Mini-percutaneous nephrolithotomy for pediatric complex renal calculus disease: one-stage or two-stage?

International Alliance of Urolithiasis (IAU) guidelines on the management of pediatric urolithiasis

The aim of this study was to construct the sixth in a series of guidelines on the treatment of urolithiasis by the International Alliance of Urolithiasis (IAU) that by providing a clinical framework for the management of pediatric patients with urolithiasis based on the best available published literature. All recommendations were summarized following a systematic review and assessment of literature in the PubMed database from January 1952 to December 2023. Each generated recommendation was graded using a modified GRADE methodology. Recommendations are agreed upon by Panel Members following review and discussion of the evidence. Guideline recommendations were developed that addressed the following topics: etiology, risk factors, clinical presentation and symptoms, diagnosis, conservative management, surgical interventions, prevention, and follow-up. Similarities in the treatment of primary stone episodes between children and adults, incorporating conservative management and advancements in technology for less invasive stone removal, are evident. Additionally, preventive strategies aiming to reduce recurrence rates, such as ensuring sufficient fluid intake, establishing well-planned dietary adjustments, and selective use pharmacologic therapies will also result in highly successful outcomes in pediatric stone patients. Depending on the severity of metabolic disorders and also anatomical abnormalities, a careful and close follow-up program should inevitably be planned in each pediatric patient to limit the risk of future recurrence rates.

Construction of an alignment diagram model for predicting calculous obstructive pyonephrosis before PNL

Background

To develop a model for the accurate prediction of calculous obstructive pyonephrosis prior to percutaneous nephrolithotomy (PNL), leading to early local anaesthesia microchannel nephrostomy for drainage of pyonephrosis.

Methods

By comparing the differences in baseline clinical indicators between the pyonephrosis group and nonpyonephrosis groups, independent risk factors were screened out, and a diagnostic alignment diagram model for predicting calculus obstructive pyonephrosis before PNL was established.

Results

Multivariate regression analysis showed that preoperative blood neutrophil count (Neu), serum creatinine level (Scr), serum albumin level (Alb), urine nitrite (UN), hydronephrosis density (HD) and fever history within one month (HFWOM) were independent risk factors for calculous obstructive pyonephrosis. The AUC value of the receiver operating characteristic (ROC) curve was 0.929. The calibration curves showed that the predictive model was well corrected and that the predictive model had strong consistency. Decision analysis curves showed good clinical efficacy of the model.

Conclusion

The alignment diagram model accurately predicts patients with preoperative calculous obstructive pyonephrosis in the PNL and provides an evidence-based basis for early renal microchannel nephrostomy.

Safety and efficacy of ultrasound-guided low-pressure perfusion mini-percutaneous nephrolithotomy in children aged 1-7 years: a retrospective observational study

PURPOSE

This article analyzed the safety and efficacy of ultrasound-guided mini-percutaneous nephrolithotomy (MPCNL) with low-pressure perfusion for the treatment of upper urinary tract stones in children.

METHODS

The clinical data of 690 patients (805 renal units) aged 1-7 years were retrospectively analyzed in terms of postoperative outcome.

RESULTS

The mean patient age was 3.7 ± 1.6 years, and the stone burden was 2.8 ± 2.1 cm². A middle posterior calyceal puncture was created in 719 (89%) renal units, and 16F puncture tracts were the most common method used in 557 (69%) renal units. The stone-free rate was 711 (88%) renal units, and the mean operation time was 35 ± 15.3 min (between 15 and 110 min). Among all cases, the transfusion rate was 4 (0.6%) patients, and the mean decrease in hemoglobin was 1.3 ± 0.9 g/L. In addition, the incidence rates of fever, sepsis, perirenal effusion, and intraperitoneal effusion were 40 (5.9%), 3 (0.4%), 28 (4.1%), and 8 (1.2%) patients, respectively. After the operation, 348 patients were followed-up for 32.8 ± 11.3 months, and stone recurrence occurred in 136 (39%) of 348 patients.

CONCLUSIONS

This study suggests that ultrasound-guided MPCNL with low-pressure perfusion technology is a safe and feasible treatment.

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.

Risk factors and outcomes of urosepsis in patients with calculous pyonephrosis receiving surgical intervention: a single-center retrospective study

Background

Urosepsis is a catastrophic complication, which can easily develop into septic shock and lead to death if not diagnosed early and effectively treated in time. However, there is a lack of evidence on the risk factors and outcomes in calculous pyonephrosis patients. Therefore, this study was conducted to identify risk factors and outcomes of intra- and postoperative urosepsis in this particular population.

Methods

Clinical data of 287 patients with calculous pyonephrosis were collected. In the univariate and multivariate analysis, all patients were divided into urosepsis group and non-urosepsis group. The diagnosis of urosepsis was mainly on the basis of the criteria of American College of Chest Physicians (ACCP)/Society of Critical Care Medicine (SCCM). Patient characteristics and outcomes data were analyzed, and risk factors were assessed by binary logistic regression analysis.

Results

Of 287 patients, 41 (14.3%) acquired urosepsis. Univariate analysis showed that white blood cell (WBC > 10*10^9/L) before surgery (P = 0.027), surgery types (P = 0.009), hypotension during surgery (P < 0.001) and urgent surgery (P < 0.001) were associated with intra- and postoperative urosepsis for calculous pyonephrosis patients. In multivariate analysis, hypotension during surgery and urgent surgery were closely related to intra- and postoperative urosepsis. Outcome analysis suggested that patients developing urosepsis had a longer intensive care unit (ICU) stay and postoperative hospital stay and higher mortality.

Conclusions

Hypotension during surgery and urgent surgery were risk factors of intra- and postoperative urosepsis for calculous pyonephrosis patients, which may lead to a prolonged ICU stay, postoperative hospital stay and higher mortality.