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Positioning & Nerve Injury

Positioning is a shared surgical, anesthesia and nursing responsibility, and it is one of the few decisions in urologic surgery where a few minutes of planning changes the risk of a serious, lasting complication. A brachial plexus stretch from a lateral position, a well-leg compartment syndrome after a long lithotomy case, and postoperative visual loss after a long head-down case are uncommon but disabling. Neuropathy, pressure injury, compartment syndrome and ocular injury can still occur despite precautions; neither a particular stirrup nor a checklist guarantees prevention. Choose the least extreme position that provides adequate access, and reassess when the operation or the patient's physiology changes.[1][2]

The positions used in reconstructive and functional urologic surgery (supine, lithotomy, steep Trendelenburg, lateral, prone, jackknife, split-leg and supine PCNL positions) each carry nerve, compartment and pressure risks, and specific steps keep the position from becoming a complication.

See also: Pelvic Neuroanatomy, Anesthesia, Nerve Blocks and ERAS.

General Principles​

  1. Stay within the patient's awake range of motion. Before induction, identify restricted joint movement, existing weakness or sensory loss, vascular disease and vulnerable skin. Positions that stretch a joint or muscle group beyond what the patient tolerates awake (for example the hamstrings in lithotomy) risk stretch injury.[1]
  2. Pad and offload bony prominences (heels, sacrum, greater trochanter, elbow, lateral malleolus, occiput, fibular head). Pressure injury is the most common positioning injury. Avoid padding or restraints that are too tight, because they can themselves cause injury.[1][2]
  3. Keep arm abduction to 90° or less in a supine patient and avoid stretching the elbow or shoulder beyond a comfortable range.[1]
  4. Recheck after the drapes go on, after table changes or docking, and after any suspected movement. The ASA advisory recommends periodic perioperative checks to confirm the position is maintained; it does not prescribe a fixed interval, so set one appropriate to the duration and risk of the case.[1]
  5. Document the position, supports, prolonged elevation or tilt, and any change made. A written check is both a safety and a medicolegal record.

Confirm limb alignment, accessible IV lines and airway, and protection from retractors and equipment after positioning. Transfers should preserve spinal alignment and avoid traction on the airway, limbs, catheters and drains. Test a planned steep tilt before draping and use pressure-distributing supports and dry linens.[1][2]

Supine​

Setup. Arms are tucked at the sides (standard for pelvic and minimally invasive work) or on padded armboards abducted to 90° or less. Keep the neck neutral, pad and offload the heels, and protect the fingers from table attachments. For tucked arms, keep the forearms neutral with the palms toward the thighs and protect the elbows. On armboards, a supinated or neutral forearm reduces pressure on the ulnar (postcondylar) groove.[1]

Urologic applications. Robotic pelvic surgery (with Trendelenburg), transperitoneal partial nephrectomy, cystectomy and diversion, and urethroplasty with separate leg access.

Main risks.

  • Ulnar neuropathy. In a review of 1,129,692 anesthetics at one center, persistent ulnar neuropathy (more than 3 months) occurred in 1 per 2,729 patients. It was more common in men, in very thin and obese patients, and after hospitalization longer than 14 days. In that older cohort, anesthetic technique and recorded intraoperative position were not associated with neuropathy, and many cases first appeared more than 24 hours after surgery.[6] A later same-center retrospective series found neuropathy lasting at least 2 months in 22/324,124 noncardiac anesthetics (1 per 14,733); a matched analysis associated tucked arms with higher odds (OR 6.16, 95% CI 1.85–20.59).[26] The cohorts used different persistence thresholds (more than 3 months versus at least 2 months).[6][26]
  • Heel pressure injury. Pad both heels and offload them with a wedge or heel-suspension device.
  • Brachial plexus stretch. Avoid abduction beyond 90° or shoulder extension.
  • Occipital pressure injury. Uncommon; reposition or pad the head in prolonged cases.

Assess both compression and stretch: generous padding does not correct excessive shoulder traction or a tightly tucked arm.

Lithotomy — Low, Standard, and Exaggerated​

Lithotomy is the position most often linked to lower-extremity positioning injury in urologic surgery. The three variants are usually described by hip and knee angle. Use only the elevation, flexion and abduction the operation requires.

VariantHip flexion (typical)Typical use
Low lithotomyabout 40–60°Cystoscopy, TURP, robotic pelvic surgery with leg access
Standard lithotomyabout 80–100°Vaginal surgery, slings, perineal urethroplasty
Exaggerated (high) lithotomyabout 110–140°Posterior urethroplasty, combined abdominoperineal cases

Move both legs slowly and together, and use symmetric, properly fitted supports. Keep the ankle and knee in line with the contralateral shoulder, protect the fibular head, and avoid forced hip rotation, excessive hip flexion with an extended knee, and concentrated calf or popliteal pressure.[1][2]

Nerve injury​

In a prospective study of 991 adults in lithotomy, 15 (1.5%; 95% CI 0.8–2.5%) developed a lower-extremity neuropathy. The nerves involved were the obturator (5 patients), lateral femoral cutaneous (4), sciatic (3) and common peroneal (3). Nearly all had paresthesia rather than weakness, symptoms were noted within 4 hours of the end of anesthesia, and 14 of 15 resolved within 6 months. Longer time in lithotomy, especially beyond 2 hours, was the main risk factor.[7] Much of that series was gynecologic and general surgery, so extrapolate cautiously to long reconstructive cases.

NerveUsual mechanismPresentation
Common peronealCompression against the fibular head by a stirrup post or strapFoot drop, dorsal foot numbness
FemoralExcess hip flexion or abduction; retractor blades on the psoasQuadriceps weakness, saphenous sensory loss
SciaticHip flexion with knee extension (hamstring stretch)Posterior leg and foot deficits
ObturatorExtreme hip abduction; obturator fossa retractionMedial thigh sensory loss, adductor weakness
Lateral femoral cutaneousCompression near the ASIS or groin flexionLateral thigh paresthesia (meralgia paresthetica)
SaphenousPressure at the medial tibial plateau from leg supportsMedial leg and foot paresthesia

Nerve injury may arise from positioning or surgical retraction. New foot drop, quadriceps weakness or sensory loss needs examination and localization.

Well-Leg Compartment Syndrome (WLCS)​

Elevating the legs, external compression and impaired perfusion can produce compartment syndrome in a previously uninjured leg. Each 2.5 cm of height above the heart lowers calf mean arterial pressure by about 2 mmHg, and lithotomy lowers lower-extremity pressure slightly more than the height gradient alone predicts.[3][8]

Incidence. Estimates vary widely with the operation and the method of ascertainment. A postal survey of 261 UK consultant urologists reported 65 cases, 51 after cystectomy with diversion, an estimated 1 in 500 after cystectomy, and rarity in procedures shorter than 4 hours. Risk factors were blood loss, peripheral vascular disease and obesity.[9] The 2019 multidisciplinary guideline quotes roughly 1 in 3,500 for abdominopelvic surgery in lithotomy; it describes obesity and peripheral vascular disease as possible risk factors, while noting that increased risk in younger pelvic-surgery patients is unproven.[3] These come from surveys and case series, so treat them as approximations.

Time limit. The guideline recommends minimizing elevation, not exceeding 4 hours of uninterrupted elevation above the heart, followed by at least 15 minutes at or below heart level. Plan earlier changes when feasible. If a step of the operation prevents lowering, document the reason and lower as soon as it is safe.[3]

Mitigation.

  • Use lithotomy only for the part of the operation that needs it. Do the abdominal or supine portions first, or reposition, rather than holding the legs up throughout.[8]
  • Keep hip and knee flexion and leg elevation to what is needed, and avoid combining maximal elevation with steep tilt when access allows. Correct intraoperative hypotension where possible and optimize fluids to avoid both excess administration and inadequate tissue perfusion.[3]
  • No leg-support design has been proved to eliminate WLCS. In the guideline's review, ankle slings were acceptable for short procedures (under about 30 minutes), while Allen-type stirrups and knee supports raised compartment pressures when the legs were elevated. Avoid tight calf straps and excessive ankle dorsiflexion.[3]
  • Use indicated, correctly fitted mechanical VTE prophylaxis; a theoretical WLCS risk alone does not justify withholding it, and comparative WLCS outcome data are absent.[3]
Postoperative leg pain can be time-critical

Any new leg pain after pelvic surgery in lithotomy warrants immediate assessment for well-leg compartment syndrome; assess pain on passive toe and ankle movement, tense or tender compartments, motor and sensory function, and distal perfusion.[3] About half of patients report leg pain on waking, and more than 99% do so within 24 hours. Normal pulses do not exclude it. Obtain immediate orthopedic or vascular help; do not delay treatment for DVT imaging or CK results. A CK above 2,000 U/L is uncommon after surgery and raises concern. If the initial clinical assessment is equivocal, repeat it within 30 minutes. Compartment-pressure measurement may assist when examination is unreliable or uncertainty persists; the guideline treats diastolic pressure minus compartment pressure <30 mmHg in any compartment as an indication for immediate bilateral four-compartment fasciotomy. Clinically likely WLCS also requires emergency open four-compartment fasciotomy, with treatment under way within one hour of diagnosis.[3]

Exaggerated Lithotomy and Rhabdomyolysis​

Prolonged exaggerated lithotomy during urethral reconstruction carries a documented risk of lower-extremity injury.[10][11] In 10 urethroplasty patients, serum CK rose above 1,000 U/L after several hours in exaggerated lithotomy despite minimal muscle dissection, and one had myoglobinuria.[10] In 185 open urethroplasties, 18 (10%) had a position-related lower-extremity complication (compartment syndrome, rhabdomyolysis or neurapraxia), 4 of them severe.[11] Risk rose with stricture length and with the duration of surgery and of lithotomy; procedures under 5 hours carried minimal risk, and stirrup type, height, weight and BMI did not change it. For long penile skin flap repairs, the authors harvested the flap supine and then moved to high lithotomy for the perineal transfer, which virtually eliminated severe complications.[11]

Limit exaggerated lithotomy to the portion of the operation requiring that exposure. The fistula-repair atlas describes approach-specific access; York–Mason is commonly performed prone jackknife.

Prolonged exaggerated lithotomy has been associated with muscle injury.[10] In the 185-patient urethroplasty series, stricture length and time in surgery or high lithotomy were associated with a combined endpoint of compartment syndrome, rhabdomyolysis or neurapraxia; BMI and stirrup type were not associated with that combined endpoint.[11] In a separate national inpatient analysis of major urologic operations, younger age, male sex, diabetes, chronic kidney disease, obesity and bleeding were associated with rhabdomyolysis.[25] Postoperative muscle pain or swelling, oliguria, dark urine or rising creatinine may signal rhabdomyolysis, although symptoms can be absent. In a suspected case, check CK, creatinine and potassium and follow serial CK and potassium; hyperkalemia may require urgent treatment.[23] Early crystalloid resuscitation, titrated to urine output and volume status, is the treatment mainstay; continued escalation during anuria risks volume overload.[23] A 2025 systematic review and meta-analysis of five studies found no significant reduction in acute kidney injury, acute renal failure or dialysis need with urine alkalinization.[20]

Trendelenburg for Robotic Pelvic Surgery​

Robotic prostatectomy, cystectomy and deep pelvic reconstruction are performed head-down, usually with the legs in low lithotomy. Use the smallest tilt and shortest exposure compatible with the operation.

Physiologic effects. Head-down tilt with pneumoperitoneum raises intracranial and intraocular pressure, reduces functional residual capacity and raises airway pressure, and can cause facial, conjunctival and laryngeal edema. Coordinate the need for continued tilt with anesthesia in prolonged cases. Extubation depends on airway assessment and recovery. Maintain an emergency undocking and access plan; see Anesthesia.

Preventing slide. Patient slide is the main mechanical risk. Use a pressure-distributing anti-slide surface or bean-bag that fits the patient and table, and test the position before draping. The ASA advisory recommends avoiding shoulder braces in a steep head-down position; braces concentrate force on the shoulder and can injure the brachial plexus.[1]

Nerve injury in robotic surgery.

StudyDesignFinding
Göksu 2025868 RARP patients, retrospective telephone symptom survey5.6% (49/868) reported postoperative limb pain, weakness or numbness attributed to positioning; only 6/49 sought medical attention; 55% reported upper- and 51% lower-extremity symptoms; higher BMI, operative time and Trendelenburg time in symptom reporters (exploratory ROC cutoffs of BMI 29, operative time 212 min and Trendelenburg time 157 min; AUC 0.58–0.67, without external validation); mean reported recovery about 6.5 months[12]
Koç 2012377 RALP patients on a split-leg table1.3% (5 patients); longer anesthesia-to-emergence time the only risk factor (about 496 vs 366 min); three had features of femoral mononeuropathy[13]
Grossmann 2025RCT, 98 RARP patients, ankle-brace vs shoulder-support fixationPostoperative-day-1 neuropathy in 15% (shoulder support) vs 6.5% (ankle brace), not significant; all but one sensory; none persisted at a median 12 months[14]
Bjøro 2020Systematic review, 11 studies of robotic surgery in lithotomy and steep TrendelenburgIncidence 0.16–10.0%; prolonged operative time, high ASA class, comorbidity and high BMI were risk factors[15]

Grossmann et al. found mainly sensory deficits and no persistent neuropathy at a median 12 months.[14] In Göksu et al.'s retrospective telephone survey, 14 patients reporting lower-limb symptoms also reported weakness, and 3 of 49 patients reporting positional symptoms still reported numbness at 12 months; longer operative and Trendelenburg times and higher BMI were associated with symptom reports.[12] Femoral-pattern symptoms occurred in 3 of 5 injured patients in Koç et al.'s split-leg series, which had no positioning comparator.[13] The small RCT was underpowered to compare fixation methods.

Eyes and Postoperative Visual Loss​

Protect closed eyelids, tape or shield the eyes, and keep all devices clear of the globe. Verify that the head has not shifted and that the eyes remain free of pressure. Visual loss has several possible mechanisms; direct globe compression is particularly relevant to retinal arterial occlusion. Adequate blood pressure and avoidance of anemia are sensible in any long, steeply tilted case.[4]

The ASA 2019 visual-loss advisory concerns prone spine surgery, where prolonged means more than 4 hours and substantial blood loss more than 800 mL. It recommends keeping the head level with or above the heart when possible, in a neutral position, monitoring blood pressure and hemoglobin, checking the eyes periodically, and ophthalmologic assessment when a high-risk patient wakes. It is not a guideline mandating timed returns to level during robotic GU surgery, and GU-specific benefit and an optimal check interval are not established. New visual impairment after any operation requires urgent ophthalmological assessment.[4]

Corneal abrasion is the most common ophthalmic complication of general anesthesia for nonocular surgery.[21][24] It is usually treatable when recognized, but microbial keratitis or permanent scarring can follow.[21][24]

Lateral Decubitus — Flank Position​

Setup. Position the operative side up. Roll the torso and pelvis together. Elevate the kidney rest and flex the table at the level of the iliac crest to open the space between the crest and the 12th rib only as far as exposure requires. Flex the down leg, extend the up leg, and place a pillow or padding between the legs. Support the dependent thorax with a roll caudal to the axilla, not in it, and support both arms without traction.[1][2]

Urologic applications. Open and laparoscopic nephrectomy, adrenalectomy, retroperitoneal lymph node dissection, open pyeloplasty and other flank-approach upper-tract reconstruction.

Main risks.

  • Brachial plexus, up side: traction from an unsupported arm or tape pulling on the shoulder.
  • Brachial plexus, down side: compression from a roll placed in the axilla instead of below it.
  • Common peroneal nerve, down leg: compression between the fibular head and the table; pad the fibular head.
  • Rhabdomyolysis and pressure injury: prolonged focal pressure on the flank, trochanter, knee and lateral malleolus, particularly in obese patients. Pronounced flank pain or swelling after a long case warrants evaluation.
  • Eye and ear: pressure from a bean-bag or head support; check both after turning.
  • Intercostal neurovascular stretch from aggressive flexion.

Prone, Prone Jackknife and Split-Leg Positions​

Setup. Support the chest and pelvis on a frame or bolsters so the abdomen hangs free. Free abdomen preserves ventilation and limits IVC compression. Tuck the arms or place them on padded boards within the patient’s comfortable shoulder range; prone abduction may exceed 90°. Avoid sustained elbow flexion and ulnar-groove pressure when possible.[1] Arrange the head support so that airway security and the absence of globe pressure can be checked.[2][4]

Urologic applications. Classic prone PCNL, prone jackknife for posterior or transanal approaches (York–Mason for rectourethral fistula), and split-leg prone setups for combined transanal and perineal access.

Main risks.

  • Ocular injury: direct pressure on the globe is the feared scenario. Check eye position after every repositioning.
  • Brachial plexus: shoulder abduction beyond 90°.
  • Ulnar neuropathy: elbow compression.
  • Breast and genital pressure: check after positioning and reposition if compressed.
  • Elevated intra-abdominal and airway pressure: from inadequate abdominal free space.

Jackknife adds table flexion at the hip to elevate the buttocks for perineal or transanal access. It adds back and hip ligament strain and lower-extremity venous congestion. Split-leg setups add abduction for combined access and bring lithotomy-type peroneal and femoral risks into the prone position. Both require reassessment of joint range, pressure points and emergency access, and neither removes the risks of a prolonged operation. Reassess after turning or flexing the table.

Supine Variants for PCNL and Combined Access​

The supine Valdivia position was described in 1998 in 557 percutaneous nephroscopies among 463 patients.[16] Its Galdakao modification adds modified lithotomy to allow simultaneous percutaneous and retrograde endoscopic access in a single setup (ECIRS), including when complex stones require both routes.[17]

Setup (as commonly described)​

  • The patient lies supine on a standard table with the ipsilateral flank and shoulder raised about 30° on a wedge or fluid bag.
  • The ipsilateral arm is placed across the chest; the contralateral arm rests on a board.
  • The leg on the puncture side is kept extended and out of the way of the flank, while the contralateral leg is abducted and flexed so the perineum is accessible for flexible ureteroscopy. Exact leg arrangements vary with the table, body habitus, target calyx and planned endoscopy, so confirm leg and arm supports with the operating team before induction.

Advantages and limits​

  • One position for combined antegrade and retrograde work, and easier airway access than prone.
  • A smaller working space for puncture. Retrorenal colon can occur in either position; one CT series found it more often prone than supine.[22] Review preoperative CT for retrorenal or interposed colon, pleura and other organs.
  • Complex upper-pole access is sometimes more ergonomic prone.

Evidence​

In the CROES global registry of 5,803 PCNLs, 4,637 (80.3% of cases with recorded position) were prone.[18] Prone PCNL had a higher stone-free rate (77.0% versus 70.2%) and shorter operative time (82.7 versus 90.1 min) but more transfusion (6.1% versus 4.3%) and fever (11.1% versus 7.6%); the authors concluded the choice should be tailored to the patient and surgeon.[18] In a randomized trial of 112 adults with complex stones, the primary postoperative-day-1 success rates were 62.5% supine versus 57.1% prone; secondary 90-day stone-free rates were 55.4% versus 50.0%.[19] Clavien grade 3 or higher complications occurred in 3.6% versus 14.3%, respectively, in this small trial.[19] The EAU 2026 evidence summary states that prone and supine positions are equally safe with equivalent stone-free rates (LE 1a); it cites meta-analyses in which supine PCNL had a shorter operative time and, in the larger analysis, fewer major complications. Supine positioning allows simultaneous retrograde access with a flexible ureteroscope. Neither position is safer for every obese or cardiopulmonary-limited patient, and prone positioning remains an established option.[5]

Common Positioning Complications — Summary​

ComplicationHighest-risk position(s)Prevention
Ulnar neuropathySupine, tucked arms; any long caseNeutral or supinated forearm; pad the elbow
Brachial plexus injuryLateral (both sides), prone, steep Trendelenburg with bracesRoll caudal to the axilla; avoid shoulder braces in steep head-down; abduction 90° or less
Lower-extremity neuropathy (obturator, LFCN, sciatic, peroneal, femoral)Lithotomy, split-legLeast elevation and flexion needed; pad the fibular head; limit time; avoid retractor pressure on the psoas
Well-leg compartment syndromeProlonged lithotomy, especially with blood loss or obesity4-hour ceiling, then at least 15 minutes level; avoid tight supports; low threshold to assess
RhabdomyolysisLong exaggerated lithotomy, long flank cases in obese patientsLimit time; supine harvest before lithotomy where possible; check CK when suspicious
Postoperative visual loss / corneal injuryProne, prolonged head-downEyes taped and free of pressure; maintain blood pressure; periodic eye checks
Pressure injuryAny long casePad and offload bony prominences; reposition when possible

Preoperative Positioning Plan — Practical Checklist​

  1. Decide the position before induction, using the patient's awake range of motion as the limit.
  2. Estimate case duration. For pelvic surgery in lithotomy, flag WLCS in the team brief and time-out; agree when to lower or reposition the legs, and document leg-elevation and recovery intervals.[3]
  3. Confirm the operative side at the time-out.
  4. Pad every bony prominence, and confirm nothing presses on the fibular head.
  5. Place the roll caudal to the axilla in lateral decubitus.
  6. Tuck arms with neutral or supinated forearms; keep abduction to 90° or less.
  7. Protect the eyes; verify no globe pressure in prone and head-down cases.
  8. Use an anti-slide surface for steep Trendelenburg and avoid shoulder braces.
  9. Document the position and recheck after draping, after table changes and at intervals suited to the case.
  10. Once the patient can participate in recovery, assess motor and sensory function and repeat on the ward.[1] Also check for tense swelling or visual change.[3][4]

Postoperative Check and Handover​

Record the position, supports, prolonged elevation or tilt, changes made and any intraoperative concern. Assess new motor or sensory deficits and skin injury when the patient can participate. Severe pain, rapidly progressive weakness, tense swelling or visual change needs urgent evaluation. Compartment syndrome, neuraxial complications and direct surgical injury must not be mislabeled as routine positional neuropraxia.

References​

1. American Society of Anesthesiologists Task Force. “Practice Advisory for the Prevention of Perioperative Peripheral Neuropathies 2018.” Anesthesiology. 2018;128:11–26. doi:10.1097/ALN.0000000000001937.

2. American Urological Association. “Optimizing Outcomes in Urologic Surgery: Intraoperative Considerations.” 2018. White paper, section on preventing falls/positioning injuries. AUA primary document.

3. Gill M, Fligelstone L, Keating J, et al. “Avoiding, Diagnosing and Treating Well Leg Compartment Syndrome After Pelvic Surgery.” Br J Surg. 2019;106:1156–1166. doi:10.1002/bjs.11177.

4. American Society of Anesthesiologists Task Force, North American Neuro-Ophthalmology Society, and Society for Neuroscience in Anesthesiology and Critical Care. “Practice Advisory for Perioperative Visual Loss Associated with Spine Surgery 2019.” Anesthesiology. 2019;130:12–30. doi:10.1097/ALN.0000000000002503.

5. European Association of Urology. “EAU Guidelines on Urolithiasis.” 2026 (limited update, March 2026). Section 3.4.7, PCNL: positioning and 3.4.7.a summary of evidence. EAU guideline.

6. Warner MA, Warner ME, Martin JT. Ulnar neuropathy. Incidence, outcome, and risk factors in sedated or anesthetized patients. Anesthesiology. 1994;81(6):1332-40. doi:10.1097/00000542-199412000-00006. PMID 7992900

7. Warner MA, Warner DO, Harper CM, et al. Lower extremity neuropathies associated with lithotomy positions. Anesthesiology. 2000;93(4):938-42. doi:10.1097/00000542-200010000-00010

8. Halliwill JR, Hewitt SA, Joyner MJ, et al. Effect of various lithotomy positions on lower-extremity blood pressure. Anesthesiology. 1998;89(6):1373-6. doi:10.1097/00000542-199812000-00014

9. Simms MS, Terry TR. Well leg compartment syndrome after pelvic and perineal surgery in the lithotomy position. Postgrad Med J. 2005;81(958):534-6. doi:10.1136/pgmj.2004.030965

10. Bildsten SA, Dmochowski RR, Spindel MR, et al. The risk of rhabdomyolysis and acute renal failure with the patient in the exaggerated lithotomy position. J Urol. 1994;152(6 Pt 1):1970-2. doi:10.1016/s0022-5347(17)32281-4

11. Anema JG, Morey AF, McAninch JW, et al. Complications related to the high lithotomy position during urethral reconstruction. J Urol. 2000;164(2):360-3. doi:10.1016/s0022-5347(05)67360-0. PMID 10893585

12. Göksu Ş, Karaören G, Tahra A, et al. Risk Factors of Positional Peripheral Nerve Injury in Robotic Laparoscopic Radical Prostatectomy. JSLS. 2025;29(3):. doi:10.4293/JSLS.2025.00031

13. Koç G, Tazeh NN, Joudi FN, et al. Lower extremity neuropathies after robot-assisted laparoscopic prostatectomy on a split-leg table. J Endourol. 2012;26(8):1026-9. doi:10.1089/end.2011.0653

14. Grossmann NC, Aschwanden FJ, Cornelius J, et al. Impact of patient positioning during surgery on neuropathies after robot-assisted laparoscopic radical prostatectomy: a randomised controlled trial. BJU Int. 2025;135(5):802-809. doi:10.1111/bju.16623

15. Bjøro B, Mykkeltveit I, Rustøen T, et al. Intraoperative peripheral nerve injury related to lithotomy positioning with steep Trendelenburg in patients undergoing robotic-assisted laparoscopic surgery - A systematic review. J Adv Nurs. 2020;76(2):490-503. doi:10.1111/jan.14271

16. Valdivia Uría JG, Valle Gerhold J, López López JA, et al. Technique and complications of percutaneous nephroscopy: experience with 557 patients in the supine position. J Urol. 1998;160(6 Pt 1):1975-8. doi:10.1016/s0022-5347(01)62217-1

17. Ibarluzea G, Scoffone CM, Cracco CM, et al. Supine Valdivia and modified lithotomy position for simultaneous anterograde and retrograde endourological access. BJU Int. 2007;100(1):233-6. doi:10.1111/j.1464-410X.2007.06960.x

18. Valdivia JG, Scarpa RM, Duvdevani M, 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):1619-25. doi:10.1089/end.2011.0110

19. Perrella R, Vicentini FC, Paro ED, et al. Supine versus Prone Percutaneous Nephrolithotomy for Complex Stones: A Multicenter Randomized Controlled Trial. J Urol. 2022;207(3):647-656. doi:10.1097/JU.0000000000002291

20. The Role of Urine Alkalinization in Preventing Rhabdomyolysis-Induced Acute Kidney Injury and Need for Dialysis: A Systematic Review and Meta-Analysis. Bull Emerg Trauma. 2025;13(4):195-202. doi:10.30476/beat.2025.107657.1618

21. Singh RB, Khera T, Ly V, et al. Ocular complications of perioperative anesthesia: a review. Graefes Arch Clin Exp Ophthalmol. 2021;259(8):2069-2083. doi:10.1007/s00417-021-05119-x

22. Hopper KD, Sherman JL, Luethke JM, Ghaed N. "The retrorenal colon in the supine and prone patient." Radiology. 1987;162(2):443-446. doi:10.1148/radiology.162.2.3797658

23. Kodadek L, Carmichael SP II, Seshadri A, et al. "Rhabdomyolysis: An American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document." Trauma Surg Acute Care Open. 2022;7(1):e000836. doi:10.1136/tsaco-2021-000836

24. Grixti A, Sadri M, Watts MT. "Corneal protection during general anesthesia for nonocular surgery." Ocul Surf. 2013;11(2):109-118. doi:10.1016/j.jtos.2012.10.003

25. Pariser JJ, Pearce SM, Patel SG, et al. "Rhabdomyolysis After Major Urologic Surgery: Epidemiology, Risk Factors, and Outcomes." Urology. 2015;85(6):1328-1332. doi:10.1016/j.urology.2015.03.018

26. Pulos BP, Johnson RL, Laughlin RS, et al. "Perioperative Ulnar Neuropathy: A Contemporary Estimate of Incidence and Risk Factors." Anesth Analg. 2021;132(5):1429-1437. doi:10.1213/ANE.0000000000005407