To the Editor: We present our experience of the anesthetic management of patients in the rarely used prone lithotomy position (Figure). During surgery, the prone position, if correctly applied, ensures free abdominal movement, is not associated with adverse effects on respiratory mechanics and improves lung volume and oxygenation.1,2 The lithotomy position, when superimposed on the prone position, improves cardiac output and hemodynamics, compensating for the decreased cardiac output due to impaired venous return in the prone position.3 Repair of a vesico-vaginal fistula under balanced anesthesia was performed in the prone lithotomy position in three ASA physical status I and II patients. In all cases, non-invasive blood pressure, central venous presure (CVP), ECG, airway pressure, end tidal carbon dioxide and oxygen saturation were monitored and changes in hemodynamic and respiratory variables were recorded. After the change of position to prone lithotomy, all variables remained stable except for a rise in airway pressure in the range of +1 to +2 cm H2O in one patient but without change in end tidal carbon dioxide tension and oxygen saturation. Another patient had a moderate rise of CVP (+2 to +5 cm H2O). Peripheral nerve injury did not occur in any of the patients. The variables returned to baseline levels after patients were placed in the supine position after surgery, before extubation. On the basis of the experience gained during these three cases, we suggest that surgery in the prone lithotomy position is not associated with major cardiovascular or respiratory derangements intraoperatively.