Compartment Syndrome Related to Patient Positioning in the Surgical Treatment of Urolithiasis

The incidence of urolithiasis is progressively increasing worldwide, as is the surgical treatment of urinary stones. The most frequent surgery for urolithiasis is ureterorenoscopy, which is performed in the lithotomy position. This position is also used in the endoscopic approach to bladder stones. Lateral decubitus is rarely used in the treatment of urinary stones. In the case of complex kidney stones, the gold standard treatment is percutaneous nephrolithotomy. This surgery has traditionally been performed in the prone position. However, the use of the supine (Valdivia) position is increasing in recent times. Furthermore, the Galdakao-modified supine Valdivia position has been widely used for percutaneous nephrolithotomy since it was described by Ibarluzea et al. in 2007. Treatment of kidney and ureteral stones simultaneously is allowed in both supine positions. In addition, they allow the removal of encrusted stents and the easy placement of double J stents and, in the case of the Galdakao-modified supine Valdivia position, percutaneous nephrostomies. Compartment syndrome is a rare complication in the lithotomy position, but scarcely described in the supine position. This especially applies to the Galdakao-modified supine Valdivia position, in which the lower limbs are in moderate flexion, with the ipsilateral lower limb in a slightly lower position relative to the other. This complication can lead to skin necrosis, myoglobinuric renal failure, amputation, permanent neuromuscular dysfunction, and even death. Risk factors include Body Mass Index, male gender, obesity, increased muscle mass, peripheral vascular disease (advanced age, hypertension, hyperlipidemia and diabetes mellitus), height, lack of operative experience, significant bleeding during surgery, hypothermia, acidemia, combination general-spinal anesthesia, prolonged surgical time, systemic hypotension, ASA (American Society of Anesthesiologists) class or vasoconstrictor drugs. Therefore, compartment syndrome of the leg is a potentially devastating complication that must be suspected and treated through early decompression of the compartment by four compartment fasciotomy. Preventive measures reduce the incidence of this condition.