Evaluation of Galdakao-modified Valdivia Position in Combined Simultaneous Access to Upper and Lower Urinary Tract Pathologies

Abstract

S imultaneous retrograde and antegrade endoscopic combined intrarenal surgery in modified supine lithotomy positions offer significant progress in the endoscopic management of urolithiasis. The operative time has been significantly reduced. The lack of repositioning of patients not only saves time but also represent other important advantages. It saves the anaesthetized patient from iatrogenic injury and trauma. It averts the potential hazard of dislodgment of endotracheal tube (life threatening condition), urethral catheter, ureteric catheter and intravenous line, some electrodes, which have been inserted. With that position, it is possible to perform PCNL with loco-regional anesthesia, complemented by intravenous sedation. In case of any complication, the supine position will enable the anesthesiologist without problem introduce an endotracheal tube and continue with a general anesthesia. The major advantage is the concomitant management of any pathological condition along the urinary tract with great ease facilitated by reterograde and antegrade approaches. The evident drawbacks of this technique narrow surgical field for renal puncture and relatively small space for nephroscopic manipulation. It can be solved by reterograde ureterorenoscopy and it could be better if there was flexible endoscopy available. During dilatation of percutaneous tract, we are also faced by more mobile kidney in supine position which means more difficult puncture and it is easily solved by constant counter pressure on the abdomen. Also, the upper pole of the kidney is deeply located within the rib cage and more challenging superior calyceal puncture. We encountered this problem by bringing the upper pole of the kidney downward through moving of puncture needle fixed in the lower pole upwards. Moreover, it is highly recommended in high risk patient with multiple comorbidities (high ASA scores) and in patient with concomitant urinary tract pathology in addition to renal stones.