e. The key is not the universal adoption of one approach over another, but rather the thoughtful selection of positioning based on the specific clinical scenario.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study demonstrates that \u003cstrong\u003esupine PCNL achieves excellent stone clearance rates (90.4%) with acceptable morbidity and efficient operative parameters\u003c/strong\u003e. The results support the growing body of evidence favouring supine positioning for selected cases, particularly where the technical advantages of supine approach align with patient and stone characteristics.\u003c/p\u003e\n\u003cp\u003eThe evolution of PCNL technique should continue to focus on \u003cstrong\u003eoptimizing outcomes through evidence-based position selection\u003c/strong\u003e rather than adhering to traditional approaches without consideration of case-specific factors. As the literature continues to mature, refined guidelines for position selection will emerge, ultimately improving patient outcomes and expanding access to minimally invasive stone management.\u003c/p\u003e\n\u003cp\u003eThe future of PCNL lies not in the dominance of one positioning approach, but in the \u003cstrong\u003eintelligent application of both techniques based on individual patient needs, stone complexity, and surgeon expertise\u003c/strong\u003e. Our results contribute to this evolving paradigm and support the continued investigation of supine PCNL as a valuable addition to the urologist's armamentarium for complex stone disease.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cul type=\"disc\"\u003e\n \u003cli\u003ePCNL: Percutaneous Nephrolithotomy\u003c/li\u003e\n \u003cli\u003eSFR: Stone-Free Rate\u003c/li\u003e\n \u003cli\u003eHU: Hounsfield Units\u003c/li\u003e\n \u003cli\u003eFAT: Fluoroscopic Access Time\u003c/li\u003e\n \u003cli\u003eVAS: Visual Analogue Scale\u003c/li\u003e\n \u003cli\u003ePOD: Post-Operative Day\u003c/li\u003e\n \u003cli\u003ePCS: Pelvicalyceal System\u003c/li\u003e\n \u003cli\u003eLP: Lower Pole\u003c/li\u003e\n \u003cli\u003eRCT: Randomized Controlled Trial\u003c/li\u003e\n \u003cli\u003eCI: Confidence Interval\u003c/li\u003e\n \u003cli\u003eSD: Standard Deviation\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Ethics Committee, Gandhi Medical College, Secunderabad, Hyderabad, Telangana, India. All procedures involving human participants were performed in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study adhered to the Declaration of Helsinki principles for medical research involving human subjects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. This manuscript does not contain any individual person's data in any form (including individual details, images or videos).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. All data generated or analysed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo external funding was received for this study as it was conducted at a government teaching hospital which offers free treatment to all patients. The study was supported by institutional resources only.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMS: Conceptualization, data collection, manuscript writing, statistical analysis. VA: Study supervision, methodology design, manuscript review and editing, final approval. GRC: Study design, surgical procedures, data interpretation, manuscript review. VV: Data collection, patient recruitment, follow-up assessment. SK: Data collection, statistical analysis, manuscript preparation. SSR: Patient recruitment, data collection, follow-up assessment. GVR: Data collection, literature review, manuscript preparation. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors acknowledge the nursing staff and residents of the Department of Urology, Gandhi Medical College for their assistance in patient care and data collection. We thank the patients who participated in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eMulay A, Deshpande A, Patil S, Desai S. Supine versus prone percutaneous nephrolithotomy for renal calculi: Our experience. Curr Urol. 2022;16(1):25-29.\u003c/li\u003e\n \u003cli\u003eReddy DR, Kumar S, Patel M, Singh A. Comparative Study between Supine Vs Prone Percutaneous Nephrolithotomy. J Contemp Clin Pract. 2025;11(8):821-831.\u003c/li\u003e\n \u003cli\u003eSohail N, Albodour A, Abdelrahman KM, El-Nahas AR. Percutaneous nephrolithotomy in complete supine flank-free position in comparison to prone position. Arab J Urol. 2016;15(1):42-47.\u003c/li\u003e\n \u003cli\u003eFalahatkar S, Moghaddam AA, Rashidi E, Asadollahzade A. Complete supine percutaneous nephrolithotripsy comparison with the prone standard technique. J Endourol. 2008;22(11):2513-2517.\u003c/li\u003e\n \u003cli\u003eSofer M, Watterson JD, Wollin TA, Nott L, Razvi H, Denstedt JD. Supine vs prone percutaneous nephrolithotomy: A case-control study. Urol Ann. 2017;9(2):130-135.\u003c/li\u003e\n \u003cli\u003eAbdel-Mohsen MY, Kandeel WS, Abdel-Aal AMA, El-Diasty TA. Supine versus prone percutaneous nephrolithotomy for treatment of staghorn stones. Urol Ann. 2011;3(3):147-150.\u003c/li\u003e\n \u003cli\u003eKumar S, Bag S, Ganesamoni R, Mandal SN, Taneja N, Singh SK. Factors Predicting Outcomes of Supine Percutaneous Nephrolithotomy. Urology. 2021;157:78-84.\u003c/li\u003e\n \u003cli\u003eShah AS, Lang EK, Thomas R, Shaikh NA. Outcomes and complications of percutaneous nephrolithotomy in the supine position. World J Urol. 2020;38(9):2155-2162\u003c/li\u003e\n \u003cli\u003eZhang W, Liu Q, Wang H, Jin J, Zhang X, Zhao F, et al. Clinical comparison of lateral supine position mini-percutaneous nephrolithotomy and standard percutaneous nephrolithotomy for renal calculi. BMC Urol. 2019;19(1):96.\u003c/li\u003e\n \u003cli\u003eAdl M, Eltaher AM, Abdelkhalek M, Saleh MI. Percutaneous nephrolithotomy in flank-free modified supine versus prone position: A prospective randomized study. Zagazig Univ Med J. 2015;21(3):1-8.\u003c/li\u003e\n \u003cli\u003eYuan D, Liu Y, Rao H, Zhong L, Da J, Li H, et al. Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: A meta-analysis. J Endourol. 2016;30(7):754-763.\u003c/li\u003e\n \u003cli\u003eG\u0026ouml;k\u0026ccedil;e Mİ, Sancı A, Ibiş A, et al. Comparison of supine and prone positions for percutaneous nephrolithotomy in treatment of staghorn stones. Urol Res. 2017;45(5):207-14. doi:10.1007/s00240-017-0988-x.\u003c/li\u003e\n \u003cli\u003eMelo PAS, Vicentini FC, Perrella R, Murta CB, Claro JFA. Comparative study of percutaneous nephrolithotomy performed in the traditional prone position and in three different supine positions. Int Braz J Urol. 2019;45(1):108-17. doi:10.1590/S1677-5538.IBJU.2018.0191.\u003c/li\u003e\n \u003cli\u003eValdivia Ur\u0026iacute;a JG, Scarpa RM, Duvdevani M, et al. Supine versus prone position during percutaneous nephrolithotomy: a report from the Clinical Research Office of the Endourological Society Percutaneous Nephrolithotomy Global Study. J Endourol. 2011;25(10):1619-25. doi:10.1089/end.2011.0110.\u003c/li\u003e\n \u003cli\u003eWang XH, Jiang CZ, Qiu SR, et al. Comparison of outcomes between supine and prone percutaneous nephrolithotomy: a randomized prospective study. J Urol. 2012;188(3):915-20. doi:10.1016/j.juro.2012.04.024\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Supine PCNL, Staghorn calculi, Stone-free rate, Renal calculi, Urolithiasis","lastPublishedDoi":"10.21203/rs.3.rs-7649869/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7649869/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eSupine PCNL has emerged as a promising alternative to prone PCNL for managing large and complex renal stones, including staghorn calculi. This prospective study included 52 patients with partial or complete staghorn stones undergoing supine PCNL at the Department of Urology in a Tertiary Teaching Hospital in Hyderabad, Telangana, India. The primary endpoints included stone-free rate (SFR), operative duration, hemoglobin drop, hospital stay, and complication rates. Supine PCNL was performed in a flank-free modified position. The results showed a mean operative time of 77.8 minutes and a 90.4% stone clearance rate. The average hemoglobin drop was 0.83 g/dL, with most patients experiencing no or mild complications. The procedure demonstrated safety, efficacy, and ergonomic benefits. Comparable to earlier studies, our outcomes suggest that supine PCNL is a viable approach for staghorn stones.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e","manuscriptTitle":"Safety and Efficacy of Supine PCNL in the Management of Partial and Complete Staghorn Renal Calculi","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-21 18:15:20","doi":"10.21203/rs.3.rs-7649869/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-11-29T04:44:34+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-27T07:07:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"304289197008078553727075554990852018241","date":"2025-11-21T22:27:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-21T08:47:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-21T07:02:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"174508157549940835048242476653421144846","date":"2025-11-21T07:01:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"140390815226425777024205496126108539371","date":"2025-11-18T23:42:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-14T21:25:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"85942832104701027709633249609413629764","date":"2025-11-11T21:15:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"116484876885824480053975843751151125360","date":"2025-11-11T15:42:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-11T15:32:35+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-13T11:01:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-03T05:49:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-01T18:30:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Urology","date":"2025-10-01T15:10:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2430189e-14f3-44a3-b802-424681e463b2","owner":[],"postedDate":"November 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-21T18:15:21+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-21 18:15:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7649869","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7649869","identity":"rs-7649869","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}