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Title: Supine versus prone position in percutaneous nephrolithotomy

for kidney calculi: a meta-analysis

Yuan DongBo1*, Liu YongDa2*, Rao HaoFu1, Cheng TianFei1, Sun ZhaoLin4, Wang
YuanLin4, Liu Jun4, Chen WeiHong4, Zhong WeiDe 3,5,6,7#, Zhu JianGuo3,4#
Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis (doi: 10.1089/end.2015.0402)

Affiliation:
1. Department of Urology, Guizhou Provincial People’s Hospital, The affiliated hospital of
Guiyang medical college, Guizhou, 550002, China
2. Department of Urology, Minimally Invasive Surgery center, The first affiliated hospital of
Guangzhou medical Universtiy. Guangdong Key Laboratory of Urology
3. Department of Urology, Guangdong Key Laboratory of Clinical Molecular Medicine and
Diagnostics, Guangzhou First People’s Hospital, Guangzhou Medical University, Guangzhou
510180, China
4. Department of Urology, Guizhou Provincial People’s Hospital, Guizhou, 550002, China
5. Guangdong Provincial Institute of Nephrology, Nanfang Hospital, Southern Medical University,
Guangzhou, 510515, China
6. Department of Urology, Huadu District People's Hospital, Southern Medical University,
Guangzhou, 510800, China;
Journal of Endourology

7. Urology Key Laboratory of Guangdong Province, The First Affiliated Hospital of Guangzhou
Medical University, Guangzhou Medical University, Guangzhou, 510230, China
*These authors contributed equally to this article.
#
Co-correspondence authors
#
Corresponding authors:Wei-De Zhong, Department of Urology, Guangzhou

First People’s Hospital, Guangzhou Medical University, Guangzhou 510180, China.

E-mail: zhongwd2009@live.cn; Phone: +8620-81048312; Fax: +8620-83373322.

Zhu JianGuo, Department of Urology, Guizhou Provincial People’s Hospital, Guizhou,

550002, China. E-mail: doctorzhujianguo@163.com; Phone: 0851-5610141.

Abstract

Background: There are several positions in the operation of percutaneous

nephrolithotomy (PCNL), such as prone position, supine position, flank position,
modified supine position for PCNL, but the supine and prone positions are the main
two choices for several years. However, there is still discrepancy on the optimal
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position for PCNL. Therefore, we performed this meta-analysis to evaluate safety and
efficacy of the supine versus the prone position in PCNL for renal calculi.
Methods: We searched MEDLINE, SCOPUS, and the Cochrane database libraries to
look for relevant studies. All eligible controlled trials comparing supine versus prone
Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis (doi: 10.1089/end.2015.0402)

position for treating renal calculi were included in the meta-analysis. The main
outcome of efficacy (stone-free rate, mean operative time, hospitalization time) and
safety (complication, blood transfusions) were assessed by using Review Manager 4.2
software. We calculated the estimate of effect associated with the two positions
according to the heterogeneity using random-effects or fixed-effects models.
Results: Thirteen studies (6 randomized controlled trials and 7 retrospective studies)
with a total of 6881 patients contributed to this meta-analysis. The meta-analysis
indicated/suggested that PCNL in the prone position was associated with a higher rate
of stone clearance than PCNL in the supine position (odds ratio [OR]: 0.74; 95%
Journal of Endourology

confidence interval [CI]: 0.65–0.84; P<0.00001). A shorter mean operative time was
observed in the supine groups (WMD: -18.27; 95% CI: -35.77 to -0.77; P=0.04).
Compared with prone position, There was also a lower incidence of blood
transfusions in the supine groups (WMD: 0.73; 95% CI: 0.56 to 0.95; P=0.02). No
difference was observed between the positions with regard to the hospital stay
(WMD:-0.14; 95% CI: -0.76 to 0.47; P=0.65) and complications (OR: 0.88; 95% CI:
0.76 to 1.02; P=0.10).
Conclusion: Compared with prone position, the PCNL in the supine position has
hgher rate of stone clearance, shorter mean operative time and lower incidence of
blood transfusions. The meta-analysis suggests that the PCNL in the supine position is
promising alternative.

Keywords: Supine, Prone, PCNL, Meta-analysis

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Introduction
Minimal invasive surgery for the treatment of urinary stones has become
increasingly popular ever since the first successful renal stone extraction through a
nephrostomy tract in 19761. The percutaneous nephrolithotomy (PCNL) has become
Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis (doi: 10.1089/end.2015.0402)

the gold-standard for treating patients with the larger renal stones and staghorn
calculi.
PCNL has been operated in the prone position under fluoroscopic or ultrasonic
guidance for decades. Prone position makes the identification of renal anatomy and
the selection of the appropriate puncture point easier. It also provides a wider surface
area for percutaneous access with low risk of abdominal visceral injuries. This
technique has been widely practiced by the endourologists with proficiency. However
operating in the prone position has many disadvantages: abdominal pressure decreases
lung volume, thus reducing the ability for patients to tolerate prolonged surgery and
Journal of Endourology

requiring higher airway pressures to ensure adequate ventilation. High ventilation

pressure can impair the venous return and may lead to cardiopulmonary complications,
especially in obese patients and in patients with cardiopulmonary disease2.
Furthermore, general anesthesia and ureteral catheterization are usually needed in the
supine position. It necessitates position change from the supine position to the prone
position after the induction of general anesthesia and retrograde ureteral
catheterization.2,3 The supine position has been developed to solve these drawbacks
and to simplify the process. Compared with the prone position, the supine position in
PCNL brings several advantages: Cardiovascular and respiratory risks are diminished.
It is easier and safer for the anesthesiologist to manage the patient and may even
lessen the amount of anesthetics required. In many situations, there is no need to
reposition the patient and the disinfection and the operation can be accomplished in
one sequence for the surgeon who used the traditional scope in operation of PCNL.2,3
Furthermore, the downward slope of the PCNL access sheath allows passive egress of
irrigation fluid and stone fragments by gravitational pull. This position also permits
simultaneous ureteroscopic access when necessary in the management of complex
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stone diseases. However, disadvantages also exist with the supine position. It has
limited surface area for puncture and there is more depth between the skin and the
kidney than the prone position. These disadvantages may increase the possibility of
visceral injuries and trauma to the intrarenal vessels4,5,6. The debate over which is the
Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis (doi: 10.1089/end.2015.0402)

better position for PCNL continues. The aim of this meta-analysis is to evaluate the
safety and efficacy of PCNL for renal calculus in the supine and the prone position.

Materials and Methods

Search strategy and eligibility and exclusion criteria

All eligible studies were retrieved from MEDLINE, SCOPUS, and the Cochrane
database libraries. The following search terms were employed without any limitation:
“Supine position”, “Prone position”, and “Percutaneous nephrolithotomy or PCNL”.
Journal of Endourology

We also manually screened the reference lists of the related studies and relevant
review articles. Trials were considered eligible for inclusion in this study: (1) patients
with renal or upper ureteral stones, (2) patients were treated with PCNL in supine or
prone position, (3) outcomes including the efficacy (stone-free rate, mean operative
time, hospitalization time) and safety (complications, blood transfusions) of the PCNL,
(4) randomized controlled trials (RCTs) involving comparative studies and case series
studies. Exclusion criteria were: (1) renal abnormalities (such as whole horseshoe
kidney and ectopic kidney), (2) pediatric patients, (3) unclear position for the PCNL,
(4) provision of insufficient data. The detail of the systematic search and selection
strategy is showed in Figure 1.

Data extraction and quality assessment

Data pertaining to the following variables were independently extracted for each
study by two authors using a standardized data extraction form: authors, year of
publication, source journal, sample size, the patients’ characteristics, stone-free rate
(The stone-free rate was defined as either no residual stone or clinically insignificant
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residual stone fragment of <4 mm in diameter and is non-obstructive and

non-infected), the mean operative time (Operative time was defined as the time from
the ureteral catheterization to the placement of the nephrostomy tube), complication
rates, blood transfusions, and hospital stay. In duplicate studies, only the most recent
Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis (doi: 10.1089/end.2015.0402)

data was included. The primary endpoint in the studies was the stone-free rate. The
secondary endpoint was complications which included fever, urinary leakage,
adjacent organ injuries (mainly colonic and pleural injury), mean operative time, and
length of hospital stay. The star scoring system21 was used to evaluate methodological
quality of the included studies, which based on the criteria related to the study design,
comparability of the patient groups, and the outcome assessment to assess the
literature quality. The total score was 9 stars, and the quality of each study was graded
as lower (0 to 5 stars) or higher (6 to 9 stars).
Journal of Endourology

Statistical analysis

The weighted mean differences (WMDs) were used for continuous outcomes,
and odds ratios (ORs) were used for the dichotomous outcomes. The summary risk
estimates were calculated using random- or fixed-effects models as appropriate based
on heterogeneity levels7. Heterogeneity among studies was assessed using the I2
statistic, which measured quantitative inconsistency in heterogeneity levels across
studies. Studies with I2 values from 25% to 50% exhibited low heterogeneity, 50% to
75% showed moderate heterogeneity, and studies with results > 75% exhibited high
heterogeneity. An I2 value > 50% and Pheterogeneity> 0.10 indicated significant
heterogeneity. All statistical analyses were conducted using Review Manager version
4.2 software (Cochrane Collaboration, Copenhagen, Denmark).

Results

Characteristics of included studies

Following the search strategy and inclusion criteria, the initial search identified
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89 citations, of which 13 studies8-20(6 randomized controlled trials8,9,11,15,17,20and 7

retrospective studies10,12,13,14,16,18,19) were include in this meta-analysis with a total of
5881 patients (1703 in the supine group and 5178 in the prone group). The main
characteristics of the 13 studies are shown in Table 1. Table 2 shows the quality
Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis (doi: 10.1089/end.2015.0402)

assessment of individual studies that has a score of ﹥6 points with the exception of
Shoma AM19 which scored was 5 points.

Stone-free rate
All 13 studies8-20 included data on stone-free rate. We used the fixed-effects
model to combine these data because heterogeneity was not evident (P = 0.46). The
stone-free rate was 77.7% (4025/5178) in the prone position versus 74.3% (1266/1703)
in the supine position. In the overall data, the stone-free rate was higher in the prone
Journal of Endourology

position than in the supine position (OR: 0.74; 95% CI: 0.65–0.84; P<0.00001, Figure
2).

Mean operative time

Six studies8,10,15,16,17,18 including 6274 patients reported the mean operative time
for PCNL in two positions. We used the random-effects model to combine the data
due to notable heterogeneity (P <0.00001). Compared with prone position in the
PCNL, operative time in the supine position was less (WMD: -18.27; 95% CI: -35.77
to -0.77; P=0.04, Figure 3),

Length of hospitalization
Six studies8,10,15,16,17,18 including 6264 patients reported the length of hospital
stay for PCNL in two positions. The random-effects model was used to combine the
data owe to notable heterogeneity (P <0.00001). In the combined data, this model
showed no significant difference between the supine position and the prone position
on hospitalization time (WMD:-0.14; 95% confidence interval [CI]: -0.76 to 0.47;
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P=0.65, Figure 4).

Complication rate
8,9,11,12,14,15,16,17,19
Data on postoperative complications, including fever, urinary
Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis (doi: 10.1089/end.2015.0402)

leakage,8,14,17,18,19,20organs injury,8,15,16pleural effusion,8,13,14,16bleeding,9,19,20 renal

colic,9,20 urinoma,13 arteriovenous fistula,13,18 septicaemia,13,18 hyponatremia,14were
collected and analyzed. Due lower heterogeneity (P=0.33), the fixed effects model
was used to pool the data. The complication rate was 20.5% (1,058/5161) in the prone
position versus 18.1 % (307/1696) in the supine position. Pooled data showed similar
overall complication rates in both supine and prone groups (OR: 0.88; 95% CI: 0.76
to 1.02; P=0.10, Figure 5), and specifically in urinary leakage (OR: 1.06; 95% CI:
0.64 to 2.44; P=0.89, Figure 6) and pleural effusion (OR: 0.76; 95% CI: 0.46 to 1.25;
P=0.28, Figure 7). Whereas the rates for fever were significantly lower in the supine
Journal of Endourology

group than in the prone group (OR: 0.64; 95% CI: 0.51 to 0.79; P<0.0001, Figure 8).

Blood transfusions
Nine studies8,10,11,13-19 including 6512 patients reported the blood transfusion rate
for PCNL in both positions. Owe to lower heterogeneity (P = 0.09), we used the
fixed-effects model to combine the data. Meta-analysis demonstrated lower blood
transfusions in the supine position than in the prone position (WMD: 0.73; 95%
confidence interval [CI]: 0.56 to 0.95; P=0.02, Figure 9).

Assessment of publication bias

We assessed potential publication bias using a funnel plot. The funnel plot shapes
for the meta-analysis of stone-free rate, complication rate, and the blood transfusion
rate show nearly symmetry (Figure 10). Hence, we did not detect the publication bias
in this meta-analysis.

Sensitivity analyses
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In sensitivity analyses, five outcomes were included. The results were showed in
Table 3. This analysis suggested that the OR, WMD, and the level of significance for
the three outcomes (complication rates, the mean operative time, and hospital stay)
were not obviously altered. While the OR and the level of significance for the
Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis (doi: 10.1089/end.2015.0402)

stone-free rate and blood transfusion was notably different in randomized controlled
trials. In addition, the stone-free rate and the blood transfusion were not significantly
different between two groups.

Discussion
Compared with open surgery and shock wave lithotripsy for the larger and
complex stones, the PCNL in prone position has lower morbidity and covalescence,
cost22. It has been the preferred position for PCNL for decades. It provides a wide
surface area for puncture sites and offer adequate space for nephroscopic
Journal of Endourology

manipulation23,24,25. Nevertheless it has some disadvantages. Foremost is the

compromised weight distribution, a milieu that can lead to cardiopulmonary
complications, especially in obese patients and individuals with cardiac diseases. It
also increase the difficulty in the airway management for the anesthesiologist. The
need for several assistants to reposition the patient before surgery and for additional
intraoperative position changes in case of simultaneous ureteroscope is needed can
also be problematic. Prone position may be contraindicated in some patients due to
circulatory and ventilatory impairment26,27. Gabriel Valdivia and colleagues described
the first case of PCNL in the supine position (sPCNL) in 1987. They touted several
benefits for the patient, especially for those patients with higher anesthetic risk.
Recently, more and more sPCNL have been reported28,29,30. It increased the
confidence for the endourologists to practice this technique and overcome the
drawbacks of the prone position. However in the normal healthy individuals, there is
still the controversy over the efficacy and safety of operating in the supine versus
prone position in PCNL.
In this meta-analysis, we included 13 clinical studies8-20 that compared sPCNL
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with pPCNL for renal calculi to adjudicate the superior position for the treatment of
kidney stones. The heterogeneity of the location and the type of calculi, as well as the
different study types was overcome by sensitivity analysis of the combined data.
Meanwhile, three common complications rather than the overall complication rate
Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis (doi: 10.1089/end.2015.0402)

were selected for this meta-analysis for a better evaluation of the safety of the supine
position in PCNL.
The stone-free rate in the supine group was 74.3 % and the rate for the prone
group was 77.7%. This meta-analysis demonstrated that operating in the prone
position was significantly better than supine position for the stone-free rate. This was
in contrary to two previous meta-analyses results,32,33 but was in accordance with
Zhang X et al’s31 conclusion. The reasons for the higher stone-free rate in prone
position might be due to the wider choice for the renal puncture site and more space
for the manipulation of the nephroscope. In addition, in the supine position it is more
Journal of Endourology

challenging to follow the migratory stones, and the upper pole approach could also be
more technically difficult.3,28,32,34 Therefore, in conclusion we believed the stone-free
rate was better achieved in the prone group.
There are only six trials8,10,15,16,17,18 that include hospitalization times. Our
meta-analysis revealed that hospital stay was not significantly different between the
supine and the prone groups, which is in accordance with/ in agreement with/
consistent with Zhang X et al’s31 findings. These data lends further support to the
efficiency of the supine approach.
Our meta-analysis of 6 clinical studies8,10,15,16,17,18 revealed significantly less
operative time in the supine groups than in the prone groups. We attributed this
mainly to not having to reposition the patient from the lithotomy to the prone position
and the repeated preparation of the operative field. There was also time saved when
PCNL and ureteroscopic procedures had to be performed simultaneously.
Furthermore, the sensitivity analysis also support sPCNL required less operative time
than the pPCNL.
The meta-analysis revealed that the blood transfusions8,10,11,13-19 in supine
position was significantly less than that of the prone position. (Perhaps because the
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kidneys are more medial and have greater mobility in the retroperitoneum with the
supine position which may reduce the need for blood transfusion.) This paragraph did
not make sense. This could likely be the result of the shorter operative time with the
sPCNL.
Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis (doi: 10.1089/end.2015.0402)

Many complications may occur after surgery. Relatively common complications

were selected in this study which included urinary leakage, pleural effusion and fever.
The total complication rate8-20 in the supine group was 18.1 %, while the rate of that
in the prone group was 20.5%. Our meta-analysis showed that total complication rate
was not significantly different between these two groups. We then analyzed each of
the complications individually. Urinary leakage8,14,17,19,20 and pleural effusion8,13,14,16
had similar complication rates between the two groups, whereas the rate of
fever8,9,11,12,14,15,16,17,19 was significantly less in the supine group. This is possibly due
to the lower respiratory stress during the supine position.
Journal of Endourology

Some limitations cannot be neglected in this meta-analysis. First, the paucity of

comparative studies on supine versus prone PCNL was the most significant drawback.
Second, between-study heterogeneity was common in the included studies. Some
series paid attention only to the different results. Others used quite different definition
for the PCNL complications. With such high degree of heterogeneity, many of these
studies would have been excluded. To explain the source of heterogeneity, we
performed sensitivity analysis. Third, different surgeons might have had different
experience with sPCNL and pPCNL. Since this meta-analysis included
non-randomized trials, these might have affected the studied outcomes. Therefore,
further prospective, randomized, and multicenter RCTs would be needed for a more
comprehensive and convincing evaluation. Fourth, different studies might have
different defining criteria for the outcomes for which we were interested; they might
not have been reported in the study methodology. Fifth, due to the inclusion of
nonrandomized studies, there were two inherent selection bias in these two groups.
Fifth, most of the surgeons who performed the sPCNL had actually swithched from
the pPCNL. It indicated that they were already experienced surgeons and found
sPCNL to be beneficial. The surgeon's experience might have affected the studied
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outcomes. Finally, we could not account for the limitation of the unpublished data and
the selection bias.

Conclusions
Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis (doi: 10.1089/end.2015.0402)

This study highlighted statistically several advantages of sPCNL over pPCNL,

especially in quantifying the safety advantages. While it was shown that the stone free
rate was somewhat lower in sPCNL, there was the distinct advantage in reducing the
mean operative time and no effect on the length of hospitalization time. Safety
outcomes in the present study highlight several advantages with lower rates of blood
transfusions and cases of presentation with fever, despite the lack of difference in
WMD for the overall complications outcome. However, since majority of the studies
in our meta-analysis were retrospective, which might lead to some selection bias
(especially with heterogeneity of complication outcomes). Therefore, to be conclusive,
Journal of Endourology

a prospective, multicenter RCTs would be necessary.

Acknowledgments
The study was supported by outstanding youth science and technology talent
cultivating object of Guizhou Province in 2013（2013-18）, young talents project of
Guizhou Province in 2012（2012-185）, the National Natural Science Foundation of
China(81360119), International Scientific and Technological Cooperation Projects of
Guizhou Province (20137031) and Science and Technology Program of Guangzhou,
China（2011J4100054）. No other potential conflict of interests relevant to this paper
was reported.

Conflict of interest
The authors have no conflicts of interest to disclose.

Author Contributions
Conceived and designed the article: Zhu JianGuo, Sun ZhaoLin, Zhong WeiDe.
 Journal of Endourology
Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis (doi: 10.1089/end.2015.0402)
This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.

and approved the final manuscript.

Analyzed the data: Zhu JianGuo, Wang YuanLin, Chen WeiHong, Liu YongDa.
Literature search and Data extraction: Yuan DongBo, Rao HaoFu, Cheng TianFei.
12

Wrote the paper: Zhu JianGuo, Liu Jun, Yuan DongBo, Liu YongDa. All authors read
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Ann Thorac Surg 2004; 77:745–53.

22. Brannen GE, Bush WH, Correa RJ, et al. Kidney stone removal: Percutaneous
versus surgical lithotomy. J Urol 1985; 133:6–12.
23. Cracco CM, Scoffone CM, et al. ECIRS (Endoscopic Combined Intrarenal
Surgery) in the Galdakao-modifi ed supine Valdivia position: a new life for
percutaneous surgery? World J Urol 2011; 29: 821-7.
24. Duty B, Waingankar N, Okhunov Z, Ben Levi E, Smith A, et al. Anatomical
variation between the prone, supine, and supine oblique positions on computed
tomography: implications for percutaneous nephrolithotomy access. Urology 2012;
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79: 67-71.
25. Wang Y, Jiang F, Wang Y, Hou Y, Zhang H, et al. Post-percutaneous
nephrolithotomy septic shock and severe hemorrhage: a study of risk factors. Urol
Int 2012; 88: 307-10.
26. Grasso M, Nord R, Bagley DH. Prone split leg and flank roll positioning:
Simultaneous antegrade and retrograde access to the upper urinary tract. J
Endourol 1993; 4:307–310.
27. Gofrit ON, Shapiro A, Donchin Y, et al. Lateral decubitus position for
percutaneous nephrolithotripsy in the morbidy obese or kyphotic patient. J
Endourol 2002; 16:383–386.
28. Hoznek A, Rode J, Ouzaid I, Faraj B, Kimuli M, et al. Modifi ed supine
percutaneous nephrolithotomy for large kidney and ureteral stones: technique and
results. Eur Urol 2012; 61: 164-70.
29. Falahatkar S, Asli MM, Emadi SA, Enshaei A, Pourhadi H, et al. 10 Complete
supine percutaneous nephrolithotomy (csPCNL) in patients with and without a
history of stone surgery: safety and effectiveness of csPCNL. Urol Res 2011; 39:
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30. Falahatkar S, Farzan A, Allahkhah A. Is complete supine percutaneous

nephrolithotripsy feasible in all patients? Urol Res 2011; 39: 99-104.
31. Zhang X, Xia L, Xu T, Wang X, Zhong S, et al. Is the supine position superior to
the prone position for percutaneous nephrolithotomy (PCNL)? Urolithiasis 2014;
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42(1):87-93.
32. Liu L, Zheng S, Xu Y, Wei Q. Systematic review and meta-analysis of
percutaneous nephrolithotomy for patients in the supine versus prone position. J
Endourol 2010; 24(12):1941–1946
33. Wu P, Wang L, Wang K. Supine versus prone position in percutaneous
nephrolithotomy for kidney calculi: a meta-analysis. Int Urol Nephrol 2011;
43(1):67–77
34. Xu KW, Huang J, Guo ZH, Lin TX, Zhang CX, et al.
Percutaneous nephrolithotomy in semisupine position:a modified approach for renal calculus.
Journal of Endourology

Urol Res 2011; 39(6):467-75.

PCNL = percutaneous nephrolithotomy;

OR= odds ratio;
CI= confidence interval;
WMD= weighted mean difference;
P= P value;
RCTs= randomized controlled trials;
RNT =retrospective nonrandomized trial;
BMI = body mass index;
NA = Not available;

35.
36.

Figure1.Computerized search and selection strategy

Figure2.Forest plot showing stone-free rate between supine and prone position
 Journal of Endourology
Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis (doi: 10.1089/end.2015.0402)
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Figure4.Forest plot showing hospital stay between supine and prone position
Figure3.Forest plot showing the operative time between supine and prone position
17
 Journal of Endourology
Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis (doi: 10.1089/end.2015.0402)
This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.

showing urinary leakage between supine and prone position

Figure5.Forest plot showing complication rate between supine and prone position

Figure6.Forest plot showing urinary leakage between supine and prone positionFigure6.Forest plot
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Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis (doi: 10.1089/end.2015.0402)
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Figure8.Forest plot showing fever between supine and prone position

Figure7.Forest plot showing pleural effusion between supine and prone position
19
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Figure9.Forest plot showing blood transfusion between supine and prone position
Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis (doi: 10.1089/end.2015.0402)

Figure10.Funnel plot for the results from all studies comparing stone-free rate, complication rate
(fever) and blood transfusion in patients between supine versus Prone position

Table 1 Characteristics of the 13 selected clinical studies

Study Location Study Group No. of No. of Gender Age BMI Stone
style patients procedures M/F year kg/m2 burden
Al-Dessoukey Supine 101 101 68/33 34.86 27.24 3.68cm
Egypt RCT
et al. (2014) Prone 102 102 68/34 37.21 26.87 3.93cm
Wang Yanbo Supine 60 60 28/32 44 24 3.1cm3
Journal of Endourology

China RCT
et al.(2013) Prone 62 62 34/28 42 25 3cm3
McCahy P et Supine 36 41 NA 53.4 30.13 32.6 mm
Australia. RNT
al.(2012) Prone 36 41 23/13 53.1 26.62 25.7 mm
Basiri A et Supine 43 43 30/13 45.7 25.29 352mm2
Iran RCT
al.(2013) Prone 46 46 31/15 44.8 24.86 345mm2
Wang Y, Hou Supine 6 6 4/2 44.8 24.5 3.6cm
China RNT
Y et al.(2012) Prone 12 12 8/4 43.8 24.2 3.3 cm
Sanguedolce Supine 65 65 41/24 53 26 20.6mm
Sweden RNT
F et al.(2013) Prone 52 52 28/ 24 49 27.1 18.1 mm
Mazzucchi E Supine 30 32 12/18 49 34 10.2cm2
Brazil RNT
et al.(2012) Prone 12 24 2/10 38.3 34.2 11.28cm2
Karami H et Supine 50 50 34/16 44.4 27.8 28.2mm
Iran RCT
al.(2013) Prone 50 50 31/19 41.5 26.1 28.3mm
Valdivia JG et Supine 1138 1126 594/544 51 26.6 470.6mm2
CROES RNT
al.(2011) Prone 4637 4585 2662/1975 48.8 26.7 449.1mm2
Falahatkar S Supine 40 40 23/17 45.35 25.6 40.6mm
Iran RCT
et al.(2008) Prone 40 40 18/22 43.02 26.3 40.3mm
Sesmero JH Supine 50 47 23/27 54.1 NA 399.93mm2
Spain RNT
et al.(2008) Prone 54 51 30/24 53.9 NA 416.36mm2
Shoma AM et Supine 53 53 34/19 43.6 NA NA
Egypt RNT
al.(2002) Prone 77 77 43/34 47.4 NA NA
De Sio M et Supine 39 39 17/22 38 28 3.4cm
Italy RCT
al.(2008) Prone 36 36 16/20 41) 26 3.3cm
RCT =randomized controlled trial; RNT =retrospective nonrandomized trial. BMI =
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body mass index; NA = Not available

Table 2 Quality assessment scoring of studies

Selection Comparability of groups Outcomes

Author Total
Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis (doi: 10.1089/end.2015.0402)

1 2 3 4 5 6 7
6
Al-Dessoukey et al ＊ ＊ ＊ ＊＊ ＊＊ ＊ ＊ 9＊
Wang Yanbo et al7 ＊ ＊ ＊ ＊＊ ＊＊ 7＊
McCahy P et al8 ＊ ＊ ＊ ＊ ＊＊ ＊ ＊ 8＊
Basiri A et al9 ＊ ＊ ＊ ＊＊ ＊＊ ＊ 8＊
Wang Y, Hou Y et al10 ＊ ＊ ＊ ＊＊ ＊＊ ＊ 8＊
Sanguedolce F et al11 ＊ ＊ ＊ ＊＊ ＊＊ ＊ ＊ 9＊
Mazzucchi E et al12 ＊ ＊ ＊ ＊＊ ＊＊ ＊ 8＊
Karami H et al13 ＊ ＊ ＊ ＊＊ ＊＊ ＊ ＊ 9＊
Valdivia JG et al14 ＊ ＊ ＊ ＊＊ ＊＊ ＊ ＊ 9＊
Falahatkar S et al15 ＊ ＊ ＊ ＊＊ ＊＊ ＊ 8＊
Sesmero JH et al16 ＊ ＊ ＊ ＊ ＊＊ ＊ 7＊
Shoma AM et al17 ＊ ＊ ＊ ＊ ＊ 5＊
De Sio M et al18 ＊ ＊ ＊ ＊＊ ＊＊ 6＊
Journal of Endourology

Selection for treatment: 1=inclusion criteria reported; 2=generalizability of patients

undergoing surgery in supine position to population undergoing surgery for kidney
calculi; 3=generalizability of patients undergoing surgery in prone position to
population undergoing surgery for kidney calculi. Comparability between groups (if
yes to all, 2 stars; if 1 of these characteristics was not reported, 1 star; if the 2 groups
differed, no stars): 4=age, sex, and body mass index; 5=Stone location, Stone burden,
and Site of puncture. Outcome assessment: 6﹥﹦5 outcomes of interested clearly
recorded (1 star); 7=adequacy of follow-up (1 star if follow-up .90%).

Table 3 Sensitivity analysis of included studies

No. of patients
Outcomes No. of studies OR/WMD 95% CI P
Supine Prone
Randomized controlled trials
Stone-free rate 333 336 6 .84 .55 to 1.27 .40*
Complication rates 333 336 6 .78 .53 to 1.14 .20
Blood transfusion 234 238 4 1.09 .56 to 2.12 .80*
The mean operative time 191 192 3 －25.65 －31.69 to －19.60 ﹤.05
Hospital stay all patients 191 192 3 －.25 －1.45 to .94 .68
Studies with star scoring≥6 points
Stone-free rate 1650 5105 12 .73 .64 to .84 ﹤.05
Complication rates 1643 5084 12 .87 .75 to 1.01 .07
Blood transfusion 1538 4974 9 .73 .56 to .95 .02
The mean operative time 1405 4869 6 －18.27 －35.77 to －.77 .04
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Hospital stay all patients 1400 4864 6 －.14 －.76 to .47 .65
Studies with No. of patients≥40
Stone-free rate 1626 5106 10 .74 .65 to .85 ﹤.05
Complication rates 1585 5065 9 .89 .77 to 1.04 .14
Blood transfusion 1472 4926 7 .77 .59 to 1.01 .06*
The mean operative time 1405 4869 6 －18.27 －35.77 to －.77 .04
Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis (doi: 10.1089/end.2015.0402)

Hospital stay all patients 1364 4828 5 －.17 －.85 to .52 .64
CI=confidence interval; Supine=supine position in PCNL; Prone=prone position in PCNL;
OR=odds ratio; WMD=weighted mean difference. *No statistically significant difference.
Journal of Endourology
 Journal of Endourology
Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis (doi: 10.1089/end.2015.0402)
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Figure1.Computerized search and selection strategy

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Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis (doi: 10.1089/end.2015.0402)
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Figure2.Forest plot showing stone-free rate between supine and prone position
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Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis (doi: 10.1089/end.2015.0402)
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Figure3.Forest plot showing the operative time between supine and prone position
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Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis (doi: 10.1089/end.2015.0402)
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Figure4.Forest plot showing hospital stay between supine and prone position
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Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis (doi: 10.1089/end.2015.0402)
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Figure5.Forest plot showing complication rate between supine and prone position
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Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis (doi: 10.1089/end.2015.0402)
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Figure6.Forest plot showing urinary leakage between supine and prone position
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Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis (doi: 10.1089/end.2015.0402)
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Figure7.Forest plot showing pleural effusion between supine and prone position
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Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis (doi: 10.1089/end.2015.0402)
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Figure8.Forest plot showing fever between supine and prone position

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Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis (doi: 10.1089/end.2015.0402)
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Figure9.Forest plot showing blood transfusion between supine and prone position
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Supine versus prone position in percutaneous nephrolithotomy for kidney calculi: a meta-analysis (doi: 10.1089/end.2015.0402)
This article has been peer-reviewed and accepted for publication, but has yet to undergo copyediting and proof correction. The final published version may differ from this proof.

(fever) and blood transfusion in patients between supine versus Prone position
Figure10.Funnel plot for the results from all studies comparing stone-free rate, complication rate
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