Is Mini Percutaneous Nephrolithotomy a Game Changer for the Treatment of Renal Stones in Children?

The safety and efficacy of miniaturized percutaneous nephrolithotomy in children

To assess the use of miniaturized percutaneous nephrolithotomy (mini-PCNL) for renal stones in children, as well as its safety and efficacy. Seventy-seven patients with more than 15 mm renal stones whose age was less than 15 years were enrolled in this prospective case-controlled study at Al-Ramadi Teaching Hospital, Ar Razi Private Hospital, and Ghazi Al-Hariri Hospital for Surgical Specialties, Anbar and Baghdad, Iraq. The study was conducted from January 2020 to January 2024. The group mentioned above served as group A, and it was compared to the control group (group B), which consisted of 70 adult patients aged 18-60 years. Patients in both groups underwent mini-PCNL. Gender, stone size and location, time of operation, stone-free rate, hemoglobin drop, need for blood transfusion, postoperative fever, associated visceral injury, and need for further interventions such as extracorporeal shock wave lithotripsy or flexible ureteroscopy (ESWL or FURS) were compared in both groups. The age of patients in group A ranged from 8 months to 15 years with a mean (4.30 ± 3.16), while in group B ranged from 18 to 60 years with a mean (36.3 ± 12.0), p-value 0.001. There were no statistically significant differences regarding gender distribution, stone size, and location, p-value > 0.05. The stone-free rate was 87.01% for group A and 88.57% for group B, with no statistical difference, p-value 0.773. Hemoglobin drop was 1.096 ± 0.412 for group A and 1.195 ± 0.110 for group B, p-value 0.046. Blood transfusion was needed in one case in each group with no statistical difference, p-value 0.946. The need for ESWL was 3 cases in group A, and 2 cases in group B, with no statistical difference between the two groups, p-value 0.729. The need for FURS was 4 cases in group A and 3 cases in group B, p-value 0.796. Operative time was 30 to 125 min in group A and 34 to 129 min in group B, p-value 0.941. Postoperative fever was seen in 23 cases in group A and 21 cases in group B, p-value 0.986. Minor liver injury was seen was seen in one case in each group. The use of mini-PCNL for treating renal stones in children is safe and effective as it is associated with a relatively low rate of significant complications and achieves a high stone-free rate.

Is percutaneous nephrolithotomy effective and safe in infants younger than 2 Years old? Comparison of mini standard percutaneous nephrolithotomy

BACKGROUND

In this study, we aimed to compare the operative outcomes, postoperative outcomes, stone-free status and complications of SPCNL and MPCNL in infants younger than two years of age.

METHODS

We retrospectively analyzed 163 patients younger than two years of age who underwent percutaneous nephrolithotomy (PCNL) in our institution between September 1999 and March 2022. The patients were divided into two groups depending on the tract size. The MPCNL group consisted of 73 patients with a tract of 22 Fr or less, and the SPCNL consisted of 90 patients with a tract greater than 22 Fr.

RESULTS

The median age of 163 patients included in the study was 17.3 (range 7-24) months. Although the median stone size was lower in the SPCNL group, no statistically significant difference was found between the two groups in terms of stone size (p = 0.073). The median operative time was 74.8 min in the MPCNL group and 62.8 min in the SPCNL group, with a statistically significant difference (p = 0.002). Stone free rates (SFR) were 89 % and 90.8 % in the MPCNL and SPCNL groups, and the clinically insignificant residual fragments (CIRF) rates were 11 % and 4.6 %, respectively (p = 0.064). The fluoroscopy time, nephrostomy withdrawal time, and hospitalization stay were similar in the two PCNL groups (p = 0.535, p = 0.253, and p = 0.143, respectively). Postoperative fever was similar in MPCNL and SPCNL groups (p = 0.504). Although bleeding (6.7%-2.7 %) and blood transfusion (3.3%-1.4 %) rates were higher in the SPCNL group, there was no statistically significant difference (p = 0.248 and p = 0.420, respectively). Prolonged urinary leakage occurred in 6 (8.2 %) patients in the MPCNL group and 1 (1.1 %) patient in the SPCNL group, with a statistically significant difference (p = 0.026).

CONCLUSIONS

With the development of MPCNL, the use of SPCNL in infants has decreased considerably. However, SPCNL continues to be an effective and reliable method when needed in suitable patients. Although PCNL in infants shows some differences from adults, it is an effective and safe method for suitable patients.

LEVEL OF EVIDENCE

Although we created our study by retrospectively examining the pediatric urology data that we created prospectively, our study is of a retrospective nature. Therefore the Level of Evidence is 3.

Comparison of Two Centers' Experience in Pediatric Supine and Prone Miniaturized Percutaneous Nephrolithotomy with Propensity Match Analysis

Introduction: Percutaneous nephrolithotomy (PNL) is the treatment of choice in children with complex and large stones. With the experience gained from adult practice, supine PNL is increasingly performed in children as well. We aimed to evaluate the comparative results of prone and supine mini-PNL (m-PNL) performed for large/complex stones in children. Patients and Methods: The study included children who underwent supine and prone m-PNL at two centers between September 2019 and 2022. Patients were divided into two groups with a 1:1 ratio to index supine m-PNL and prone m-PNL cases for the size, number, location of the stones, degree of hydronephrosis, and age. Operative related parameters, success, and complication rates are being discussed on a procedure-based manner. Results: Forty-two patients (21 supine and 21 prone) were included. The mean age was 9.6 ± 4 years and mean stone size was 28.8 ± 13.6 mm. Regarding the operative data, the mean duration of procedure time was 65.7 ± 17.8 minutes in supine group, whereas 86.9 ± 19.0 minutes in prone group (p = 0.001). Fluoroscopy time was shorter in supine group (p = 0.027). Tubeless PNL was performed in 11 cases of prone group (52%), whereas this number was 18 (86.7%) in supine group (p = 0.019). Stone-free rates were similar in both groups (supine m-PNL: 90.5%, prone m-PNL: 85.7%, p = 0.634). Complications were minor in nature in most of the cases of both groups, which resolved with supportive measures in a short period of time. However, there was a statistically significant difference regarding the location and number accesses between two groups (p = 0.008). Simultaneous flexible ureterorenoscopy was performed in eight patients in the supine PNL group (<0.001). Conclusions: Our current findings and the highly limited data reported in the literature indicate that as an established minimal invasive treatment alternative m-PNL procedure in supine position can also be performed with similar success and complication rates in pediatric population.

Paediatric kidney stone surgery: state-of-the-art review

While urolithiasis in children is rare, the global incidence is rising, and the volume of minimally invasive surgeries being performed reflects this. There have been many developments in the technology, which have supported the advancement of these interventions. However, innovation of this kind has also resulted in wide-ranging practice patterns and debate regarding how they should be best implemented. This is in addition to the extra challenges faced when treating stone disease in children where the patient population often has a higher number of comorbidities and for example, the need to avoid risk such as ionising exposure is higher. The overall result is a number of challenges and controversies surrounding many facets of paediatric stone surgery such as imaging choice, follow-up and different treatment options, for example, medical expulsive therapy, shockwave lithotripsy, ureteroscopy, and percutaneous nephrolithotomy. This article provides an overview of the current status of paediatric stone surgery and discussion on the key topics of debate.

Pediatric Urolithiasis: Current Surgical Strategies and Future Perspectives

New technological innovations and cutting-edge techniques have led to important changes in the surgical management of pediatric urolithiasis. Miniaturized technologies and minimally invasive approaches have been increasingly used in children with urinary stones to minimize surgical complications and improve patient outcomes. Moreover, the new computer technologies of the digital era have been opening new horizons for the preoperative planning and surgical treatment of children with urinary calculi. Three-dimensional modeling reconstructions, virtual, augmented, and mixed reality are rapidly approaching the surgical practice, equipping surgeons with powerful instruments to enhance the real-time intraoperative visualization of normal and pathological structures. The broad range of possibilities offered by these technological innovations in the adult population finds increasing applications in pediatrics, offering a more detailed visualization of small anatomical structures. This review illustrates the most promising techniques and devices to enhance the surgical treatment of pediatric urolithiasis in children, aiming to favor an early adoption and to stimulate more research on this topic.

Outcomes of Mini-Percutaneous Nephrolithotomy in Children and Adolescents: A 10-Year Single-Centre Experience From Kuwait

The current study retrospectively reviewed data for all children and adolescents who underwent mini-percutaneous nephrolithotomy (PCNL) at Ibn Sina Hospital and Sabah Al Ahmad Urology Centre in Kuwait over 10 years. Accordingly, the 40 patients underwent mini-PCNL. Among them, 21 patients (52.5%) had varying degrees of hydronephrosis, with mild to moderate severity accounting for nearly half of them, whereas six (15%) had multiple stones. The median operative time was 54.5 (43.3-64) minutes. Moreover, 11 patients needed flexible ureteroscopy (URS) and double-J (DJ) ureteric stent, and one patient required DJ ureteric stent only. None of the cases developed intraoperative bleeding. The median hospital stay of the included patients was three (2.3-4) days. Residual stone was observed in 11 patients (27.5%), with a median size of 3 (2 to 7) mm. The incidence of postoperative complications was 27.5% (n = 11 patients), with three patients experiencing postoperative bleeding (7.5%) and eight patients developing a fever (20%). All patients had mild postoperative pain. However, no leakage, sepsis, or pelvic injury occurred. None of the patients required revision. In conclusion, mini-PCNL was a safe and effective procedure in children and adolescents with renal stones.

Minimally invasive surgery for pediatric renal and ureteric stones: A therapeutic update

The incidence of pediatric urolithiasis (PU) is growing worldwide. The corresponding therapeutic methods have become a research hot spot in pediatric urology. PU has the characteristics of abnormal metabolism, easy recurrence, and immature urinary system development, which make its treatment different from that of adults. Pediatric urologists should select the optimal treatment modality to completely remove the stones to prevent recurrence. Currently, the curative treatments of PU include extracorporeal shock wave lithotripsy (ESWL), ureteroscopy, retrograde intrarenal surgery, percutaneous nephrolithotomy (PCNL), laparoscopic, robot-assisted laparoscopic, and open surgery. This review aims to conduct a therapeutic update on the surgical interventions of both pediatric renal and ureteric stones. It accentuates that pediatric surgeons or urologists should bear in mind the pros and cons of various minimally invasive surgical treatments under different conditions. In the future, the treatment of PU will be more refined due to the advancement of technology and the development of surgical instruments. However, a comprehensive understanding of the affected factors should be taken into account by pediatric urologists to select the most beneficial treatment plan for individual children to achieve precise treatment.