Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 74209

AbstractMaterial and MethodsResultsDiscussionConclusionReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"

Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018

Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."

Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
On Sep 2018

Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."

Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata

Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : March | Volume : 16 | Issue : 3 | Page : PC10 - PC15 Full Version

Thoracic Mass Lesions in Children and their Management: A Prospective Interventional Study

Published: March 1, 2022 | DOI:
SB Srinibash, Prasanta Kumar Tripathy, Kaumudee Pattnaik, Pradeep Kumar Jena, Pramod Kumar Mohanty, Sushree Swagata Dash

1. Senior Resident, Department of Paediatric Surgery, Sardar Vallabhbhai Patel Post Graduate Institute of Paediatrics, Srirama Chandra Bhanja Medical College, Cuttack, Odisha, India. 2. Associate Professor, Department of Paediatric Surgery, Sardar Vallabhbhai Patel Post Graduate Institute of Paediatrics, Srirama Chandra Bhanja Medical College, Cuttack, Odisha, India. 3. Assistant Professor, Department of Pathology, Srirama Chandra Bhanja Medical College, Cuttack, Odisha, India. 4. Professor, Department of Paediatric Surgery, Sardar Vallabhbhai Patel Post Graduate Institute of Paediatrics, Srirama Chandra Bhanja Medical College, Cuttack, Odisha, India. 5. Professor, Department of Paediatric Surgery, Sardar Vallabhbhai Patel Post Graduate Institute of Paediatrics, Srirama Chandra Bhanja Medical College, Cuttack, Odisha, India. 6. Senior Resident, Department of Pathology, Srirama Chandra Bhanja Medical College, Cuttack, Odisha, India.

Correspondence Address :
Prasanta Kumar Tripathy,
Arunodaya Nagar, Link Road, Cuttack, Odisha, India.


Introduction: Supine Percutaneous Nephrolithotomy (PCNL) has failed to gain popularity despite the various advantages, primarily due to a lack of standardised technique. A simple and replicable technique is needed to increase its popularity amongst urologists.

Aim: To simplify and standardise the puncture technique of supine PCNL and compare it with the Clinical Research Office of the Endourological Society (CROES) PCNL global study.

Materials and Methods: A prospective interventional study was conducted in a tertiary care hospital in Dehradun, Uttarakhand, India, between June-December 2020. A total of 82 consecutive patients underwent the procedure with a modified technique of initial puncture using bony landmarks. The results of present study were compared with the outcomes of the patients who underwent supine PCNL in the CROES PCNL global study which is the largest prospective database regarding the supine and prone positions of PCNL till date. Statistical analysis of various demographic variables, patient characteristics and results was done using Statistical Package for the Social Sciences (SPSS) version 24.0 software.

Results: The mean age of patients was 47.52±13.044 years and mean stone burden of 266.146±172.430 mm2. The mean operative time was 85.59±12.733 minutes. Lower calyceal puncture was done in 97.56% of patients. Stone clearance was achieved by a single puncture in 73 (89.0%) patients while 9 (11.0%) patients required two punctures. Sixteen patients (19.51%) had postnephrostomy drain removal leak which settled within 24 hours. Only in one patient the leak continued beyond 24 hours but was managed conservatively. On comparison, it was observed that mean stone burden was lesser (p-value=0.0001) and the stone free rate was comparatively higher in present study (p-value=0.024).

Conclusion: Supine PCNL is an effective and safe procedure in a subset of patients with predominant lower calyceal stone bulk.


Congenital lobar emphysema, Congenital pulmonary airway malformation, Pulmonary blastoma

The PCNL is the most preferred and widely used procedure for the removal of large and complex renal calculi. In recent years, it has almost completely replaced open surgery. It was first described by Fernstrom I and Johansson B (1). Since then, it is traditionally done with the patient in prone position, with a high success rate and acceptable morbidity. As prone position is not acceptable for all patients particularly morbidly obese and patients with respiratory compromise (2),(3),(4),(5),(6), the demand for easier and more comfortable access to the entire urinary tract for combined retrograde and antegrade endoscopic surgery, led to the introduction of alternative patient positions for PCNL. Some of these were not widely accepted in the urological community but all of them had a significant role in the dynamic process of further refinement (7).

There have been several positional modifications in the technique of PCNL (8),(9),(10). Valdivia JG et al., in 1987-88 reported a safe access to the kidney in a supine patient and their in-vivo experience was reported 10 years later (2),(8). In supine PCNL, as the abdominal wall is punctured more laterally, away from the lumbar muscles, the movements of the endoscopic instruments are less restricted. The direction of the tract maintains a low pressure in the renal pelvis, and thereby reduces the risk of fluid absorption and allows even spontaneous clearance/washout of fragments. There are other multiple benefits also like avoidance of supra costal (pleural) puncture, intercostal vessel and nerve injury and simultaneous access for uretero renoscopy for migrated or residual stones (8),(9),(10),(11),(12),(13). The presumed risk of bowel and other solid organ injury has been comprehensively allayed by numerous anatomical Computed Tomographic (CT) studies (2),(11),(12).

Despite these advantages, supine PCNL has not gained the confidence of urologists in general. The present study aims to standardise and simplify the puncture technique for supine PCNL to improve its acceptability. The study also aims to compare the outcomes with the supine PCNL arm of the CROES global PCNL study (14).

Material and Methods

A prospective interventional study was conducted at Shri Mahant Indiresh Hospital, a tertiary care centre in Dehradun, Uttarakhand, India, between June-December 2020 after taking approval from the Institute Ethics Committee (IEC) (SGRR/IEC/4419). Convenience sampling method was adopted.

Inclusion criteria: Patients (aged 20-70 years) with renal and/or ureteric stones who gave informed consent were included in the study.

Exclusion criteria: Patients with absolute contraindications for PCNL (namely sepsis, blood coagulation abnormalities), previous history of ipsilateral laparoscopic or open renal/abdominal surgery, multiple calyceal calculi requiring multiple punctures, bifid pelvicalyceal system with upper calyceal stone mass were excluded from the study.

Study Procedure

A total of 82 consecutive patients with renal stone disease who presented to Department of Urology were included and underwent PCNL in the supine position with modified technique under spinal or general anaesthesia. All the patients had necessary clearance and underwent preoperative evaluation (of routine haematological and biochemical parameters) for surgery and anaesthesia (American Society of Anesthesiologists (ASA) Grade) (15). Postoperative pain was assessed using Visual Analogue Scale (VAS) and analgesics were administered as per the score (16). Body Mass Index (BMI) was calculated and the patients were classified using the World Health Organisation (WHO) classification of obesity (17).

Modified Technique of Calyceal Puncture

Positioning: After giving anaesthesia, patient was positioned in supine position with a bolster placed under ipsilateral scapula and rib cage (not extending below 10th rib). This bolster could be a silicone bolster or 500 mL intravenous fluid plastic bottle with average thickness of 3 inches. The purpose of putting the bolster under thorax was to bring lower pole of kidney at the level of highest point of iliac crest for calyceal puncture. The thickness and placement of the bolster is very important as a thicker bolster placed further down could lift the lower pole of kidney beyond the level of highest point of iliac crest and could also bring colon in the trajectory of puncture needle (Table/Fig 1).

The window for entry of the puncture needle was between iliac crest and the 12th rib. After prepping the patient, ureteric catheterisation was done in either frog leg position or Galdakao modified position if simultaneous ureteroscopy was planned (7).

Surface marking for initial puncture: A horizontal line drawn from a point just below highest point of iliac crest to the 12th rib, serves as the site of puncture. The use of the posterior axillary line in determining the entry site can be fallacious in obese or very thin patients. Rather, the use of fixed bony landmarks is more uniform and therefore desirable. The preferred calyx for entry was usually the lower calyx and sometimes the middle calyx if it was accessible through the window (Table/Fig 2).

The needle entry tract should be in a straight line with the desired calyx and renal pelvis as guided by monoplanar flouroscopy. Care was taken to keep the puncture needle parallel to the operating table while entering the desired calyx. A pyelogram obtained via a preplaced ureteric catheter assisted in puncturing the desired calyx.

After placing guide wire into the pelvicalyceal system and preferably in the ureter, tract dilatation was done using Alken’s dilators under fluoroscopic guidance and a 22F or 24F Amplatz sheath used depending on the diameter of calyx.

In most of the cases, the nephroscope could easily reach the upper and the middle calyx albeit with some angulation. If required, simultaneous ureterorenoscopy could be done to retrieve fragments. Complete clearance was possible in most of the cases. A double-J stent and nephrostomy drain was placed in all cases.

Statistical Analysis

The variables compared were demographic variables (age, sex and BMI), ASA grade, co-morbidities, stone characteristics (side, size, location), operative time, puncture site, stone free rate, postoperative complications and duration of hospital stay. Mean comparison was calculated with the help of Independent t-test and proportion testing was done with the help of z-test. SPSS version 24.0 software was used for statistical analysis. A p-value <0.05 was taken as statistically significant.


The mean age of presentation was 47.52±13.044 years. Among the patients, men outnumbered women (M:F-48:34). The mean BMI at the time of presentation was 26.77±2.209 kg/m2. Lower calyceal puncture was done in majority i.e., 80 patients (97.56%). In all the patients, the preferred calyx for puncture was anterior lower calyx as it gave easy access to all calyces including middle and upper (both anterior and posterior) calyces. Semi-rigid or flexible ureteroscopy was done (in five patients) simultaneously to retrieve stone fragments from the upper calyces which were difficult to reach due to angulation. In two patients, the stone fragments migrated into inaccessible middle calyces which were at an acute angle to the pelvis and could not be removed.

Sixteen patients (19.51%) had postnephrostomy drain removal leak which settled within 24 hours. Only in one patient the leak continued beyond 24 hours but was managed conservatively. A single shot of analgesic was given to all patients in postoperative period within 12 hours. A total of 43 (52.43%) patients required analgesic after 24 hours of surgery whereas 19 (23.17%) patients required analgesic after 48 hours. Nine (11.0%) patients required analgesics even after 2 days of surgery. The results were compared with the outcomes of the patients who underwent supine PCNL in the CROES PCNL Global study (14), which included patients from various countries (Table/Fig 3), (Table/Fig 4). On comparison, it was observed that the subjects in present study were comparatively younger (p-value=0.0373) and therefore had lesser co-morbidities. The mean stone burden was lesser (p-value=0.0001) and the stone free rate was comparatively higher in present study (p-value=0.024).


The effective position for PCNL has always remained a topic of debate among the urologists around the globe. Various centres have a fixed protocol regarding the same. The CROES PCNL global study is the largest prospective database regarding the supine and prone positions of PCNL till date (14).

In the present study, authors have endeavored to simplify the technique of supine PCNL so that it can be reproduced and mastered with relative ease as the puncture site is in relation to a fixed bony landmark. In order to test the results, authors compared the results with the outcomes of the patients who underwent supine PCNL in the CROES PCNL global study which included patients from various countries. The results were found to be comparable (Table/Fig 4). The limitation of such a comparison between two heterogeneous groups with varied inclusion criteria is well understood. Despite the various well-documented advantages of supine PCNL, it has failed to gain the confidence of an average urologist. This is partly due to the fear of inadvertent bowel/visceral injury and partly due to the lack of a standardised technique of calyceal puncture. The former has been comprehensively addressed by numerous anatomic studies, which have proven the fears to be false (11),(12). Authors have attempted, in this study, to simplify the technique of calyceal puncture so that it can be reproduced by any urologist. The over reliance on the use of posterior axillary line for initial puncture, in our opinion, can lead to a higher failure rate especially in obese and very thin individuals. Moreover, in a draped patient the posterior axillary line is not readily visible if the need to revisit the puncture site arises intraoperatively. Thus, bony landmarks, namely the 12th rib and iliac crest were used in guiding the initial puncture site, and have succeeded with comparable results.

Another major advantage of the supine position is that simultaneous procedures (antegrade and retrograde) can be done for clearance of migratory stones. Seven of the patients in this study had upper ureteric stones, which were fragmented partially or pushed back into the kidney, and removed percutaneously without changing the position of the patient. This is advantageous in setups, like ours, where flexible ureteroscope and lasers are not readily available. Ergonomically also, supine PCNL favours both, the urologist and the anaesthesiologist.

Access through lower calyx usually gives easy access to superior and middle calyx unless it is at an acute angle so stone clearance is done with minimal need of additional puncture. As suggested by Sofer M et al., access to superior calyx is easier in supine position in comparison to prone position (18). In a randomised study of 38 patients with upper calyceal stones Soliman T et al., concluded a better stone clearance rate with supine as compared to prone PCNL (19). Another recently published study also claimed better stone clearance and lesser complications with supine PCNL for lower calyceal stones (20). Therefore, the benefits of this procedure can only be made available to the patients only when the procedure becomes standardised, simplified and reproducible. Authors have endeavored to achieve this by present study.


The inferior calyx was punctured in all patients and only two patients required additional middle calyceal puncture. In none of the patients upper calyx was accessed percutaneously, which may be a drawback of this technique. This problem can be partially overcomed by the judicious use of flexible nephroscopes. Although reported by others, supracostal and upper calyceal punctures were not done in the current study. These can be the subject of further studies. One problem which was encountered in two patients where the stone fragments migrated into inaccessible middle calyces which were at an acute angle to the pelvis, thereby precluding access. Inaccessibility by nephroscope can also result when stone fragments migrate into other anterior calyces


Supine PCNL is an effective and safe procedure in a subset of patients with predominant lower calyceal stone bulk. It has the potential to become the procedure of choice in this subset. In patients with upper ureteric calculi, supine PCNL provides concomitant antegrade and retrograde access, without the need for changing patient position.


Fernstrom I, Johansson B. Percutaneous nephrolithotomy: A new extraction technique. Scand J Urol Nephrol. 1976;10:257. [crossref] [PubMed]
Valdivia JG, Valer J, Villarroya S, López JA, Bayo A, Lanchares E, et al. Why is percutaneous nephroscopy stills performed with the patient prone? J Endourol. 1990;4:269-77. [crossref]
Ferena Perez LA, ZungriTelo ER, Valdivia JG. Supine position as the best option for percutaneous surgery of renal calculi in morbidly obese patients. Actas Urol Esp. 2005;29:997-1000.
Gravenstein D. Extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy. Anaesthesiol Clin North Am. 2000;18:953-71. [crossref]
Blackshear R, Gravenstein N. Positioning the surgical patient. In: Kirby RR, Gravenstein N (eds): Clinical Anaesthesia Practice. Philadelphia: WB Saunders, 1994; Pp. 503-13.
Martin JT. The ventral decubitus (prone) position. In: Martin JT, Warner MA (eds): Positioning and Anaesthesia in Surgery, 3rd ed. Philadelphia: WB Saunders, 1997; Pp. 155-95.
Karaolides T, Moraitis K, Bach C, Masood J, Buchholz N. Positions for percutaneous nephrolithotomy: Thirty-five years of evolution. Arab J Urol. 2012;10(3):307-16. [crossref] [PubMed]
Valdivia Uría JG, Valle Gerhold J, López López JA, Villarroya Rodriguez S, Ambroj Navarro C, Ramirez Fabián M, et al. Technique and complications of percutaneous nephroscopy: Experience with 557 patients in the supine position. J Urol. 1998;160:1975-78. [crossref]
Lehman T. Reverse lithotomy: Modified prone position for simultaneous nephroscopic and ureteroscopic procedures in women. Urology. 1998;32:529-31. [crossref]
Gofrit ON, Shapiro A, Donchin Y, Bloom AI, Shenfeld OZ, Landau EH, et al. Lateral decubitus position for percutaneous nephrolithotripsy in the morbidly obese or kyphotic patient. J Endourol. 2002;16:383-86. [crossref] [PubMed]
Hopper KD, Sherman JL, Luethke JM, Ghaed N. The retrorenal colon in the supine and prone patient. Radiology. 1987;162:443-46. [crossref] [PubMed]
Tuttle DN, Yeh BM, Meng MV, Breiman RS, Stoller ML, Coakley FV. Risk of injury to adjacent organs with lower-pole fluoroscopically guided percutaneous nephrostomy: Evaluation with prone, supine, and multiplanar reformatted CT. J Vasc Interv Radiol. 2005;16:1489-92. [crossref] [PubMed]
Rana AM, Bhojwani JP, Junejo NN, Das Bhagia S. Tubeless PCNL with patient in supine position: Procedure for all seasons- with comprehensive technique. Urology. 2008;71:581-85. [crossref] [PubMed]
Valdavia JG, Scarpa RM, Duvdevani M, Gross AJ, Nadler RB, Nutahara K, 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):19-25. [crossref] [PubMed]
Daabiss M. American Society of Anaesthesiologists physical status classification. Indian J Anaesth. 2011;55(2):111-15. [crossref] [PubMed]
Delgado DA, Lambert BS, Boutris N, McCulloch PC, Robbins AB, Moreno MR, et al. Validation of digital visual analog scale pain scoring with a traditional paper-based visual analog scale in adults. Journal of the American Academy of Orthopaedic Surgeons. Global Research & Reviews. 2018;2(3):e088. [crossref] [PubMed]
17. Internet. World Health Organisation. June 2021.
Sofer M, Giusti G, Proietti S, Mintz I, Kabha M, Matzkin H, et al. Upper calyx approachability through a lower calyx access for prone versus supine percutaneous nephrolithotomy. J Urol. 2016;195(2):377-82. [crossref] [PubMed]
Soliman T, Khalil M, Omar R, Mohey A, Ahmed S, Sherif H, et al. Management of upper calyceal stone by percutaneous nephrolithotomy through lower calyx access: prone versus supine position. Afr J Urol. 2020;26:14. [crossref]
Choudhury S, Talukdar P, Mandal TK, Majhi TK. Supine versus prone PCNL in lower calyceal stone: Comparative study in a tertiary care center. Urologia. 2021;88(2):148-52. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2022/52582.16118

Date of Submission: Sep 25, 2021
Date of Peer Review: Dec 21, 2021
Date of Acceptance: Jan 06, 2022
Date of Publishing: Mar 01, 2022

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

• Plagiarism X-checker: Dec 01, 2021
• Manual Googling: Feb 05, 2022
• iThenticate Software: Feb 12, 2022 (7%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)