Percutaneous nephrolithotomy in children: lessons learned in 5 years at a single institution

Experience of percutaneous nephrolithotomy using adult-size instruments in children less than 5 years old

OBJECTIVE

We present our experience with percutaneous nephrolithotomy (PCNL) for management of large renal calculi in children less than 5 years old, and determine its safety and efficacy when using an adult-size device.

PATIENTS AND METHODS

Twenty patients younger than 5 years old underwent PCNL between August 2003 and July 2008. After retrograde catheterization, the nephrostomy tract dilated up to 26Fr. Then a 24-Fr rigid nephroscope was used and stones were fragmented with a pneumatic lithotripter.

RESULTS

Twenty patients with a mean age of 3.1 years underwent 26 PCNL procedures on 24 renal units. Four patients had bilateral renal stones. Five patients (20%) had staghorn stones, as did five of the other cases with multiple stones. Four patients had undergone previous stone surgery on the same side. All of the patients were managed with only one tract. The mean stone size was 33 (20-46)mm and average operative time was 93.25 (78-174)min. Stones were completely cleared in 79.16% of patients, which increased to 91.67% with adjunctive shockwave lithotripsy. The overall complication rate was 15.38% and mean hospital stay was 5.26 (3-8) days.

CONCLUSION

PCNL is an effective and safe treatment for renal calculi in children less than 5 years old, even when using instruments designed for adults.

Pediatric urolithiasis

PURPOSE OF REVIEW

We review the recent literature on pediatric urolithiasis and present up-to-date findings on epidemiology, diagnosis, and medical and surgical management.

RECENT FINDINGS

There are surprisingly few reliable data on pediatric urolithiasis incidence, but widespread anecdotal and single-center reports suggest that more children with stones are being seen. The contamination of Chinese infant formula with melamine caused urolithiasis and other renal problems in hundreds of thousands of infants in the region, underlining the role of environmental factors in urolithiasis. Efforts continue to determine normal metabolic parameters in children, but have been hampered by variations among regions, races, and ethnicities. The Bonn Risk Index may prove to be a useful tool for assessing risk of urolithiasis in children. Children with recurrent urolithiasis are more likely to have detectable metabolic abnormalities. Surgical approaches to urolithiasis in children continue to evolve, with robotic-assisted laparoscopy being perhaps the most significant new technique. Finally, clinicians and radiologists must be aware of the potential for dextranomer/hyaluronic acid (Deflux) implants to mimic distal ureteral stones on computed tomography (CT) scan.

SUMMARY

Pediatric urolithiasis is an expanding field, due in part to the apparent increase in cases. Research continues, seeking to refine the appropriate diagnostic and therapeutic approaches in these unfortunate children.

Endourological management of pediatric stone disease: present status

PURPOSE

The incidence of nephrolithiasis in the pediatric population has been steadily increasing. The miniaturization of endoscopic instruments and improvement in imaging modalities have facilitated safe and effective endourological treatment in this patient population. We reviewed the current status of pediatric stone disease management.

MATERIALS AND METHODS

A comprehensive literature review was performed using MEDLINE/PubMed to evaluate the indications, techniques, complications and efficacy of endourological stone management in children.

RESULTS

In the 1980s shock wave lithotripsy revolutionized stone management in children, becoming the procedure of choice for treating upper tract calculi less than 1.5 cm. Percutaneous nephrolithotomy has replaced open surgical techniques for the treatment of stone burdens greater than 1.5 cm with efficacy and complication rates mirroring those in the adult population. However, at an increasing number of centers ureteroscopy is now being performed in cases that previously would have been treated with shock wave lithotripsy or percutaneous nephrolithotomy. Results from recent retrospective series demonstrate that stone-free rates and complication rates with ureteroscopy are comparable to percutaneous nephrolithotomy and shock wave lithotripsy. Although concerns remain with all endoscopic techniques in children regarding damage to the urinary tract and renal development, neither short-term nor long-term adverse effects have been consistently reported.

CONCLUSIONS

Shock wave lithotripsy, percutaneous nephrolithotomy and ureteroscopy are highly effective endourological techniques to treat stone disease in the pediatric population. A lack of prospective randomized trials comparing treatment modalities coupled with a vast disparity in the access to resources worldwide continues to individualize rather than standardize stone treatment in children.

[Urolithiasis in children--rational diagnosis, therapy, and metaphylaxis]

With a proportion of 1-5%, children constitute only a small number of all patients with urolithiasis. Nevertheless, pediatric stone disease is an important health care problem because of the high recurrence rate and the threat of progredient renal function impairment with consecutive loss of quality of life. Modern therapies, especially extracorporeal shock wave lithotripsy (ESWL), ureteroscopy (URS), and percutaneous nephrolithotomy (PCNL), have caused a revolution in the operative treatment spectrum. Open surgery is required for stone removal only rarely, such as for the simultaneous repair of urinary tract anomalies. The minimally invasive modalities of modern stone therapy - mainly ESWL as the treatment of first choice - have led to widespread disregard of stone metaphylaxis. The important principle that says an urinary stone is just a symptom and not the cause of the disease is often forgotten. So it must be noted that despite the high standard of care in Germany, not all problems regarding urinary stone disease are being resolved, particularly in childhood. This article presents the current knowledge of the most important aspects of stone therapy and the methods of treatment in children.