Upper pole access is safe and effective for pediatric percutaneous nephrolithotomy

Retrorenal colon in pediatric patients with urolithiasis: Is the supine position for PCNL advantageous?

INTRODUCTION

Percutaneous nephrolithotomy (PCNL) is one of the main approaches for the treatment of large and complex stones in pediatric patients. The patient position for PCNL has been classically divided into prone or supine and the prone position is more commonly used. One of the most feared complications of this surgical technique is colon injury and the objective of this work is to evaluate the incidence of retrorenal colon (RRC) both supine and prone position, in pediatric patients, through radiological images.

MATERIALS AND METHOD

A retrosepctive review was performed of all abdominal CT scans performed in one center, in patients under 18 years since 2017 to 2019. The ideal path for percutaneous puncture was traced in the upper, middle, and lower calyces of both kidneys in the prone and supine positions and contact with the kidney and adjacent organs was evaluated, with a uro-radiologist. Chi-square test and Student's t test were applied.

RESULTS

50 CT-scans were performed on 44 children. Patients had a mean age of 12.6 years and 71.4% were male. Twenty-five scans were performed in the prone and 25 in the supine position. The incidence of RRC for the left kidney (LK) was significantly higher in the lower calyx in prone position than in the supine position, 28% vs 4% (p = 0.049), and the right kidney (RK) presented RRC only in the prone position. The liver was the most frequent retrorenal organ (97.7%) for the RK, with a non-significant difference by position, while for the LK the spleen was the most frequent (61.1%).

DISCUSSION

Colon injury is one of the most morbid complication in PCNL and one of the reasons to perform a CT scan before surgery, on which its incidence appears to be <1% in adults. The present study revealed RRC to be present in three (12%) patients in the supine position and seven (28%) patients in the prone position (p=0.15). These results were slightly higher from those reported in adults (supine: 1.7%-10%; prone: 6.8%-20%), but there are no reports in the literature on this issue to allow appropriate comparison. This is the first study to attempt to assess the incidence of RRC in children according to position.

CONCLUSION

The incidence of RRC for an ideal puncture was significantly higher in the lower calyx of the left kidney in the prone position than in the supine position, and in the right kidney, the RRC only occurred in the prone position.

Superior calyceal access vs. other calyceal access in percutaneous nephrolithotomy: A systematic review and meta-analysis

Purpose

To evaluate the superior calyceal access’s performance and safety in relation to other calyceal access during percutaneous nephrolithotomy (PCNL).

Methods

The suggested reporting items for systematic reviews and meta-analysis were used to conduct this meta-analysis (PRISMA). To find pertinent studies for this meta-analysis, we searched PubMed, Embase, Web of Science, and China National Knowledge Infrastructure (CNKI). Operation time and hospital stay are two secondary outcomes, whereas failed stone clearance and complication events are the two major outcomes. Utilizing Stata 15.0, RevMan 5.3, and R 4.0.2, relative data were extracted and evaluated.

Results

This meta-analysis was based on 16 studies with 8,541 individuals. Pooled results suggested that superior calyceal access could offer fewer failed stone clearance [odds ratio (OR): 0.64, 95% confidence interval (CI), 0.47–0.88, P = 0.006] and lower additional puncture rate (OR: 0.35, 95% CI, 0.24–0.51, P < 0.001) than other calyceal access. No complication difference was found (OR: 1.10, 95% CI, 0.78–1.56, P = 0.57). Superior calyceal access could offer shorter operation time [standard mean difference (SMD): −0.57, 95% CI, −0.98 to −0.15, P = 0.007]. No hospital stay difference was found (SMD: 0.07, 95% CI, −0.09 to 0.22, P = 0.38). Large heterogeneity was detected in stone clearance comparison (I²= 71%, P < 0.001) and operation time (I²= 97%, P < 0.001). The stone clearance comparison also identified significant publication bias (P = 0.026). These defects weaken the credibility of the results.

Conclusion

Superior calyceal access in PCNL may result in a higher stone clearance rate, a lower rate of subsequent punctures, and a faster operation duration with no increase in postoperative complications or hospital stay for kidney stone patients, despite the significant heterogeneity and publication bias. By conducting bigger randomized controlled studies, this discovery still has to be confirmed.

Efficacy and Safety of Supracostal Access for Mini Percutaneous Nephrolithotomy in Pediatric Patients

OBJECTIVE

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.

MATERIALS AND METHODS

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.

RESULTS

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.

CONCLUSION

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.