Management Of Pediatric Urolithiasis Research Articles

Clinical patterns and implications of prescription opioid use in a pediatric population for the management of urolithiasis in the emergency room.

Extrapolations from the adult population have suggested that opioids should be avoided in the management of pediatric urolithiasis, but the literature is sparse with regards to actual practice patterns and the downstream implications. We sought to investigate the rate of oral opioid administration for children presenting to the emergency room (ER) with urolithiasis and to identify associations between opioid administration and return visits and persistent opioid use. The TriNetX Research and Diamond Networks were used for retrospective exploratory and validation analyses, respectively. Patients <18 years presenting to the emergency room with urolithiasis were stratified by the receipt of oral opioids. Propensity score matching was performed in a 1:1 fashion. Incident cases of opioid administration and risk ratios (RRs) for a return ER visit within 14 days and the presence of an opioid prescription at 6 to 12 months were calculated. Of the 4672 patients in the exploratory cohort, 11.9% were prescribed oral opioids. Matching yielded a total of 1084 patients. Opioids at the index visit were associated with an increased risk of return visits (RR 1.51, 95% CI 1.04-2.20, P = 0.03) and persistent opioid use (RR 4.00, 95% CI 2.20-7.26, P < 0.001). The validation cohort included 6524 patients, of whom 5.7% were prescribed oral opioids. Matching yielded a total of 722 patients and demonstrated that opioids were associated with an increased risk of return visits (RR 1.50, 95% CI 1.04-2.16, P = 0.03) but not persistent opioid use (RR 1.70, 95% CI 0.79-3.67, P = 0.17). We find that the opioid administration rate for pediatric urolithiasis appears reassuringly low and that opioids are associated with a greater risk of return visits and persistent use.

Scoping review of recent evidence on the management of pediatric urolithiasis: summary of meta-analyses, systematic reviews and relevant randomized controlled trials.

This scoping review aimed to evaluate and summarize the recent 10year pediatric urolithiasis literature with a particular focus on systematic reviews, randomized-controlled trials (RCT) and meta-analysis. The systematic literature search performed on September 1, 2021, restricted to the recent 10years, focused on pediatric urolithiasis that are RCTs, meta-analysis and systematic reviews. The summarized literature included etiology, diagnostics, medical and surgical management. GRADE criteria are used to evaluate and standardize the reporting of evidence quality. A total of 33 relevant articles were included. The recent high-level studies included topics of genetic and diet association with pediatric stone formation, diagnostic assessment, medical management intervention including medical dissolution and expulsion therapy. The study extended to include the efficacy and safety of extracorporeal lithotripsy, percutaneous nephrolithotomy and retrograde intrarenal surgery. However, evidence quality was ranked "very-low" or "low". Based on the GRADE criteria downgrading of the quality level was due to heterogeneity and low precision. A majority of the RCTs were categorized as having a "high" to "uncertain" risk of bias. The relevant RCTs, meta-analyses and systematic reviews within the past decade are of low quality. Consequently, the research provided no clear evidence-based recommendations for managing pediatric urolithiasis. More rigorous research and high-quality studies are needed to determine the best practices.

Osteogenezis imperfekta tanılı pediatrik hastada ultra-mini perkütan nefrolitotomi

Osteogenesis imperfecta (OI) is a rare, inherited disease group with genetic and clinical diversity. There is a defect in the type 1 collagen structure. Increasing bone fragility, osteopenia, and skeletal deformities can be seen. Surgical applications in patients with OI may cause complications such as spinous process injury in vertebrates or bone fracture. Therefore, in the management of pediatric urolithiasis, the decision of surgery should be carefully considered, and safe techniques that shorten the procedure time should be preferred. Percutaneous nephrolithotomy (PCNL) operation is the first choice for large kidney stones in adult patients. Along with the technological advances, more minimally invasive approaches such as mini-PCNL, ultra-mini-PCNL, and micro-PCNL have been developed, and these methods are safely used in pediatric patients due to their low morbidity. Because of its potential risks, urinary stone surgery in OI patients has rarely been reported in the literature. This study presents a 4-year-4-month-old girl with OI and kidney stone, whom we performed ultra-mini-PCNL. Keywords: endourology, urolithiasis, pediatric urology, ultra mini pcnl

Rigid and flexible ureteroscopy (URS/RIRS) management of paediatric urolithiasis in a not endemic country.

In the last years due to miniaturization of endoscopic instruments and percutaneous surgery, endourology has become very popular in paediatric urinary stone managment. We reported our single-centre experience in retrograde endoscopic procedures in children. Results and complications of URS/RIRS are discussed. We retrospectively reviewed our experience in patients ≤ 16 years old affected by urinary stones who underwent URS/RIRS procedures performed by two surgeons with expertise in endourology. A total of 30 renal Units (RUs) underwent endoscopic procedures (URS, RIRS or both). Surgical complications according to the ClavienDindo's classification and stone-free rate were evaluated at 3 months follow-up. Success of URS was defined as stone-free status after single procedure while RIRS success rate was considered as presence of residual stone fragments smaller than 4 mm at first procedure. The mean age of our patients was 8 years, range 2- 16 years. A total of 30 renal units (RUs) underwent 40 endourological procedures (23 URS and 17 RIRS; 10 children underwent both procedures at the same time). 17/30 (56.6%) RUs were pre-stented before surgery. The stone-free status was achieved in 23/30 renal units treated, with a 76.6% success rate. The remaining 7 patients had residual stones greater than 4 mm and underwent further treatments. After a second surgery the stone-free rate turned out to be 93.3% (28/30 renal units). Rigid and flexible ureteroscopy (URS/RIRS) is a reliable technique for treatment of < 2 cm urinary stones in paediatric age group. It shows low rate of major complications and promising results in terms of stone-free rate.

Minimally Invasive Approaches in Pediatric Urolithiasis. The Experience of Two Italian Centers of Pediatric Surgery.

Background: Over the last 30 years, the incidence of pediatric urolithiasis (PU) has been increasing and the surgical management has evolved toward a minimally invasive approach (MIA). We reported the experience of two Centers of Pediatric Surgery in the management of PU, focusing on MIA as first choice in treatment.Methods: Data were retrospectively analyzed from October 2009 to October 2019 in children with urolithiasis who were admitted to two referral Italian Centers of Pediatric Surgery. Demographic and clinical data of the patients, features of the urolithiasis, type of surgery were considered.Results: Seventy patients (7.3 ± 5.0 years) with normal renal function were treated for calculi in the pyelocaliceal system (45.7%), ureter (34.3%), bladder (4.3%), urethra (1.4%), and multiple locations (14.3%). Size of calculi was >10 mm in 55.7% of cases (kidney>bladder/urethra>multiple>ureter, p = 0.01). Symptoms were present in 75.7% of patients. Family history was positive in 16.9% of cases. MIA was performed in 59 patients (84.3%): 11.8% shockwave lithotripsy (kidney>ureter>multiple); 32.2% ureteral retrograde surgery (ureteral>other localizations); 30.5% retrograde intrarenal surgery (kidney>other localizations); and 25.4% other procedures including percutaneous nephrolithotomy, cystoscopic bladder stone removal or laser cystolithotripsy (kidney>bladder>multiple). Preoperative stenting was necessary in 52.8% of cases. Four MIA procedures (6.9%, kidney>ureter/multiple) were converted to open surgery. Open surgery was required as first approach in 15.7% of patients (kidney>ureter>multiple) who needed urgent surgery or had associated congenital renal anomalies. In 18/70 of children (25.7%), with prevalence of stones in kidney and multiple location (p < 0.01), a second procedure completed the treatment (88.8% MIA). Intraoperative difficulties were recorded in 8.5% of cases, without difference between location and size of calculi. Late complications (5.7%) were related to displacement and infection of the ureteral stent.Conclusions: MIA resulted to be feasible in more than 75% of primary surgery and in more than 85% of cases requiring a second procedure. Preoperative stent was mandatory in more than 50% of children. The technological evolution allowed to overcome many of the technical difficulties related to the approach to the papilla and lower calyxes. Open surgery is reserved for selected cases and endoscopic surgery represents the best choice of treatment for PU.

Management of Pediatric Urolithiasis

Urolithiasis, the formation or presence of calculi in the urinary tract, is a broad term covering a multifaceted disease process with wide-ranging clinical and economic implications. Stones, often originating in the renal papillae, may be found from the renal parenchyma through the renal pelvis, ureter, or bladder. Stones can be composed of a multitude of molecules either in pure form or mixtures of several compounds. Historically considered a disease of adults, the prevalence of stones has increased among children. This review highlights pathophysiology of urolithiasis, common clinical presentations, work-up, and surgical and medical management of this increasingly common pediatric condition. The authors review the chemical pathways by which stones form, common stone types, common operative techniques, and epidemiology. This review contains 4 tables, and 59 references. Key Words: extracorporeal shockwave lithotripsy, kidney stones, lithotripsy, nephrolithiasis, percutaneous nephrolithotomy, pediatrics, renal calculi, ureteroscopy, urolithiasis

PT336 - Diagnosis and management of paediatric urolithiasis: A contemporary review and update on behalf of the EAU Urolithiasis Guidelines Panel

PT336 - Diagnosis and management of paediatric urolithiasis: A contemporary review and update on behalf of the EAU Urolithiasis Guidelines Panel

Management of Pediatric Urolithiasis Using a Combination of Laparoscopic Lithotomy and Pyeloscopy.

Minimally invasive procedures have become the standard option for treatment of urinary stones; the use of more invasive techniques is not a common practice currently. This emergent technology is not always available and laparoscopy is the alternative option. There are few reports of laparoscopic management for urinary lithiasis in pediatric patients. This study is about the use of laparoscopic surgery combined with pyeloscopy as a feasible first-line treatment for pediatric urolithiasis in renal and proximal ureteral locations. We reviewed the records of 14 patients with renal and proximal ureteral stones who underwent laparoscopic pyelolithotomy and pyeloscopy in a period from January 2011 to July 2016. The outcome measures were needed for auxiliary procedures, treatment success, and complication rates. A total of 16 procedures were carried out in 14 patients, 15 transperitoneal and 1 retroperitoneal laparoscopic pyelolithotomies were done. It was necessary to perform upper ureterolithotomies to remove ureteral stones in 2 cases. The holmium laser and/or pneumatic lithotripter were used to fragment staghorn calculi. Some of the complications were blood transfusion in 12.5% and self-limited urinary leak in 18.7% of the patients. The success rate after undergoing one procedure was 92.8%. Transperitoneal or retroperitoneal laparoscopic lithotomy is a safe and feasible procedure for the treatment of pediatric urolithiasis. It can be an alternative to shock-wave lithotripsy and percutaneous nephrolithotomy when these are not feasible or possible.

Minimal access surgery in the management of pediatric urolithiasis.

In contrast to adult patients, a relatively large number of open surgical procedures are still needed in the treatment of urolithiasis in children. Since almost all open surgical techniques may be reproduced by minimal access surgery (MAS), there is a rationale to apply the latter in the management of pediatric urolithiasis. Our study aimed to assess the feasibility and outcome of MAS in the treatment of pediatric urinary calculi. The charts of patients with urolithiasis submitted to MAS between 1994 and 2007 were retrospectively reviewed. The inclusion criteria were contraindication for and failure of lithotripsy or endourology techniques. Demographic data, lithiasis characterization (location, dimension, composition), predisposing factors (anatomic or metabolic) and surgical approach (technique and outcome) were evaluated. Fifteen consecutive patients (eight girls, seven boys) with a median age of 108 months (range: 10-297 months) were elected for MAS. Eleven (73%) children had associated urogenital malformations and three (20%) presented metabolic abnormalities. A total of 17 procedures were performed laparoscopically: three nephrolithotomy (one transperitoneal, two by retroperitoneoscopy), four pyelolithotomies (retro), three ureterolithotomy (trans) and seven cystolithotomies (suprapubic approach). Five patients underwent concomitant correction of urological anomalies (three calyceal diverticula, one obstructive megaureter, one ureteropelvic junction obstruction). Complete removal of calculi was accomplished in 14 (82%) procedures. There were two perioperative complications (one intraperitoneal vesical perforation and one perivesical urinoma). At a median follow up of 4 years (range, 1 month to 11 years), four patients have developed recurrence. MAS is an effective and safe approach for urolithiasis in children who are not candidates for minimally invasive modalities.

Outcomes of Ureteroscopic Management of Pediatric Urolithiasis: A Comparative Analysis of Prepubertal and Adolescent Patients

To compare the outcomes of ureteroscopic intervention in terms of both the stone-free rate and complications in both prepubertal and adolescent patients. Although safety of pediatric ureteroscopic intervention is well established, a comparative outcome of prepubertal and adolescent patients is lacking. Pediatric patients who underwent ureteroscopic treatment of a renal or ureteral stone at our institution from July 2005 to August 2014 were retrospectively identified. Patients were classified by age either as prepubertal (≤11 years) or adolescent (>11 years) for purposes of comparison. Demographic and intraoperative variables as well as 30-day postoperative complication rates were compared between groups. Data were analyzed using χ(2) and Fisher's exact tests as appropriate. A total of 104 patients were identified, of whom 64 (62%) were prepubertal and 40 (38%) were adolescent. Ureteroscopic failure occurred in a minority of patients (5% vs 4.7%, P > .9). Complication rates including ureteral perforation (0% vs 1.6%, P > .9), postoperative urinary tract infection (2.5% vs 4.7%, P > .9), hematuria with clot passage (0% vs 7.8%, P = .15), and persistent flank pain (15% vs 17%, P = .85) were not significantly different between adolescent and prepubertal patients, respectively. In spite of small size and small body habitus, the ureteroscopic management of pediatric urolithiasis can be performed successfully in both the prepubertal and adolescent patients with acceptable and equivalent morbidity as well as successful clearance of stone.

Are Adult Ureteroscopes Safe in the Management of Urolithiasis in a Pediatric Population?

Introduction: Debate remains regarding the optimal caliber of ureteroscopes in the management of pediatric urolithiasis, ranging from pediatric scopes to standard scopes. The aim of this study was to assess the safety and efficacy of stone management in a pediatric population using standard adult ureteroscopes. Methods: A retrospective review of all ureteroscopic procedures in patients under the age of 16 years was carried out. Standard adult 7.5 French semi-rigid and 6 French flexible ureteroscopes were used. Results: During the study period, 8 patients underwent 21 ureteroscopic procedures. Two patients had rigid ureteroscopy, seven had flexible ureterorenoscopy and one had a subsequent open procedure. No patients required ureteric dilation. Double J ureteric stents were utilized in 7 patients. There were no complications. All patients required extra corporeal shock wave lithotripsy. Stone clearance was achieved in all patients. Conclusion: Our series demonstrates that, in skilled hands, adult ureteroscopes can be use safely for the treatment of urolithiasis in pediatric patients.

Current role of PCNL in pediatric urolithiasis.

The incidence of pediatric stone disease has been increasing. Though there are geographical variations, there remains a common theme in that this is a high-risk population with regard to stone formation and recurrence. Consequently, it is important to keep the number of procedures performed to a minimum and to save the developing kidney from the deleterious effects of intervention. Of the number of available treatment options, Percutaneous Nephrolithotomy (PCNL) offers a number of distinct advantages albeit with its own set of concerns. In the present article, the current literature on PCNL in pediatric urolithiasis was reviewed by a MEDLINE/PubMed search that was limited to literature in the English language, with emphasis on the current state of art in PCNL. Within the last few years, there have been improvements in radiological techniques, particularly computed tomography (CT), with dedicated reconstructions and development of scoring systems leading to better preoperative planning. Also, there has been miniaturization of instruments, particularly smaller nephroscopes, innovative sheaths and the potential to use lasers as well as smaller pneumatic and ultrasound probes. The combination of these has led to various modifications, such as miniperc, microperc and ultra-mini perc techniques. These modifications have been shown to be associated with a decrease in morbidity and high clearance rates. In this article, we analyze the current role of PCNL and its modifications, in terms of the indications, techniques, results, and complications in management of pediatric urolithiasis.

Factors Affecting Complication Rates of Percutaneous Nephrolithotomy in Children: Results of a Multi-Institutional Retrospective Analysis by the Turkish Pediatric Urology Society

We assessed factors affecting complication rates of percutaneous nephrolithotomy in children. We retrospectively evaluated data on 1,205 renal units in 1,157 children treated with percutaneous nephrolithotomy at 16 Turkish centers between 1991 and 2012. Of the patients 28.3% had a history of urolithiasis. Complications were evaluated according to the Satava classification system and modified Clavien grading system. Univariate and multivariate analyses were done to determine predictive factors affecting complication rates. A total of 515 females and 642 males were studied. Mean ± SD patient age was 8.8 ± 4.7 years (range 4 months to 17 years). Mean ± SD stone size, operative time and postoperative hospital stay were 4.09 ± 4.06 cm(2), 93.5 ± 48.6 minutes and 5.1 ± 3.3 days, respectively. Postoperative stone-free rate was 81.6%. A total of 359 complications occurred in 334 renal units (27.7%). Complications were intraoperative in 118 cases and postoperative in 241. While univariate analysis revealed that stone history, positive urine culture, operative time, length of hospitalization, treatment success, punctured calyx and location of the stone significantly affected the complication rates (p <0.05), operative time, sheath size, mid calyceal puncture and partial staghorn formation were the statistically significant parameters affecting complication rates on multivariate logistic regression analysis. Percutaneous nephrolithotomy is the treatment of choice for most renal calculi in children. The technique is effective and safe in children, with a high success rate and a low rate of major complications. The significant factors identified should be considered by clinicians to decrease associated complication rates.

E26 Percutaneous nephrolithotomy (PCNL) in paediatric stones

Abstract Purpose To evaluate the role and outcome of percutaneous nephrolithotomy (PCNL)in the management of paediatric urolithiasis. Material and methods We retrospectively reviewed the records of children who underwent PCNL procedures for renal calculi from 2004 to 2007 A total of 300 children with renal calculi were treated with PCNL. Patient's age at operation ranged from 8 months to 15 years. Patients had pre-operative blood and urine analysis, ultrasonography of kidneys, ureter, bladder and X-ray IVU. A tract was made in the prone position using fluoroscopy and ultrasound. 22 to 26 Fr sheaths with 18.0, 20.5 and 24 Fr nephroscopes were used accordingly. Ultrasound and pneumatic lithoclast alone or in combination were used for stone fragmentation. Results 300 PCNL procedures were performed. Stone burden ranged from 3.1 ± 3.7 cm2 (simple 2.1 ± 1.5 cm2, complex 5.0 ± 8.8 cm2) with stone clearance rates of 92% and 78% in simple and complex stones respectively. During the procedure mean Hb drop was 1.36 ± 0.8 gm% while 26 (14.6%) patients required blood transfusion. Intra and post operative complications included excessive bleeding, and conversion to open surgery in 8, extravasation of fluid in 11 and 5 cases with urinary sepsis. Conclusions Percutaneous nephrolithotomy is a suitable and safe procedure in children including the pre-school age group for both simple and complex stones.

Minimally invasive approaches and their efficacy in pediatric urolithiasis.

We compared the frequency of usage and success of minimally invasive approaches in the management of pediatric urolithiasis in our clinic. Data from pediatric patients (≤16 years of age) who had undergone percutaneous nephrolithotomy (PNL), ureterorenoscopy (URS), and extracorporeal shock wave lithotripsy (ESWL) between January 2001 and December 2011 were retrospectively investigated. In this study, 415 pediatric patients, who were treated for 291 renal, and 124 ureteral stones, were evaluated. The patients were treated with PNL (n=148; 82 boys, 66 girls), URS (n=99; 58 boys, and 41 girls) or ESWL (n=168; 91 boys, and 77 girls). The mean patient ages were 7.3 (1-16), 9.1 (1-16), and 8.8 (1-16) years in the PNL, URS, and ESWL groups, respectively. The stone-free rates after treatment with PNL, URS, and ESWL were 77, 83.8 and 88.7%, respectively. It is important that selected therapies are properly planned, and the use of minimally invasive approaches is important in pediatric patients due to potentially high recurrence rates. Currently, ESWL, PNL and URS are performed with high success rates for the treatment of stones, and open surgery is rarely used due to the success obtained with minimally invasive approaches.

Calcolosi Reno-ureterale Nella Sindrome di V.A.C.T.E.R.L. Risoluzione Endourologica

The endourological technique is a safe and effective approach in the treatment of large stones in the pediatric population with congenital malformations. The VACTERL association is a group of congenital malformations that include vertebral defects, anal atresia, cardiac defects, tracheoesophageal fistula with atresia, renal defects, and radial upper limb dysplasia. Renal anomalies are found in approximately 90% of patients. We present a case of a 7-year-old girl with VACTERL association and cloacal malformations, undergoing multiple surgeries with subsequent Mitrofanoff continent appendico-vesicostomy. She presented at our attention for centimetric left ureteral and inferior pyelo-calyceal stones. She underwent flexible ureteroscopy with laser lithotripsy of both stones. A ureteral catheter and a nephrostomy tube have been left at the end of the procedure. The ureteral catheter was removed in the 2nd post-operative day, the tubes were removed after a nephrostogram in the 8th post-operative day. The patient is stone-free. No complications were observed in the post-operative time. Endoscopy is the method of choice for the management of pediatric urolithiasis with complex renal calculi, due to its low incidence of major complications and a high stone-free rate.

Percutaneous Nephrolithotomy in Children with Cystine Stone: Long-Term Outcomes from a Single Institution

We determined the effectiveness of percutaneous nephrolithotomy in children with cystine stones and present the long-term outcomes. We reviewed the data of 65 renal units in 51 children who underwent percutaneous nephrolithotomy for cystine stones between 2000 and 2012. Of the patients 19 (37%) had undergone ipsilateral renal surgery and 11 (22%) had undergone extracorporeal shock wave lithotripsy. Children were designated as being stone-free or having residual stone (any evidence of persistent stone fragments irrespective of size). Medical treatment with α-mercaptopropionylglycine, potassium citrate or potassium sodium hydrogen citrate was recommended for all patients after stone analysis. Median stone burden was 3.3 cm(2) (range 1 to 13) and median patient age was 6 years (1 to 17). Stone-free status was achieved in 41 renal units (63.1%). Stone-free status was increased to 73.8% with additional endoscopic procedures. The remaining patients with residual stones were followed. Complication rate was 15.4%. A total of 35 children (68.6%) receiving regular medical treatment were followed for a median of 95 months (range 6 to 136). The recurrence rate for children achieving stone-free status was 31.2%, and the regrowth rate for children with residual stones was 29.4%. Percutaneous nephrolithotomy is a safe and effective treatment for children with cystine stones. Our high recurrence and regrowth rates emphasize that our treatment schedule is inadequate to prevent recurrent cystine calculi. Additional investigation is needed to determine the optimal medical therapy for preventing recurrence and regrowth of cystine stones.

What changed in the management of pediatric stones after the introduction of minimally invasive procedures? A single-center experience over 24 years

ObjectiveTo assess the impact of new technology on the management of pediatric urolithiasis by analyzing our local practice over the past 24 years, and determining the role of open surgery at the present time. MethodsWe retrospectively reviewed the charts of 768 children (783 procedures) who underwent surgical treatment for urolithiasis between June 1987 and October 2010. Data were analyzed with respect to patient characteristics and changing patterns of treatment with time. We compared the type of procedures performed between four time periods: the first was before ESWL, the second was after the introduction of ESWL, the third was after introduction of PCNL, and the fourth was our experienced period with a pediatric urologist. ResultsThe mean age of the children was 7.50 years (range 9 months–17 years). There were 495 renal, 228 ureteral, 21 bladder, 11 urethral stones, and the remaining 13 had stones in multiple locations. Of the 783 procedures performed, 75.9% were open surgery during the first period (1987–1992), 29.7% during the second period (1993–1998), 6.1% during the third period (1999–2004) and 0.2% during the fourth period (2005–2010). The number of children who underwent urinary stone treatment increased significantly (p = 0.001) and the age of the children at the time of surgery decreased (9.09–6.08 years) (p = 0.001) with time. ConclusionThe majority of stones in children can be managed using endourological procedures. Additionally, technological advances and improved surgical skills have greatly reduced the number of children requiring open surgery, which is mainly used for those with complex urinary calculi presenting with anatomic abnormalities. Minimally invasive techniques allow us to treat stones at an earlier age.

Pediatric percutaneous nephrolithotomy using adult sized instruments: our experience.

To evaluate the safety and efficacy of pediatric percutaneous nephrolithotomy (PCNL) using adult sized instruments in the management of pediatric urolithiasis. We retrospectively reviewed the medical records of 38 children younger than 15 years who had undergone 45 PCNLs with adult sized instruments in our center between August 2007 and February 2010. There were 26 boys and 12 girls, with a mean age of 8.4 ± 4.24 years (range, 12 months to 13 years). Twelve patients had complete staghorn stone. Mean stone burden was 2.93 ± 0.89 cm. The tract was dilated between 26 and 30F. Standard PCNL was performed in 8 patients and tubeless PCNL in the next 37 subjects. Simultaneous transurethral lithotripsy was done in 9 patients. Stone clearance rate was 67%. Mean pre and postoperative hemoglobin levels were 12.67 ± 1.7 and 11.39 ± 1.6 g/dL, respectively. Mean hospitalization was 3.5 ± 1.1 days. Eight subjects had postoperative fever beyond day 1. Blood transfusion was required in only one patient. In one patient (3 years old) with a staghorn stone, hyponatremia and seizure occurred, which were treated conservatively without any adverse sequela. There was a significant difference in hospital stay between tubeless and standard PCNL groups (P < .02). We concluded that PCNL using adult sized instruments was relatively safe in children, with a clearance rate of 67%. We suggest prospective randomized studies to compare mini-perc and adult sized instruments use in pediatric PCNL.

Ureteroscopy: The standard of care in the management of upper tract urolithiasis in children

ObjectivesAdvances in technology and the continued evolution in the design of ureteroscopes now permit a primary endoscopic approach to the upper urinary tract of pediatric patients on a routine basis to treat a diverse group of conditions that include urolithiasis, hematuria and strictures. The purpose of this review article is to demonstrate that ureteroscopic lithotripsy is now to be considered the standard of care in the management of upper tract urolithiasis in the pediatric patient, replacing shockwave lithotripsy (ESWL) as the first line of therapy. Additionally, the article will discuss the available endoscopic equipment and the lessons learned over the years to optimize the success of these procedures in children.Materials and MethodsA systematic review of articles written about ureteroscopy (URS) in the contemporary urological literature (1990-2009) on PubMed was undertaken. The success rates and complications of pediatric ureteroscopic procedures were abstracted from the identified publications and the results were tabulated and compared with the success rates of shockwave lithotripsy.ResultsIn over 832 URS cases, there was a 5.9% complication rate and a stone-free rate of 93.4%. The stone-free rates of URS are superior to those obtained with the published success rates with ESWL of 80.3% in 1,839 cases.ConclusionsThe safety and outcomes of ureteroscopic lithotripsy in the management of pediatric urolithiasis now justify that this treatment modality be considered the standard of care and first line of therapy in the management of children who present with upper tract stones.