Nephrolithotomy In Pediatric Patients Research Articles

Safety of Supracostal Percutaneous Nephrolithotomy in Paediatric Population: A Single Centre Experience

Objective
 The objective of this study is assessment of safety and efficacy of supracostal mini percutaneous nephrolithotomy in pediatric patients.
 Methodology
 This is prospective study of patients whose kidney stones were treated with mini percutaneous nephrolithotomy through supracostal approach between February 2019 and Dec 2020.These patients were selected for supracostal puncture based on preoperative ultrasound and CT KUB findings and peroperative assessment of stone burden, stone location and anatomy of pelvicalyceal system.
 Results
 Of 80 patients 72(90%) were treated with only one supracostal puncture while additional 2nd puncture was used for 8(10%) patients. Overall stone clearance is 85% only with percutaneous nephrolithotomy and the stone clearance has reached to 95% with ancillary procedures.13% of patient had hydrothorax , 3.75% had urosepsis, 2.75% had bleeding and 1.25 % had perinephric fluid collection.
 Conclusion
 This study concludes that the safety and efficacy of supracostal percutaneous nephrolithotomy is same as subcostal pcnl if surgical boundaries are not violated.

Efficacy and Safety of Supracostal Access for Mini Percutaneous Nephrolithotomy in Pediatric Patients

To evaluate the efficacy and safety of supracostal percutaneous nephrolithotomy (PCNL) through the 11th intercostal space and compare it with subcostal PCNL in children with renal calculi. Children with renal calculi who underwent PCNL between January 2010 and December 2017 were divided into 2 groups: supracostal PCNL (group 1) and subcostal PCNL (group 2). Stone location, stone burden, location of the access points, operative time, postoperative visual pain score, success rate, hospital stay, and complications according to the modified Clavien classification were compared. Comparison of medians was done using Mann Whitney U test and the means were compared using t test. Group 1 had 50 patients while group 2 had 60 patients. The stone-free rate was 84.0% and 85.0% in groups 1 and 2, respectively after 1 session of PCNL (P=.885). After auxiliary procedures, it increased to 96.0% and 96.6%, respectively (P=.852). The mean fall in hematocrit was 0.9% in group 1 and 1.5% in group 2 (P=.11) whereas the median pain score was 4 in group 1 and 3 in group 2 (P=.37). In all, 54 complications were recorded the commonest among which were grade I (81.5%). Twenty-nine complications were observed in group 1 while 25 complications were observed in group 2 (P=.088). One patient developed nephropleural fistula while another patient developed hydropneumothorax. Both belonged to group 1. Supracostal access for PCNL is an effective and safe alternative to subcostal access for children with renal calculi in terms of stone-free rate and complications.

P060 - Semi-closed-circuit vacuum-assisted mini percutaneous nephrolithotomy in pediatric patients: The initial experience by two tertiary referral centers

P060 - Semi-closed-circuit vacuum-assisted mini percutaneous nephrolithotomy in pediatric patients: The initial experience by two tertiary referral centers

Fluoroscopy-free ultrasonography-guided percutaneous nephrolithotomy in pediatric patients: a single-center experience.

To present the safety and efficacy of fluoroscopy-free ultrasound-guided PCNL for the treatment of renal calculi in pediatric patients of all ages. 30 children with mean age of 5years (6months-12years) underwent totally ultrasound-guided PCNL from March 2013 to August 2016. The pyelocalyceal system was punctured in prone position using only ultrasonography guidance, and the tract was dilated using a single shot dilation technique. No fluoroscopy was used during any of the stages of renal access. The procedure was performed using adult-sized instruments. The mean stone size was 27.1±8.7mm. Mean access time was 4.3±2min. Mean nephroscopic time was 34.6±15.2min. Mean hospital stay of patients was 3days (range 2-5). 21 patients were stone-free after the procedure (70% success rate). Only four patients out of 30 experienced postoperative complications. The results of this study showed that fluoroscopic-free ultrasound-guided PCNL in pediatric patients of all ages is safe, highly efficient, and minimizes potential radiation exposure risks associated with the procedure.

Tubeless versus standard percutaneous nephrolithotomy in pediatric patients: a systematic review and meta-analysis

This systematic review and meta-analysis was designed to evaluate the post-operative outcomes between tubeless and standard percutaneous nephrolithotomy (PCNL) among children. Literature searches were performed following the Cochrane guidelines. We conducted a systematic review and meta-analysis that included three trials investigating the outcomes including the length of hospital stay, operation time, hemoglobin decrease, blood transfusion rate, perirenal fluid presence, post-operative fever, stone clearance rate, and the need for a second operation. The patients who underwent tubeless PCNL had shorter length of hospitalization compared to standard PCNLs (mean difference -1.57, 95% confidence interval -3.2 to 0.07, p = 0.06). No significant decrease was detected in hemoglobin after tubeless PCNL compared to standard PCNL (mean difference 0.05, 95% confidence interval -0.03 to 0.13, p = 0.21). There were no significant differences in operation time (p = 0.7), perirenal fluid presence (p = 0.15), post-operative fever (p = 0.72), stone clearance (p = 0.68), and the need for a second operation (p = 0.90). This study showed no significant difference between tubeless and standard PCNLs in children. However, due to the lack of data, the results should be mentioned prudently. Future randomized trials with more sample sizes and longer follow-ups are warranted.

050 - Supine supercostal percutaneous nephrolithotomy in pediatric patients

050 - Supine supercostal percutaneous nephrolithotomy in pediatric patients

A novel drainage technique during micropercutaneous nephrolithotomy in pediatric patients: double angiocath

Micropercutaneous nephrolithotomy (microperc) is a recently introduced percutaneous nephrolithotomy (PNL) technique that has the smallest tract size. The absence of an amplatz sheath during the microperc technique is a fundamental difference that distinguishes it from all other types of PNL (standard, mini, ultramini). Increasing of the intrarenal pelvic pressure (IPP) was demonstrated by the authors in adult patients but this problem may be even more serious in pediatric patients. Previously, the authors defined the use of a 14 gauge angiocath needle and sheath (microsheath) during microperc surgery for pediatric patient to reduce the IPP. In this novel technique, a second angiocath is used to access the renal collecting system to drain fluid during surgery. This technique is more effective in reducing IPP during microperc, especially in pediatric patients.

Ultrasound-guided micropercutaneous nephrolithotomy in pediatric patients with kidney stones.

To present the outcomes of ultrasound-guided micropercutaneous nephrolithotomy for the treatment of renal stones in pediatric patients. Ultrasound-guided micropercutaneous nephrolithotomy was carried out on 25 pediatric patients from June 2012 to October 2014. Micropercutaneous nephrolithotomy surgery was completed without the use of fluoroscopy in 19 patients. Medical records were retrieved from our institutional database and retrospectively reviewed. Percutaneous puncture was carried out by an "all-seeing needle" in seven patients and by a 14-G intravenous cannula in 18 patients. After entering to the collecting system through an "all-seeing needle" or by Microsheath, the calculus was fragmented using a 273-micron holmium yttrium aluminium garnet laser. After the stone was fragmented to the smallest pieces possible, the operation was terminated. Single access was obtained in all patients using ultrasound guidance. The average age of the patients was 4.12 ± 5.33 years. The mean stone size was 13.45 ± 3.11 mm. The mean operative time was 51.45 ± 30.69 min. The mean duration of hospitalization was 3.18 ± 1.77 days. Treatment success was 92%. Two patients had residual fragments after the procedure; these patients were followed conservatively. A total of three minor complications were observed and all of them were managed conservatively. To our knowledge, this is the first study of ultrasound-guided micropercutaneous nephrolithotomy in the pediatric population. Our findings suggest that micropercutaneous nephrolithotomy can be safely carried out with ultrasound guidance in children by experienced hands, allowing to minimize risks associated with radiation exposure in this patient population.

S065: Percutaneous nephrolithotomy in pediatric patients

S065: Percutaneous nephrolithotomy in pediatric patients

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.

Reliability of Percutaneous Nephrolithotomy in Pediatric Patients: Comparison of Complications With Those in Adults

PurposeTo assess the reliability of percutaneous nephrolithotomy (PNL) in pediatric patients by comparing complications between pediatric patients and adults by use of the modified Clavien grading system.Materials and MethodsThe data of 74 pediatric (0 to 16 years) and 535 adult (17 years and older) patients who underwent PNL owing to kidney stone disease between January 2005 and December 2011 were analyzed retrospectively. The complications in the pediatric and adult patients were classified in five grades according to the modified Clavien system.ResultsThe most frequent cause of grade I complications was fever requiring antipyretics, which was seen in 4 pediatric patients (5.4%) and 30 adult patients (5.6%). Grade II complications (blood transfusions, <12 hours urinary leakage) were observed in 11 pediatric patients (14.8%) and 80 adult patients (14.9%). Grade III complications were also seen in 6 pediatric patients (8.1%) (grade IIIb; D-J catheter implantation under general anesthesia) and 78 adult patients (14.5%) (grade IIIa; D-J catheter implantation and angio-embolization under local anesthesia). There was no statistically significant difference between the two groups in terms of grade I, II, or III complications (p>0.05). Colonic injury occured in one patient (1.3%) in the pediatric group (grade IVa). In the adult group, one patient (0.2%) died as the result of myocardial infarction (grade V).ConclusionsThanks to technological developments and minimalization of the equipment used, when indicated, pediatric patients can be safely treated with PNL with low complication rates similar to those in adult patients.

Re: Efficiency of percutaneous nephrolithotomy in pediatric patients using adult-type instruments

We read the retrospective study comparing the outcomes of percutaneous nephrolithotomy (PCNL) in pediatric patients with great interest [1]. The authors have performed the procedure with 19F, 24F and 30F nephroscopes and 20F– 30F Amplatz sheath in all children. They performed the operations in prone position under fluoroscopy guidance. The study has shown that PCNL in children using adulttype instruments is safe and effective. Since the initial report by Woodside et al. [2], PCNL has come to be accepted as a well-established, minimally invasive procedure in children as well as adults. However, few centers have reported their experiences of PCNL in infants and very young children. PCNL with adult-size instruments may present problems in infants and preschool age children because of small size and mobility of the pediatric kidney, friable renal parenchyma, and the small size of the collecting system [3]. The authors have used the adult sized nephroscopes in this study. It might be well accepted to use single size equipment for all adults but this approach is not realistic for children. Children with a large stone burden and dilated collecting systems are good candidates for adult sized equipment. When the collecting system is not dilated, the instruments used in adults may be more traumatic because of their size. Additionally preschool age children have mobile and small size kidney. In our clinic, we use pediatric sized instruments in preschool children and older children with small stone burden or not dilated collecting system. The radiation exposure is an important concern in pediatric cases. Most of the urologists prefer to establish the access by themselves under fluoroscopy as in this study. We routinely use lead aprons under the child patients located between the X-ray tube and patient, except for abdomen, for radiation protection. We believe and suggest that this prevents the harmful effects of radiation on gonads and vital organs [4]. We think that, with experience, using a gentle technique, avoiding manipulations such as levering the nephroscope, and usage of flexible endoscopes and nitinol basket when necessary are important to increase the stone-free rate in PCNL. Also we believe that a holmium laser and nitinol basket catheter can be used through flexible nephroscope for locations unreachable using the rigid instruments. These manipulations might lower residual stone with higher stone-free rate in pediatric PCNL. Another potential complication of percutaneous nephrolithotomy is hypothermia, especially in this age group. Hypothermia during anesthesia produces potentially severe complications such as impaired platelet function and coagulation, decreased drug metabolism, increased wound infection rate and cardiac arrhythmias, and prolonged postanesthesia unit stay. We believe that warm air insufflators, electrical carpets, increased room temperature and warm infusion fluid are helpful to avoid hypothermia during PCNL.

Efficiency of percutaneous nephrolithotomy in pediatric patients using adult-type instruments

To evaluate the efficiency of percutaneous nephrolithotomy using adult-type instruments in children with kidney stones. Between September 2004 and October 2009, 18 children (19 renal units) underwent percutaneous nephrolithotomy using adult-type instruments. Following percutaneous access under fluoroscopy, 20-30F tract dilatation was performed (1,92,427F), and lithotripters were used. Postoperatively, kidney-ureter-bladder X-ray and antegrade pyelography were performed to evaluate residual stones and contrast passage to the bladder. 8 boys and 10 girls with a mean age of 9.8 ± 4.56 years were evaluated. Mean stone burden was 338 ± 196.21 mm². Stones were located in the left and right kidneys in 16 (84.2%) and 3 (16.8%) patients, respectively. Horse-shoe kidney was present in one patient. Mean operation (including cystoscopy) and fluoroscopy times were 106 ± 49.60 and 5.2 ± 2.14 min, respectively. Postoperatively, 10(52.6%) patients were stone free and 4 (21.1%) patients had clinically insignificant stones. Saline extravasation developed in three patients and surgery was aborted in one patient. Stone fragments migrated into the ureter in two patients and managed by additional endourological interventions. Nephrostomy catheters were kept for a mean of 2.6 ± 1.12 days. Four patients required blood transfusion due to bleeding. Postoperative fever of <39°C developed in five patients and >39°C in one patient. Mean hospitalization time was 5.3 ± 3.12 days. Overall, 73.7% of our patients were stone free, including patients with clinically insignificant stones. Particularly in children with a high-stone burden, the use of adult-type instruments might have a positive impact on stone-free rate, operation time and fluoroscopy time without increasing the complication rate.

Percutaneous nephrolithotomy in pediatric patients: is computerized tomography a must?

The aim of this study was to retrospectively evaluate the results of pediatric percutaneous nephrolithotomy (PNL) cases, and discuss the results and necessity of non-contrast computerized tomography (CT) in these cases. In all, 48 pediatric patients who underwent PNL were retrospectively evaluated. Before PNL, either intravenous urography or CT was performed. In all patients, we evaluated the PNL time, scopy time with stone burden, and complications. During the PNL procedure, we switched to open surgery in two cases: in one because of renal pelvis perforation and in the other because of transcolonic access. In one patient who was scheduled to undergo PNL, we performed open surgery, primarily because we detected a retrorenal colon with CT. The stone burden in 45 patients who underwent PNL was 445 ± 225 mm(2), the PNL time was 51 ± 23 min, and the scopy time was 6.1 ± 2.7 min. We removed nephrostomy tubes 1-4 days after the procedure. In two patients, 24 h after removal of nephrostomy tubes, we inserted double J stents because of prolonged urine extravasation from the tract. In all, 34 of the 45 patients were stone-free, 5 patients had clinically insignificant stone fragments, and 6 patients had residual stones. PNL is a safe and effective method in the treatment of pediatric patients with kidney stones. Clinical experience is the most important factor in obtaining stone-free results. CT should be performed in all pediatric patients in order to prevent colon perforation.

Safety and Efficacy of Supracostal Percutaneous Nephrolithotomy in Pediatric Patients

This study was conducted to evaluate the safety and efficacy of the supracostal approach for percutaneous nephrolithotomy in pediatric patients. We retrospectively reviewed 60 percutaneous nephrolithotomy procedures done in 50 children (32 boys and 18 girls) between 2000 and 2007. Mean patient age was 7 +/- 4 years (range 9 months to 14 years). Noncontrast computerized tomography was the primary radiological investigation for most of the cases. The subcostal approach was used in 40 procedures, and the supracostal approach (above the 12th rib) was required in 20. We compared both approaches regarding preoperative characteristics, stone-free and complication rates, and the need for auxiliary procedures. The preoperative characteristics of the patients, urinary tracts and stones were comparable for both treatment groups. There were no major complications. Significant bleeding requiring blood transfusion was observed in 3 patients (5%), transient fever in 3 (5%) and urinary leakage through the nephrostomy site in 3 (5%). The distribution of complications among subcostal and supracostal approaches was comparable. Of the 60 renal units 46 (77%) were stone-free after percutaneous nephrolithotomy at discharge from the hospital. Of the remaining 14 units 9 (15%) were stone-free after shock wave lithotripsy and 5 (8%) had insignificant residual stones. Therefore, the overall stone-free rate at 3 months was 92.5%. Comparing the subcostal and supracostal approaches, there were no significant differences between hospital stays, complication rates, unplanned auxiliary procedures, and stone-free rates at discharge home and at 3-month followup. Percutaneous nephrolithotomy for treating renal stones in children provides a high degree of safety and efficacy whether a supracostal or subcostal approach is used.