|Year : 2001 | Volume
| Issue : 1 | Page : 22-24
Pediatric PCNL - our experience
Sanjeev Mehrotra, B Abraham, Nitin S Kekre, G Gopalakrishnan
Department of Urology, Christian Medical College and Hospital, Vellore., India
Nitin S Kekre
Department of Urology, Christian Medical College and Hospital, Vellore, 632004
Source of Support: None, Conflict of Interest: None
| Abstract|| |
PCNL is a well-established procedure for renal stone disease. This procedure has been used successfully in pediatric patients. Various modifications in technique and in instruments are tried. We report our results of PCNL in pediatric age group.
19 (22 renal units) children below the age of 15 years underwent PCNL from 1988 to 1998 at Dept. of Urology Unit-11.
All patients underwent single stage procedure under general anaesthesia. Complete clearance was achieved in 18 renal units, 4 renal units had residual fragments which cleared in 3 months. 3 patients required blood transfusion.
Pediatric PCNL is a safe procedure and can be used safely with acceptable morbidity
Keywords: Pediatric; PCNL; Renal Stone.
|How to cite this article:|
Mehrotra S, Abraham B, Kekre NS, Gopalakrishnan G. Pediatric PCNL - our experience. Indian J Urol 2001;18:22-4
| Introduction|| |
Renal stone disease is not an uncommon problem in children of developing countries. The advent of SWL by Chaussy et al- in 1982 has redefined the treatment of stone disease. Several reports have attested to its safety in pediatric population.,, However, in cases of larger stone burden one needs to resort to either open or percutaneous stone surgery. Safety of PCNL has also been established in this age group., However, methodology and type of equipment used differ. In this paper, we report our experience and a modification using the inner sheath of adult Wolf nephroscope. This combines the advantage of safety and convenience of using adult size energy probes and instruments. In this paper, we have examined the efficacy and safety of one stage percutaneous nephrolithotomy (PCNL) and our modified technique using adult Wolf nephroscope without outer sheath in pediatric age group.
| Materials and Methods|| |
We retrospectively analyzed the results and outcome of PCNL in children (below 15 years) who were treated at the department of Urology Unit-II, Christian Medical College & Hospital, Vellore from 1988 to 1998. 19 patients (22 renal units) in the age group of 4-15 years (average 8.47 years) underwent PCNL for nephrolithiasis during this period. Amongst these patients, 13 were male and 6 female. 14 patients had single stones and 5 had multiple stones. There were 16 unilateral and 3 bilateral stones. There were 10 pelvic, 8 calyceal, 3 upper ureteric and 2 partial staghorn calculi. The stone size varied from 8 mm to 3.5 cm and average size was 2.4 cm. The commonest presenting features were pain, hematuria and urinary tract infection.
The basic workup of these patients included renal function, urine culture and intravenous pyelography. 6 patients had a positive urine culture.
All patients underwent PCNL in single stage using adult instruments (Stortz and Wolf). After 1994 we were using Wolf adult nephroscope with only inner sheath (size 20 F). This was possible because of the design of nephroscope (integrated scope with working channel). All procedures were done under general anesthesia. Puncture and tract dilatation was done under fluoroscopic control. The size of amplatz selected was 24 F, nephroscope (size 20 F) was used without outer sheath. Ultrasonic and pneumaticlithotripsy was used to fragment the stones. Average operation time was 90 minutes. 3 patients required blood transfusion.
Nephrostomy tubes were left in situ after the procedure. Postoperative PCV estimation was done in all patients 12 hours after the procedure. Follow-up KUB radiograph was done in all cases to check stone clearance. Nephrostomy was removed 48 hours later provided drainage was clear and patient was afebrile. After removing all tubes, urine culture was done. IVP was done after 3 months. Every patient underwent metabolic evaluation.
| Results|| |
In all patients. operation was done as single stage procedure. 1 patient required relook nephroscopy for a residual fragment.
In most of the patients' collecting system, access was through posterior inferior calyx. In 3 patients middle calyceal puncture and in 1 patient upper calyceal puncture was made. The average operation time was 90 minutes (range 60 to 120). 3 patients required blood transfusion. These patients had bilateral stone disease with large stone burden and blood transfusion was probably related to prolong operation time to clear stone. Complete clearance was achieved in 18 renal units, 4 units had residual fragments (largest 4 mm) which cleared at 3 months' followup check X-ray.
At 3 months. all patients were stone free and no metabolic cause was found for stone disease in any patients. Follow-up ranged from I month to 72 months and there was no stone at the time of last follow-up.
| Discussion|| |
Pediatric urolithiasis poses management challenges because of small kidney size, less knowledge about the longterm effects of newer modalities of treatment on kidneys and etiology of the stone. Shock wave lithotripsy is the treatment of choice for most of small calculi,, while PCNL or open surgery is reserved for larger stones or stones with anatomic abnormalities.
Aim of treatment is complete clearance and treatment of the underlying cause. The first series on pediatric PCNL was published by Woodside et al claiming 100% stone free rate with no significant complications. They used standard dilatation technique. In series reported by Boddy et al'' 90% stone free rate was achieved and after sequential dilatation 24 to 26 F sheath was used with no major complications. Segura has suggested the use of adult instruments in children.- Desai et al suggest limited tract dilatation < 21 F and use of pediatric instruments.
The drawback with pediatric instruments is small instrument port, which necessitates use of small probes and forceps. This results in prolongation of operation time.
Blood loss is a major complication of pediatric PCNL. which is directly related to tract size dilatation. Reduced incidence of major intrarenal vessel injury using a pediatric nephroscope has been reported by Zattoni et al.
It is believed that adult instrument may cause more bleeding and amplatz may be too big for the pediatric kidneys. We have been doing PCNL on pediatric patients since 1988 using adult instruments (Stortz) without any significant problem. Since 1994 this problem was taken care of in our series by using Wolf adult nephroscope inner sheath (20 F), which allowed placement of smaller amplatz sheath. More effective fragmentation of stone was achieved using adult size ultrasonic and pneumatic energy sources. The advantages of this technique are better visibility, quick, effective stone fragmentation and retrieval using adult size energy probes and stone graspers. One can avoid buying separate pediatric set of instruments which may result in considerable cost saving for a department in a developing country.
| Conclusion|| |
Pediatric PCNL is a safe and effective procedure and can be performed in single stage in pediatric patients. Adult instruments can be used in pediatric patients using adult nephroscope inner sheath (Wolf) without significant hemorrhage. Majority of large stones (> 2.5 cms) can be treated with PCNL. Open surgery is reserved only for stones with anatomical abnormalities.
| References|| |
|1.||Esen T. Krautschik A. Alken D. Treatment update on Pediatric urolithiasis. World J Urol 1997; 15: 1295. |
|2.||Chaussy C, Schmiedt E, Jocham D et al. First clinical experience with extracorporeally induced destruction of kidney stones by shock waves. J Urol 1982: 127: 417-420. |
|3.||Shephard P. Thomas R, Harmon EP. Urolithiasis in children: Innovations in management. J Urol 1988: 140: 790-792. |
|4.||Marberger M. Turk C, Steinkogler 1. Piezoelectric electrocorporeal shock wave lithotripsy in children. J Urol 1989; 142: 349-352. |
|5.||Gupta M. Bolton DM. Irby P III et al. The effect of newer generation lithotripsy upon renal function assessed by nuclear scintigraphy. J Urol 1995; 154: 947-950. |
|6.||Callaway TW. Lingardh G, Basata S. Sylven M. Percutaneous nephrolithotomy in children. J Urol 1992: 148: 1067-1068. |
|7.||Mor Y. Elmasry YET, Kel lett MJ. Duffy PG. The role of percutaneous nephrolithotomy in the management of pediatric renal calculi. J Urol 1997: 158: 1319-1321. |
|8.||Esen T. Krautschik A. Alken D. Treauiient update on pediatric urolithiasis. World J Urol 1997; 15: 1295. |
|9.||Kramolowsky EV. Willoughby BL. Loening SA. Extracorporeal shock wave lithotripsy in children. J Urol 1987: 137: 934-941. |
|10.||Woodside JR. Stevens GF. Stark GL et al. Percutaneous stone removal in children. J Urol 1985; 134: 1166-1167. |
|11.||Buddy SAM. Kellett MJ. Fletcher MS et al. Extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy in children. J Pediatr Surg 1987; 22: 223-227. |
|12.||Segura JW. Role of percutaneous procedures in the management of renal calculi. Urol Clin North Am 1990: 17: 207-216. |
|13.||Desai M. Ridhorkar V, Patel S et al. Pediatric percutaneous nephrolithotomy: Assessing impact of technical innovations on safety and efficacy. J Endo Urol 1999: 13: 359-364. |
|14.||Callaway TW. Lingardh G, Basata S. Sylven M. Percutaneous nephrolithotomy in children. J Urol 1992: 148: 1067-1068. |
|15.||Zattoni F. Passerini-Glanzel G. Tasca A et al. Pediatric nephroscope for percutaneous renal stone removal. Urology 1989: 33: 404-406. |