A study of paediatric percutaneous nephrolithotomy in a tertiary care center

Joshi A1, Tiwari P2, Chanchlani R3

1Dr Arvind joshi, Assistant Professor, Department of Surgery, 2Dr Punit Tiwari, Assistant Professor, Department of  Surgery, 3Dr Roshan Chanchlani, Associate Professor, Deparment of Surgery, all are affiliated to Chirayu Medical College and Hospital Bhopal, MP, India

Address for correspondence: Dr Roshan Chanchalani, roshanchanchlani@gmail.com

Abstract

Aims: To evaluate the technique of Paediatric Percutaneous Nephrolithotomy in terms of safety, outcome and efficacy in age group 1 to 14 years. Material & Methods: The observational study was done from October 2011 to October 2014 in Chirayu Medical College Bhopal. 25 cases of renal stone in paediatric age group were admitted in our hospital and evaluated for size of the stone, number of stones, associated congenital anomalies and complications. PCNL was done by standard technique. Results: A total number of 25 children were operated. Sex distribution in our study was male 15 and female 10, most of the patients were of age group 10-14 years 15(60%). Most of the children15(60%) had large stones >2cm stones and small stone was seen in 6(24%) cases. Malrotated kidney having stone was seen in 8(32%) cases. Complications as fever and haematuria was observed in 1 (4%) case. The maximum sheath size used inchildren was 24 F. Out of 25 children, only one patient required blood transfusion. Conclusion: Paediatric PCNL is safe procedure in expert and experienced hands. Minimal invasive procedures are beneficial in paediatric age group because of longer life expectancy andmore riskof recurrence.

Keywords: PCNL (Percutaneous Nephrolithotomy), Stone Disease, Congenital Anomaly

Manuscript received: 1st Aug 2015, Reviewed: 9th Aug 2015
Author Corrected: 17th Aug 2015, Accepted for Publication: 25th Aug 2015

Introduction

The prevelance of renal stone is approximately 2-3% in general population.In developing countries renal stone disease in children is not uncommon. Malnutrition, racial factors, anatomical and metabolic abnormalities as hypercalciuria, hyperoxaluria, hypocitraturia are important risk factors for high incidence and recurrence of stones in children [1]. In India.It is moreprevalent in northern states than in southern states of India.Earlier urinary stones were a major health problem, with a significant proportion of patients requiring extensive open surgical procedures with its high morbidity.In adults PCNL is well established as successful procedure and it has been reported effective inpediatric population since 1985.

Advancements in endoscopy instrumentation, such as smaller nephroscopesefficient energy sources for intracorporeal lithotripsy, including holmium: yttriumaluminum-garnet (YAG) laser and smaller pneumatic lithoclast and ultrasound probes have greatlyfacilitated percutaneous treatment techniquesin children. However, there is currently no international consensus on the indications forPCNL in children as open surgery has lost ground.

Material and Method

TheStudy period includes three years from October 2011 to October 2014.After ethical committee approval the study was done in Chirayu Medical College and hospital Bhopal. 25cases of renal stone in paediatric age group <14 years were admitted in our hospital were included and evaluated for size of the stone, number of stones,associated congenital anomalies and complications.

Inclusion criteria: Renal stones of >1.0 cm, failed cases of URS /ESWL, anatomical abnormalitywhich obstructs the drainage &clearance, Exclusion criteria: CRF and bleeding disorders. All cases were evaluated preoperatively with routine laboratory investigations including urine examination, culture and sensitivity, Blood urea,S creatinine, X-ray KUB, Ultra sound KUB region, IVP, Non-contrast CT scan of KUB region for radiolucent calculi and patients with renal anomalies.Technique: Intravenousantibiotic prophylaxis was given andunder general anesthesia, patients were subjected to retrograde catheterization(4-6 Fr) using cystoscope. After doing RGU patients were turned to prone position. Posterior inferior calycealpuncture with fluoroscopic guidance was performed by using 18 G needle and single step dilatation oftract over guide wire was performedupto 18-24 F as per stone burden and size of the patient by using rigid nephroscope.Heated sterile saline was used for irrigation of tract. Stone fragmentation done by pneumatic lithoclast and three prong grasper was used to extract stone fragments and DJ Stent was placed. Nephrostomy was kept in all patientswhich was removed after 2 days.At the conclusion of procedure, stone clearance was evaluated fluoroscopically andsonologically. On the 1st Post-operative day -X-Ray KUB & Ultra Sound KUB regiondone in all the patients to assess the stone clearance before removing the nephrostomy.

Results

In our centre, a total number of 25 children were operated. Outof 25 patients 10 patients had congenital anomaliesbut none ofthe anomalies did not give us any problem during the PCNL procedures which was due to expertise surgeons except the horse shoe kidneyin which the stone was approached through the upper calyx and in all other cases the approach to thestone was through the lower calyx. Sex distribution in our study was male 15 and female 10,most of the patients were of age group 10-14 years 15(60%).(Table.1)Most of the children15(60%) had large stones >2cm stones and small stone was seen in 6(24%) (Table.2) cases.Malrotated kidney having stone was seen in 8 (32%) cases. (Table.3) Complications as fever and haematuria was observed in 1 (4%) case. (Table.4)All the patients were followed for one year period and were doing well.

1. Table showing agewise distribution of cases

Age Group

No of Patients-25

%

0-5 years

2

8

5-10 years

8

32

10-14 years

15

60

2. Table showing various sizes of stones in patients

Size of Stone

No of patients- 25%

Small stone(<2cm,multiple)

6 24

Large stone(>2cm)

1560

Staghorn calculus

 1 4

Bilateral (<2cm)

 3 12

3. Table showing distribution of congenital anomalies in patients

Congenital anomalies

No of patients-25

%

Horse shoe kidney

1

4

Malrotated kidney

8

32

Duplex moiety

1

4

Total

10

40

4. Table showing various complications in patients

Complications

No of patients-25

%

fever

1

4

haematuria

1

4

Paralytic ileus

2

8

Urosepsis

1

4

Perinephric collection

0

0

conversion to opennversion to open

00

0

Discussion

With the evolution of technique and miniaturization of urological instruments the management of pediatric stone diseasehas significantly changed.Traditionally Shock wave lithotripsy is the treatment of choice for most of small calculi while PCNL or open surgery is reserved for larger stones with anatomic abnormalities [2,3].

The indication of PCNL are large upper tract stone burden (>1.5 cm), lower pole calculi > 1cm, concurrent anatomic abnormalities impairing urinary drainage, including uretero pelvic junction obstruction.The use of ESWL is the treatment option in children with upper ureter and renal pelvic stones <2cm and lower pole calyx stone < 1cm.Stone free rates following PCNL are reported in literature as 73-96%.The first series on paediatric PCNL was published by Woodside et al with 100% stone free rate with no significant complications[4]. large retrospective series of PCNL monotherapy have demonstrated highefficacy rates that approach 90%. Samadetal found age and weight not to be barrier to performing PCNL successfully [5]. In an effort to reduce the number of tracts and associated morbidity, some centers havechosen to follow primary PCNL with adjunctive SWL therapy to clear residual stone fragments. Bayraketal compared PCNL and open surgery and concluded that PCNL had better results [6]. Similar to adult population, large retrospective series have demonstrated that PCNLis a safe and effective procedure for the management of nephrolithiasis in children.

Schuster et al described PCNL as completely replacing open surgery for renal stones in paediatric population [7]. Zerenandassociatesreported a 87% stone-free rate using ultrasound and EHL for fragmentation and tract dilatation from18F to 30F [8]. In our study we have evaluated the indications of PCNL in pediatric age group by doing PCNL indifferent clinical situations like children with anatomical anomalies, children with unfavorablecalyceal anatomy.%). In our series most of the children15(60%) had large stones >2cm stones and small stone was seen in 6(24%) cases.Anatomical anomaly Malrotated kidney having stone was seen in 8(32%) cases which is comparable with the literature.Complications as fever and haematuria was observed in 1 (4%) case.Desai and coworkersreported a stone-free rate of 89.8% using EHL through a 14Fnephroscope and a 20-24 F sheath. Of these, 61% needed multiple tracts, and 45% were stagedprocedures[9]. With increasing experience, PCNL is currently being used as monotherapy and incombination with SWL (sandwich therapy) in children and ESWL is accepted as firstlinetheary in management of paediatric stones [10].

Conclusion

Paediatric PCNL is safe procedure in expert and experienced hands.Minimal invasive procedures are beneficial in paediatric age group because of longer life expectancy and more risk of recurrence.

Funding: Nil, Conflict of interest: None initiated.
Permission from IRB: Yes

References

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How to cite this article?

Joshi A, Tiwari P, Chanchlani R. A study of paediatric percutaneous nephrolithotomy in a tertiary care center. Int J Med Res Rev 2015;3(8):832-835. doi: 10.17511/ijmrr.2015.i8.156.