Type of the Paper (Article LMRJ Volume 3 Issue 4 116 | P a g e Case Report Hydroperitoneum: A complication of mini PCNL in pediatric age group? -A case report Farheen Batool1, Waqar Ahmed Memon1, Javed Altaf Jat1, Shewak Ram1, Taimoor Jatoi1, Abdul Qayoom Ghangro 1 1Department of Urology, Liaquat University of Medical & Health Sciences, Jamshoro, Pakistan, ABSTRACT Renal stones account for approximately 40% of renal disorders in Pakistan including silent stones constituting up to 3%. Nephrolithotomy and Pyeloli- thotomy used to be the only surgical options offered to the patients present- ing with large stones, with additional risk of complications. Percutaneous nephrolithotomy (PCNL) has now being offered to the patients with even large renal stones for over the past three decades. With recent advances and provision of more modern equipments and technology, PCNL has become the gold standard treatment with quick recovery and reduced morbidity and mortality, and fewer associated complications. A boy aged 13 years, under- went mini PCNL for treatment of left side renal stone causing hydronephro- sis, previously evaluated by KUB X-Rray and non-contrast CT scan. His ret- rograde-percutanous access to the collecting system was done under fluoro- scopic guidance. After the procedure patient developed rigid and distended abdomen. Aspiration revealed presence of intraperitoneal fluid. Patient was effectively treated with immediate placement of abdominal drain with im- provement of clinical presentation Hydroperitoneum is a rare complication of conventional PCNL. Based on our experience and review of published lit- erature, our case of hydroperitoneum after mini PCNL, is the first of its kind. A high degree of sensitivity and knowledge of this complication during PCNL in children would help identify and manage this complication in fu- ture. We recommend examination of abdomen post-PCNL in every child be- fore he/she is brought out of anesthesia Key Words: Hyperperitoneum, Renal Stone, PCNL INTRODUCTION Urinary stone disease is a common global health issue involving 12% of the world population. Urinary stones constitute 20% of the patients in the urology OPD (1, 2). There is a geographical and age related variation in the incidence of urolithiasis but remains a major health concern in developing countries (3). Renal stones account for 40% of renal disorders in Pakistan (4), with silent stones constituting up to 3%, which are usually incidentally discovered while undergoing investigation for some other illness or on screening. Percutaneous approach to access kidney for the first time described by Goodwin et al. in 1955 for drain- age of an obstructed renal system (5) followed by Fernstrom and Johansson in 1976 who removed a renal stone by using the same approach. These successful procedures opened up a whole new era of percutaneous renal surgery (6). Before introduction of the percutaneous approach the only option avail- able for large stones was the surgical removal by open surgical technique such as nephrolithotomy and Correspondence: Dr. Waqar Memon Department Of Urology, Liaquat University Of Medical & Health Sci- ences, Jamshoro, Pakistan Email: drwaqarmemon@ya- hoo.com DOI: 10.38106/LMRJ.2021.3.04- 07 Received: 12.11.2021 Accepted: 22. 12.2021 Published: 30. 12.2021 LMRJ Volume 3 Issue 4 117 | P a g e pyelolithotomy, which was associated with a high risk of per-operative and post-operative complica- tions. Percutaneous nephrolithotomy (PCNL) is now being considered as the hallmark of treatment for large renal stones for past three decades(7). With advancement in the modern equipments and technol- ogy PCNL has now become the gold standard for this disease, resulting in reduced recovery time, shorter hospital stay and decreased morbidity and mortality (8, 9). PCNL is generally a safe procedure with a fewer complications(10). Some of these complications occur secondary to tract access with injury to the adjacent organs such as lung, pleura, liver, colon and spleen. It may also be associated with gen- eral complications which can occur with any surgical procedure including hemorrhage, post-operative pain and fever (11). However, PCNL has advantage of having small incision, much less number of com- plications and shorter convalescence period (10). Neverthless rate of stone removal has been reported to be almost 95% following PCNL. Due to limited facility of ESWL and PCNL open surgery remains the most commonly used procedure in many devel- oping countries including Pakistan(12). Though many centres in Pakistan are now offering these proce- dures but still limited to cities. Mini PCNL (mPCNL), was introduced in early 1990s, where the modified procedure was defined as a PCNL performed through a track of < 22 F (13, 14). The first report of mPCNL presented 60 pediatric pa- tients, who underwent PCNL using a 16-F sheath and 11-F Pediatric cystoscope (15). Case Report A 13-years-old boy was brought to the urology clinic by his mother with 7-months history of left flank pain. He has recently developed pain in the right flank and dysuria for the same duration. He had been seen by many general practitioners and was on empirical medication off and on, with partial or no remission in symptoms. The patient looked well with no specific physical signs. His urine culture showed no bacterial growth. The ultrasound KUB reported bilateral renal stones with hydronephrosis, which were further confirmed on x-ray KUB which showed radiopaque shadows in both renal areas. A CT - KUB was done which revealed 3.5 cm size stone in renal pelvis and 1 cm size stone in lower pole with moderate hydronephrosis on left side and multiple stones without hydronephrosis on right side (Figure. 1 a and b) a b Figure 1: X-Ray (a) and CT KUB (b)of the 13-years-old child showing bilateral stones with left hy- dronephrosis LMRJ Volume 3 Issue 4 118 | P a g e He was planned to undergo a mini PCNL in two stages, we opting to operate on the left side first. With the help of a 10 F pediatric cystoscope, a retrograde urogram (RGU) was done using a 4F ureteric catheter. A single radiopaque stone of approximately 3.5 cm size was visualized in the renal pelvis. A smaller stone (approx. 1 cm) was seen in the lower pole. Initial puncture was done in the lower pole with ‘Bull’s Eye’ technique. Serial dilatations were done up to 21F and a 22F Amplatz’s sheath was placed. Both stones were fragmented with pneumatic lithoclast. One fragment of stone migrated into upper calyx. For complete clearance of stones, another puncture was done with a simple dilator in upper pole. Outer sheath of nephroscope was used in the tract and the stone was retrieved. The total time for the procedure, from RGU to skin suturing, was 60 minutes. After the procedure, abdominal distension was seen when the patient was turned supine. Aspiration with 10cc syringe in the dependent part of abdomen was done. The aspirant was clear fluid and was thought to be irrigating fluid. An intra-peritoneal drain was placed. The patient’s postoperative recovery was un- eventful. The drain output was 800cc on first postop- erative day. On 3rd postoperative day, the drain was removed and patient was discharged. The postoper- ative x-ray KUB showed no evidence of residual stones (Figure. 2). Figure 2: Postoperative x-ray KUB DISCUSSION Surgical treatment of renal tract stones has been revolutionized in the recent past with availability of more minimal invasive options and less invasive techniques including ESWL and PCNL (16). PCNL is now being commonly performed procedure in patients presenting with renal stones (17). It is generally safe procedure with quick recovery and shorter hospital stay. Hemorrhage has been reported to the most frequently occurring complication, which can occur during needle passage or at the time of tract dilatation (18-20). Other complications, rare albeit life-threatening, include injuries to colon, pleura, splenic and liver (11). Hydroperitoneum, although a recognized complication of PCNL, is rarely men- tioned in the literature. Chen Rui et al., in his article published in 2011, reported 2 cases of hydroper- itoneum in a series of 86 adult patient undergoing PCNL (21). Liu Zhong-Ze et al. report 11 cases of hydroperitoneum as complication among 436 patient series of PCNL done in age group 14 to 71 years (22). Alfonso Benincasa et al. report same complication occurring in two patients, both adults, who were managed by placement of intra peritoneal drain (23). No such complication in pediatric age group has ever been reported. We report hydroperitoneum oc- curring in a 13-year old boy, who was successfully treated by placement of an abdominal peritoneum drain. CONCLUSION LMRJ Volume 3 Issue 4 119 | P a g e Hydroperitoneum is a rare complication of conventional PCNL. Based on our experience and review of published literature, our case of hydroperitoneum after mini PCNL, is the first of its kind. A high degree of sensitivity and knowledge of this complication during PCNL in children would help iden- tify and manage this complication in future. We recommend examination of abdomen post-PCNL in every child before he/she is brought out of anaesthesia. Ethical Consideration: This is a case report, anonymized. Patient’s permission was sorted before us- ing imaging. Conflict of Interest: There is no conflict of interest. Funding: No funding involved in this case report. REFERENCES 1. Moe, O.W., Kidney stones: pathophysiology and medical management. Lancet, 2006. 367(9507): p. 333-44. 2. Romero, V., H. Akpinar, and D.G. Assimos, Kidney stones: a global picture of prevalence, inci- dence, and associated risk factors. Rev Urol, 2010. 12(2-3): p. e86-96. 3. Resnick, M.I. and L. Persky, Summary of the National Institutes of Arthritis, Diabetes, Digestive and Kidney Diseases conference on urolithiasis: state of the art and future research needs. J Urol, 1995. 153(1): p. 4-9. 4. Naqvi, S.A., Regional problems in Pakistan-most prevalent kidney diseases and related prob- lems. In Jakarta, 1989: p. p.283–8. 5. Goodwin, W.E., W.C. Casey, and W. Woolf, Percutaneous trocar (needle) nephrostomy in hydro- nephrosis. 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