Study Type – Therapy (case series)Level of Evidence 4What's known on the subject? and What does the study add?Supine percutaneous nephrolithotomy (PCNL) has been described for over a decade and has equivalent success rates when compared with the more widely used prone position. The supine position offers a shorter operative duration with better access to the airway for the anaesthetist and also allows for simultaneous retrograde intra‐renal surgery (RIRS). Various supine positions have been described but there is little data regarding their differing benefits and disadvantages.The present study looks at the different supine PCNL positions and compares the strengths and weaknesses of each. Each of the previously described supine PCNL positions have some limitations, e.g. ease of puncture under image guidance, the ability and ease of making and dilating multiple tracts, and allowing simultaneous RIRS. The new ‘Barts flank‐free modified supine position’ is described, which seems to offer a good compromise and addresses some of these issues. It is important to highlight that one supine position does not fit all and the endourologist should familiarise themselves with these positions so the appropriate position can be used for the right patient and stone burden.OBJECTIVE To discuss the relative merits of the different described supine positions for percutaneous nephrolithotomy (PCNL) and highlight the new ‘Barts flank‐free modified supine position’, as the last decade has seen the emergence of various supine positions for PCNL. MATERIALS AND METHODS We reviewed English publications on supine PCNL to look at the different positions being used to carry out PCNL and their relative merits. We describe the new ‘Barts flank‐free modified supine position’, which we think will add significantly to the armamentarium of the endourologist. RESULTS Five different supine positions are discussed. These include the complete supine, the Valdivia, the Galdakao modified Valdivia, the Barts modified Valdivia and the herein described Barts flank‐free modified supine position These positions all differ in regard to ease of puncture under image guidance, operative field availability, ability to make multiple tracts and the ease of combining retrograde intra‐renal surgery. CONCLUSIONS All of the supine positions decrease operative duration, as there is no need for repositioning and allow quick access to the airway for the anaesthetist. However, one supine position does not fit all and the right one must be chosen for the right patient with the right stone burden. It is important for endourologists of today to familiarise themselves with these positions to be able to make these judgements.

Introduction: Rapture of a renal angiomyolipoma and massive retroperitoneal hemorrhage, during pregnancy is rare and occasionally fatal. The association of this complication with pregnancy has been reported sporadically in the literature.

Objective. With this review, we provide a comprehensive overview of the main aspects and currently used drugs for analgesia in shockwave lithotripsy. Evidence Acquisition. We reviewed current literature, concentrating on newer articles and high-quality reviews in international journals. Results. No standardized protocols for pain control in SWL exist, although it is crucial for treatment outcome. General and spinal anaesthesia show excellent pain control but are only recommended for selected cases. The newer opioids and nonsteroidal anti-inflammatory drugs are able to deliver good analgesia. Interest in inhalation anaesthesia with nitrous oxide, local anaesthesia with deep infiltration of the tissue, and dermal anaesthesia with EMLA or DMSO has recently rekindled, showing good results in terms of pain control and a favourable side effect profile. Tamsulosin and paracetamol are further well-known drugs being currently investigated. Conclusion. Apart from classically used drugs like opioids and NSARs, medicaments like nitrous oxide, paracetamol, DMSA, or refined administration techniques for infiltration anaesthesia show a good effectiveness in pain control for SWL.

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Endourological techniques are used more often nowadays in the treatment of ureteric strictures of various etiologies. Advances in technology have provided new tools to the armamentarium of the endoscopic urological surgeon. Numerous studies exist that investigate the efficiency and safety of each of the therapeutic modalities available. In this review, we attempt to demonstrate the available and contemporary evidence supporting each minimally invasive modality in the management of ureteric strictures.

Background: The last decade has seen the emergence of a variety of supine positions for carrying out percutaneous nephrolithotomy (PCNL). These positions all differ with regard to ease of puncture under image guidance, operative field availability, ability to make and dilate multiple tracts and ease of combining retrograde intrarenal surgery (RIRS). As all of these positions have their limitations regarding the important parameters mentioned above, there is a need for a supine position which addresses some of the difficulties. Methods: We describe and illustrate our flank-free modified supine position, which we believe addresses a number of the issues. Results: Our position allows easy percutaneous access under fluoroscopy (torso only tilted to around 15°), space for placing (flank free of support) and dilating multiple tracts (kidney lies in a fairly neutral position and hence less mobile), a fairly horizontal tract allowing low intrarenal pressures and easy washout of fragments as well as allowing RIRS in a position of relative familiarity. The lesser torso rotation compared with the Valdivia, Galdakao modified and the Barts modified Valdivia positions also means it is more comfortable for patients. Conclusions: Our results are encouraging and easily comparable with published series on prone position, Valdivia, complete supine and the Barts modified Valdivia positions. We would like to highlight the Barts ‘flank-free’ modified supine position as one of the standard positions for carrying out supine PCNL.

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