Open surgery is dead, long live endourology: is it always true? (Re: comparative analyses of percutaneous nephrolithotomy versus open surgery in pediatric urinary stone disease)

Abstract

We read with great interest the recent article by Bayrak et al. [1] on the comparative study of open surgery and percutaneous nephrolithotomy (PNL) for the management of pediatric kidney stones. In this article, authors compared the groups according to the stone surface area, stone-free rates, hospitalization time, blood transfusion rates and the D-J implantation rates. They concluded that PNL supersedes open surgery in terms of the use of advanced instruments and technological developments for modern pediatric surgery. Renal stones are not common in children, but they are often associated with metabolic disturbances, anatomical abnormalities or infectious diseases. Such events lead to high-risk of stone recurrence [2]. So minimally invasive procedures are very important in this age group patients [3]. Currently, the three minimally invasive techniques are available for renal stones in children: shock wave lithotripsy (SWL), PNL and retrograde intrarenal surgery (RIRS). Majority of renal stones can be managed successfully with these techniques. However, open surgery is still needed in some difficult cases. The European Association of Urology, 2012 guidelines state clearly that the indications of open surgery includes: failure of primary therapy, very young children with complex stones, severe congenital deformities, which limit positioning of endoscopic procedures, abnormal kidney position and congenital malformation requiring simultaneous surgical correction [4]. In the article, the authors concluded the significant advantages of the PNL procedure in terms of reduced hospital stay, requirement of a minimal incision and lower requirement of a secondary process [1]. However, in differents series major complications have been identified as a result of PNL with a rate of 0.03 to 10 % [5, 6]. A viable alternative in this population is RIRS, which may be performed at single or multiple stages depending on stone location and size [7]. In a recent multi-institutional study, Resorlu et al. [3] examined their experience with mini-PNL and RIRS for 1 to 3 cm renal stones in children by evaluating stone-free rates and associated complications . They demonstrated that RIRS is an effective alternative to mini-PNL in children and operation time, hospital stay, radiation exposure and, morbidities of PNL can be significantly reduced with this technique. But also they concluded that mini-PNL continues to be the best choice traetment modality for stones larger than 2 cm in size because of its more effective nature.