Paediatric percutaneous nephrolithotomy: Single-centre 10-year experience

doi:10.1016/j.jpurol.2013.02.004

Journal of Pediatric Urology

Volume 9, Issue 4, August 2013, Pages 472-475

https://doi.org/10.1016/j.jpurol.2013.02.004 Get rights and content

Abstract

Introduction

Percutaneous nephrolithotomy (PCNL) is a standard management option for complex and large renal calculi. In children, there is some concern over potential perioperative complications. We reviewed our 10 years of experience of PCNL in children and present our data.

Material and methods

Data for paediatric patients who underwent PCNL at our centre in the last decade were retrieved. PCNL was performed in standard prone position under fluoroscopic guidance. Patient characteristics, outcomes and complications were reviewed. Complications were graded according to the modified Clavien system. A comparison was also made between supracostal and infracostal accesses.

Results

95 children underwent PCNL in our institute in the last decade. 7 patients had bilateral PCNL. The most common presentation was flank pain (85%). 83% patients were stone-free after first PCNL and overall 94% were stone free after second-look PCNL and auxillary procedures. 6 cases had clinically insignificant residual fragments. Supracostal puncture was performed in 32 cases. Complications were higher in the supracostal puncture group (16 (50%)) and included fever in 11, sepsis in 2 and hydrothorax in 3 patients. There were 7 (10%) complications in the infracostal group: fever in 5 and perinephric collection in 2 patients. 16 patients had grade 1, 9 had grade 2 and another 2 cases developed grade 3 complications.

Conclusion

PCNL is a safe and effective procedure in children. It enables excellent stone clearance with minimal number of interventions.

Introduction

Paediatric urolithiasis is a common clinical problem. Its management requires stone clearance, eradication of urinary infection and treatment of associated metabolic abnormalities. Percutaneous nephrolithotomy (PCNL) is a well recognized modality for clearance of large renal stones in adults. There is some concern about its use in children due to potential renal damage, radiation exposure and the risks of major complications including fluid and electrolyte imbalance and bleeding. Recent publications attest to the safety of PCNL even in children below a school-going age [1], [2]. We routinely perform PCNL in the paediatric age group and analysed our experience of the last 10 years.

Section snippets

Material and methods

We retrospectively reviewed data of the last 10 years of paediatric patients less than 18 years of age who underwent PCNL at our centre. The indications for PCNL were renal stones greater than 2 cm and smaller stones that failed shock-wave lithotripsy (SWL) treatment. All patients underwent metabolic evaluation, including serum calcium, phosphate and uric acid, and 24 h urinary albumin, creatinine, calcium, phosphate and uric acid. Some patients had an extensive metabolic evaluation which

Results

95 paediatric patients underwent 102 PCNLs (7 bilateral) during the 10 year period beginning 2001. During the same period, 192 children underwent shock-wave lithotripsy for renal stones. The mean age of the patients was 11.95 years (range 3–17 years). 13 patients were between 3 and 6 years of age (preschool age group), 36 patients were between 6 and 12 years of age (preadolescent age group). 46 patients were 12–17 years of age (adolescents). Their demographic data and clinical features are

Discussion

Paediatric urolithiasis is a significant health problem, especially in developing countries. The challenge in the management of paediatric urolithiasis is due to greater probability of stone recurrence, metabolic abnormalities and urinary tract infection. These factors make minimally invasive procedures more important in children.

PCNL is the treatment of choice for large, complex, multiple, hard and staghorn renal calculi. It is associated with a lower requirement of auxillary procedures and

Conclusions

Percutaneous nephrolithotomy is a safe and effective procedure in children allowing maximal stone clearance with minimal auxillary or repeat procedures. A supracostal approach is valuable in terms of stone clearance, especially in staghorn and complex renal stones, but is associated with a higher rate of chest complications.

Conflict of interest

None.

Funding

None.

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Cited by (34)

Shockwaves and the Rolling Stones: An Overview of Pediatric Stone Disease
2023, Kidney International Reports
Citation Excerpt :
Today, PCNL is the first line treatment modality for Staghorn stones, renal stones >20 mm, lower pole stones >10 mm, cystine, or struvite stones.93 Where there is a residual stone after PCNL, this can be treated by ESWL, “second-look” PCNL and/or uretero-renoscopy.92,94–96 Successful stone clearance in >90% of cases has been reported.82
Urinary stone disease is a common problem in adults, with an estimated 10% to 20% lifetime risk of developing a stone and an annual incidence of almost 1%. In contrast, in children, even though the incidence appears to be increasing, urinary tract stones are a rare problem, with an estimated incidence of approximately 5 to 36 per 100,000 children. Consequently, typical complications of rare diseases, such as delayed diagnosis, lack of awareness, and specialist knowledge, as well as difficulties accessing specific treatments also affect children with stone disease. Indeed, because stone disease is such a common problem in adults, frequently, it is adult practitioners who will first be asked to manage affected children. Yet, there are unique aspects to pediatric urolithiasis such that treatment practices common in adults cannot necessarily be transferred to children. Here, we review the epidemiology, etiology, presentation, investigation, and management of pediatric stone disease; we highlight those aspects that separate its management from that in adults and make a case for a specialized, multidisciplinary approach to pediatric stone disease.
Efficacy and Safety of Supracostal Access for Mini Percutaneous Nephrolithotomy in Pediatric Patients
2020, Urology
Citation Excerpt :
The most common complications after supracostal PCNL are still grade I complications, which were found in 44/54 patients (81.5%) in our study. Bhageria et al reported 59% grade 1 complications in their series.3 Grade 2 complications were found in 8/54 patients (14.8%) in the present study.
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.
Ureteroscopy and laser stone fragmentation (URSL) for large (≥1 cm) paediatric stones: Outcomes from a university teaching hospital
2017, Journal of Pediatric Urology
Citation Excerpt :
There was minimal morbidity. Complication rates for ESWL and PCNL were higher – up to 15% and 24%, respectively [22,23]. Centralisation of specialised treatment and development of a dedicated paediatric stone team has proven to be a successful model in achieving these results.
The treatment of large renal stones (≥1 cm) in paediatric patients is challenging. The usual treatment options include percutaneous nephrolithotomy (PCNL) or shockwave lithotripsy (SWL). There is a rise in the use of ureteroscopy and laser stone fragmentation (URSL) for paediatric stones; however, outcomes of treatment for large renal stones in this age group are still largely unknown.
To investigate the outcome of URSL for large paediatric renal stones ≥1 cm treated at the present institution over the last 5 years.
A retrospective review was performed of outcomes from the prospectively maintained stone database. Only paediatric patients undergoing ureteroscopic (rigid or flexible ureteroscopy (URS)) procedures for stones ≥1 cm were included. Patient demographics, operative details, stone burden, hospital stay, complications and stone clearance were recorded and analysed.
From April 2010 to June 2015, 18 paediatric patients with a mean age of 10.4 years (range 3.6–15) underwent 35 ureteroscopic procedures for large stones (≥1 cm). The stone location was in the kidney (n = 14), ureter (n = 1), and in both the kidney and ureter for the remaining three patients. Nine patients had multiple stones. There was a preceding history of PCNL in four patients, with one patient having URS combined with a PCNL. The mean follow-up was 2.7 years (range 0–5).
A postoperative stent was inserted in 21 (60%) patients. The overall stone-free rate (SFR) was 89% for a mean of 1.8 procedures per patient (range 1–4) – see Summary Table below. There was an inability to access stone within a lower pole calyx in one patient, despite maximum deflection of the ureteroscope. No intra- or post-operative complications were noted, and mean hospital stay was 1.1 days (range 0–5).
Published papers in adult literature have shown that ureteroscopy and laser fragmentation (URSL) is a viable alternative to PCNL. Newer equipment and improved techniques have resulted in SFRs being comparable with PCNL. A recent systematic review reported an SFR of 91% for large adult stones (>2 cm) for a mean 1.45 procedures per patient, and an overall complication rate of 8.6%. The present study has also demonstrated excellent outcomes in the use of ureteroscopy and laser fragmentation for the management of large paediatric stones with no complications.
The results show that paediatric URSL for large stones achieves a good SFR with minimal morbidity and is a good treatment option in established endourological units.
Clinical effectiveness in the diagnosis and acute management of pediatric nephrolithiasis
2016, International Journal of Surgery
The incidence of pediatric nephrolithiasis has risen over the past few decades leading to a growing public health burden. Children and adolescents represent a unique patient population secondary to their higher risks from radiation exposure as compared to adults, high risk of recurrence, and longer follow up time given their longer life expectancies. Ultrasound imaging is the first-line modality for diagnosing suspected nephrolithiasis in children. Although data is limited, the best evidence based medicine supports the use of alpha-blockers as first-line MET in children, especially when stones are small and in a more distal ureteral location. Surgical management of pediatric nephrolithiasis is similar to that in adults with ESWL and URS first-line for smaller stones and PCNL reserved for larger renal stone burden. Clinical effectiveness in minimizing risks in children and adolescents with nephrolithiasis centers around ED pathways that limit CT imaging, strict guidance to ALARA principles or use of US during surgical procedures, and education of both patients and families on the risks of repeat ionizing radiation exposures during follow up and acute colic events.
Percutaneous Nephrolithotomy in Children: 17 Years of Experience
2016, Journal of Urology
We analyzed factors that might affect outcome in terms of success and incidence of complications in children up to 17 years after undergoing percutaneous nephrolithotomy.
The data of 346 renal units (294 patients) were analyzed in terms of postoperative outcome. Factors investigated that might affect outcome were patient gender, age, stone laterality, largest stone size, stone burden, number of stones, location of a single stone, previous intervention and instrument size.
Mean ± SD patient age was 8.51 ± 4.91 years, and male-to-female ratio was 209:137. Mean ± SD stone burden was 3.49 ± 3.3 cm². Stone-free rates after a single procedure were 84.4% and 73.1% in patients with and without clinically insignificant residual stones, respectively. On univariate and multivariate analyses stone burden and number of stones affected the stone-free rate. Complications consisted of bleeding in 41 patients (11.8%), postoperative urinary tract infection in 21 (6%), urosepsis in 4 (0.1%) and hydrothorax in 4 (0.1%). One patient died of multiple organ failure. Through the years blood transfusion and complication rates decreased, and the use of smaller instruments increased significantly. Although bleeding occurred less often in cases where a 14Fr sheath was used rather than a larger sheath (5% vs 12%, p = 0.142), the difference was not significant. No significant factor affecting complication rates was detected.
As in adults, percutaneous nephrolithotomy can be used in children with acceptable complication rates and good success rates for surgical treatment of complex renal stones. Number of stones and stone burden are predictive of postoperative stone-free rate.
Percutaneous nephrolithotomy vs retrograde intrarenal surgery for large renal stones in pediatric patients: A randomized controlled trial
2015, Journal of Urology
We compared outcomes of percutaneous nephrolithotomy and retrograde intrarenal surgery in the treatment of children with renal calculi larger than 2 cm.
A total of 38 patients younger than 16 years with renal calculi larger than 2 cm were randomized to undergo percutaneous nephrolithotomy or retrograde intrarenal surgery between May 2011 and February 2014. Demographic data, stone criteria, operative technique, radiation time, complications, blood transfusion, hemoglobin decrease, stone-free rate and length of hospital stay were compared between the groups. Stone-free status was documented if there were no residual stones after 1 month.
The study included 43 renal units, of which 21 were subjected to retrograde intrarenal surgery and 22 to percutaneous nephrolithotomy. Operative time was comparable for both groups. Mean radiation time and hospital stay were longer after percutaneous nephrolithotomy (p <0.001). Stone-free rate was significantly lower after retrograde intrarenal surgery monotherapy vs percutaneous nephrolithotomy monotherapy (71% vs 95.5%, p = 0.046). Patients in the percutaneous nephrolithotomy group had significantly more complications compared to the retrograde intrarenal surgery group (p = 0.018). Three patients in the percutaneous nephrolithotomy group received blood transfusions, compared to none in the retrograde intrarenal surgery group (p = 0.015).
For treatment of large or complex renal stones in pediatric patients percutaneous nephrolithotomy monotherapy has the advantage of better stone-free rates, while retrograde intrarenal surgery has the advantages of decreased radiation exposure, fewer complications and shorter hospital stay.

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Paediatric percutaneous nephrolithotomy: Single-centre 10-year experience

Abstract

Introduction

Material and methods

Results

Conclusion

Introduction

Section snippets

Material and methods

Results

Discussion

Conclusions

Conflict of interest

Funding

J Pediatr Urol

J Pediatr Urol

Urology

J Urol

J Urol

J Urol

J Urol

Urol Clin North Am

Percutaneous nephrolithotomy in children before school age: experience of a Pakistani centre

BJU Int

Safety and efficacy of a superior caliceal puncture in pediatric percutaneous nephrolithotomy

J Endourol

Proposed classification of complications of surgery with examples of utility in cholecystectomy

Surgery