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Research Letters

Percutaneous Nephrolithotomy: Update, Trends, and Future

Directions for Simultaneous Supine Percutaneous

Nephrolithotomy and Retrograde Ureterolithotripsy in the

Galdakao-modified Supine Valdivia Position for Large Proximal

Ureteral Calculi

Tsung-Yi Huang

* ,

Kathy Ming Feng, Ing-Shiang Lo

We analyzed several population-based studies reporting

outcomes and innovations in the practice of percutaneous

nephrolithotomy (PCNL) since 2000. Current treatments

for removal of renal calculi include extracorporeal shock

wave lithotripsy (ESWL), ureterolithotripsy, PCNL, and

laparoscopic and open surgery


. According to the

European Association of Urology (EAU) guidelines on

urolithiasis, PCNL is recommended for large renal calculi.

However, the treatment for large, proximal ureteral

calculi (located between the ureteropelvic junction and

the lower border of the fourth lumbar vertebra) remains


Retrograde ureterolithotripsy for large proximal ureteral

stones requires several passages with the ureteroscope to

remove all the stone fragments after intracorporeal

lithotripsy. This not only increases ureteral trauma; the

continuous high-pressure irrigation may also result in stone

migration back to the renal pelvis or calices. The stone may

become unreachable and require further use of a rigid or

semi-rigid ureteroscope


. Laparoscopic or open ureter-

olithotomy is not recommended because of longer hospi-

talization and greater postoperative morbidity such as

postoperative ileus, urinary leakage, and peritonitis

[3] .

Endoscopic combined intrarenal surgery in the Galda-

kao-modified supine Valdivia (GMSV) position is consid-

ered a single-step treatment for a simultaneous antero-

retrograde approach using retrograde flexible uretero-

scopy (fURS) and PCNL


. However fURS is expensive,

skill-dependent, and time consuming. Therefore, we

prefer semi-rigid ureteroscopes because of their durabili-

ty and affordable price range for hospitals. Hence, we

propose a technique that uses simultaneous supine PCNL

and retrograde semi-rigid ureterolithotripsy in the GMSV

position for large proximal ureteric calculi.

Between September 2014 and May 2015, our group

collected data for 13 patients with large proximal ureteral

stones (


15 mm in length) who underwent simultaneous

supine PCNL and retrograde ureterolithotripsy in the GMSV

position at Kaohsiung Medical University Hospital. The

mean operation time was 40 min (range 25–55) and

ureteral stents were introduced without a nephrostomy

tube (tubeless method) in all patients. The average

postoperative hospital stay was 3.4 d (range 2–5). All

patients were stone-free at 3-mo follow-up.

We believe that simultaneous PCNL and ureterolitho-

tripsy is a new strategy to explore for the treatment of

upper tract urolithiasis. This approach creates an open,

low-pressure system that reduces the absorption of

irrigation fluid into the circulation. The proximal ureteral

stone can be pushed back and retrieved via forceps with a

nephroscope through an Amplatz sheath in a single

procedure without the need for baskets, reducing the

risk of ureteral injury. An Amplatz sheath allows removal

of fragments of up to 1 cm. In addition, during withdrawal

of the ureteroscope, the ureter and bladder can be

evaluated for any residual stone fragments, bleeding, or

blood clots.

In conclusion, simultaneous supine PCNL and retrograde

ureterolithotripsy in the GMSV position represents signifi-

cant progress in the treatment of large proximal ureteral

stones. It is likely that as experience using the modified

supine lithotomy position increases, this approach will gain

increasing acceptance among urologists in the coming


E U R O P E A N U R O L O G Y 7 1 ( 2 0 1 7 ) 8 3 7 – 8 4 3

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2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.