PCNL is traditionally performed in the prone position. It offers a wide operative field, which can make the surgeon to puncture and dilate the tracts more easily, however it has potential disadvantages, such as it may cause circulatory and ventilatory compromise, especially in the obese or skeletal malformation patients and it is not feasible for the anterograde and retrograde access simultaneously [5, 6]. The supine PCNL position can overcome these drawbacks stated above. In addition, the operative time can be decreased, as there is no need for re-positioning and allow quick access to the airway for the anesthetist [7]. However, Patients with marginal lung and heart function can not tolerate the prone or supine position well. These problems are further compounded through general anesthesia, which uses muscle paralysis. In order to decrease the influence of PCNL on the respiratory and circulatory functions, we decided to treat him in the sit position under local anesthesia.
We reported the first case of PCNL in sit position. The patient had a long history of COPD and smoking, with severe ventilatory and cardiac dysfunction, and cannot keep in the prone or supine position for a long time. The patient received the surgery in sit position, which has several advantages. Firstly, the venous return to the heart decreased and the ventilation increased during the surgery for the patient in a comfortable sit position. Therefor the sit position, which has minimally impact on the respiratory and circulatory functions, can be used in patients with severe cardio-pulmonary dysfunction. Secondly, the surgeon can also do the surgery in the comfortable sit position, which is labor saving. Thirdly, the patient reversely rode on the chair, bend over the chairback. The intercostal space widened, which can ease the puncture and dilation. Moreover the kidney moved down when the patient maintained in the sit position, the risk of pleural injury during the surgery was decreased.
The development of PCNL under local anesthesia has several reasons, including that general anesthesia is not optional for some patients due to severe comorbidity, the need for cost suppression and hospital-stay reduction. Hulin li et al. [8] described their experience of 2000 cases of PCNL under local infiltration anesthesia. Thorsten H. Ecke et al. [9] retrospectively analyzed 439 patients of PCNL under local anesthesia and demonstrated that PCNL performed under local infiltration anesthesia was a feasible method, which can provide satisfactory positive clinical outcomes.
The pain during PCNL procedure is mainly caused by the dilatation of the renal capsule and parenchyma and not by stone fragmentation. Therefore, the renal capsule should also be infiltrated with the lidocaine [10]. We firstly used the ultrasonography to observe the position of calculi, to choose the puncture site and direction, and then injected lidocaine by the use of a 23-gauge spinal needle from the skin to the renal parenchyma, to ensure that lidocaine would be infiltrated along the entire tract. In our case report, the patient gave the VAS sore of 3, and tolerated the surgical procedure well without changing the type of anesthesia or increasing the usage of anesthetic drug.
The best indication of PCNL in sit position under local infiltration anesthesia is for patients with renal and/or upper ureter calculi that can be treated by the single-tract PCNL,and patients with severe cardiopulmonary dysfunction or skeletal malformation. As these patients are unable to maintain in the prone or supine position for a long time. Therefore we believe that in these high-risk patients who need to undergo PCNL, a combination of sit position and local infiltration anesthesia is an alternative method.