Supine versus prone percutaneous nephrolithotomy: A narrative and analytical review of technique

ABSTRACT Introduction: Percutaneous nephrolithotomy (PCNL) remains the gold standard for large and complex renal calculi. Although the prone position has traditionally been used since the introduction of PCNL in 1976, supine PCNL and its modifications have gained increasing acceptance with growing evidence supporting their efficacy and safety. This narrative review aims to compare supine and prone PCNL across various domains. Methods: Databases, PubMed/MEDLINE, Cochrane Library, Scopus, Web of Science, and Google Scholar were included. Priority was given to randomized-controlled trials, meta-analyses, and large prospective studies (>100 patients). Evidence was synthesized across operative, anesthetic, safety and technological domains. Results: Supine PCNL demonstrated stone-free rates comparable to prone PCNL. Multiple meta-analyses showed significantly shorter operative times (by 13–25 min), improved anesthetic safety, reduced radiation exposure, shorter learning curve, lower infectious complications, and superior ergonomics with the supine approach. Supine PCNL facilitates Endoscopic Combined Intrarenal Surgery and is particularly advantageous in obese, pediatric, elderly, and cardiovascular high-risk patients. Miniaturized PCNL techniques further enhance these benefits. Ultrasound-guided access contributes to improved procedural safety, whereas gravity-assisted drainage helps maintain low intrarenal pressure and facilitates gravity-assisted fragment evacuation. Emerging technologies such as vacuum-assisted systems and robotic-assisted PCNL appear inherently more compatible with the supine position. Conclusion: Supine PCNL offers significant operative, anesthetic, and technological advantages while maintaining equivalent stone-free outcomes. It can be considered an equally useful approach in most clinical scenarios, whereas prone PCNL has definite advantages in selected anatomical situations.