U J 02 - Spring 2012 - All 008- without adv.pdf 465Vol. 9 | No. 2 | Spring 2012 |U R O LO G Y J O U R N A L Pediatric Percutaneous Nephrolithoto- my Using Adult Sized Instruments Our Experience Masoud Etemadian,1 Robab Maghsoudi,1 1 Mohammad Reza Mokhtari,1 Behkam Rezaeimehr,1 Mohsen Shati2 Purpose: - - lithiasis. Materials and Methods: We retrospectively reviewed the medical records of 38 - Results: - ard PCNL was performed in 8 patients and tubeless PCNL in the next 37 subjects. Simultaneous transurethral lithotripsy was done in 9 patients. Stone clearance rate had postoperative fever beyond day 1. Blood transfusion was required in only one occurred, which were treated conservatively without any adverse sequela. There was (P Conclusion: We concluded that PCNL using adult sized instruments was relatively safe in children, with a clearance rate of 67%. We suggest prospective randomized studies to compare mini-perc and adult sized instruments use in pediatric PCNL. Keywords: percutaneous nephrolithotomy, child, kidney calculi, treatment outcome Corresponding Author: Robab Maghsoudi, MD Department of Urology, Hasheminejad Kidney Center, Valinejad St., Vanak Square, Tehran, Iran Tel: +98 21 8864 4486 Fax: +98 21 8864 4497 E-mail: rmaghsudy@yahoo. com Received May 2011 Accepted August 2011 1Hasheminejad Clinical Re- search Development Center (HCRDC), Tehran University of Medical Sciences (TUMS), Tehran, Iran 2 School of Public Health, Tehran University of Medical Sciences (TUMS), Tehran, Iran Endourology and Stone Disease 466 | INTRODUCTION Uin developed countries, of which 1% to 3% are children. Certain factors, such as anatomical and metabolic abnormalities, small children stone treatment. Surgical management of stone has evolved over the past two decades. in the 1980s, most stones have been treated with this modality. Although SWL is the treatment of choice for stones in children, percutaneous nephrolithotomy - tions, including large stone burden, cysteine stones, and residual stones after failed SWL or open surgery. by Fernstrom and Johansson in 1976 and the - sides and colleagues with adult sized instrument in 1985. Today, PCNL is a well established treatment option for pediatric nephrolithiasis. Concerns about major complications and seque- lae of renal puncture with adult sized instruments lead to the design of small sized instruments and the mini-perc technique. Nonetheless, single- - - crease in the tract site. Wadhwa and associates and DMSA scans pre-operatively and 3 months after the procedure, and showed that adult sized instruments had no adverse effect on renal func- function improved after stone removal and there was no new scar on renal DMSA scan after stand- ard PCNL. Similarly, other studies using radioi- sotope scans found no change in differential renal - cant increase in GFR in the long-term follow-up after PCNL. Li and coworkers prospectively showed that acute - - vasiveness remains unproven. It is reported that bleeding and transfusion are more common after standard PCNL. In this study, we present our exprience in this area. MATERIALS AND METHODS Study Population We retrospectively reviewed medical records of 38 children younger than 15 years who had un- The pre-operative workup included urinalysis, urine culture, serum level of creatinine, coagula- - contrast abominal CT scan. Patients with positive antibiotics. Prophylactic antibiotics were admin- istered to all other children. Surgical Technique - eter was inserted in retrograde fashion for opaci- - oscopy-guided punctures were made at the lower posterior calyx with the patient in the prone posi- - 30F Amplatz sheath based on the degree of hydro- injection and surgeon preferance. Intercostal ac- cess was obtained by creating skin punctures over the lateral portion of the rib during full expiration. Pneumatic and/or ultrasonic stone fragmentation Endourology and Stone Disease 467Vol. 9 | No. 2 | Spring 2012 |U R O LO G Y J O U R N A L was done using the Swiss LithoClast Master. A nephrostomy tube was left in the kidney at the During our experience with standard PCNL, we observed that spontaneous displacement of the nephrostomy tube in some of our patients caused - ver, protracted urine leakage, or transfusion; thus, we performed tubeless PCNL in our next subjects. - sidual fragments or the presence of fragments less This study was approved by the Medical Ethics Committee of Hasheminejad Clinical Research Development Center and was fully explained to the patients’ parents. A written informed consent was obtained from all the parents. Statistical Analysis The data were analyzed using SPSS software (the Statistical Package for the Social Sciences, Univariate analyses were perfomed to detect any - pendent and independent variables. The 95% con- RESULTS Percutaneous nephrolithotomy was done on the family history of stone disease in 30% of patients. Three patients had history of open surgery and 6 had unsuccessful SWL. Twelve patients had com- pelete staghorn stones. Mean stone burden was Access was gained from the lower posterior calyx access. The tract was dilated to 30F in 33 renal was done in 37 renal units and a nephrostomy tube was inserted in 8 patients. In 37 renal units, there was subcostal access, 7 had intercostal ac- cess, and one was a transplanted kidney. Simul- taneous transurethral lithotripsy was done in 9 patients. Table 1 shows patients’ characteristics in a comparison of pre and postoperative parametres in the standard and tubeless groups. Based on the Table 1. Basic information in the tubeless and standard PCNL.* Variable Tubeless PCNL Standard PCNL P Gender .033 Male Female 12 0 Side .030 Right 22 1 Left 15 7 Mean age, y 6.3 ± 2.2 Mean stone burden, cm 3.0 ± 0.9 2.5 ± 0.5 .19 *PCNL indicates percutaneous nephrolithotomy. Percutaneous Nephrolithotomy with Adult Instruments | Etemadian et al 468 | Eight subjects had postoperative fever beyond day 1 up to 7th postoperative day, and were treated conservatively without any other intervention. No readmission occurred because of fever or other complications. Transfusion was required only in one patient because of Hb drop below 7 g/dL. - mosis sterile water. In a 3-year-old patient with staghorn stone, seizure occurred after tubeless PCNL; workup showed hyponatremia (Na = 113 - through slow correction of hyponatremia, and discharged from the ICU without any adverse - tions in the two groups. between tubeless and standard PCNL groups (P < - operative fever, stone burden, Hb drop, and Am- group differences in Hb drop and Amplatz size (P access site. DISSCUSION Anatomic and metabolic abnormalities in chil- dren have made stone recurrence and multiple surgical interventions more likely. To avoid any sequela, less invasive procedures, such as SWL and PCNL, are treatments of choice. Stone-free rates after pediatric PCNL range from 67% to 100%. Large retrospective studies have shown success rates as high as 90% with PCNL monotherapy. Mahmud and Zaidi achieved a stone-free rate of 60% with PCNL monotherapy, which was improved to 100% with SWL sand- wich therapy. Our stone-free rate was 67% at center over the country, many patients are fol- lowed up elsewhere and most of our patients were lost due to long-term follow-up period. Our rela- tively lower stone-free rate can be attributed to more complex stones and usage of a single tract only. Although multiple access tracts increase the stone-free rate, we refrained from this approach Table 3. Frequency of complications in the tubeless and standard percutaneous nephrolithotomy. Complication Tubeless Standard Transfusion 1 0 Fever 6 2 Extravasation 0 0 0 0 0 0 Hyponatremia (seizure) 1 0 Table 2. Pre and postoperative parameters in tubeless and standard percutaneous nephrolithotomy.* Parameters Tubeless Standard P Pre-operative Hb, g/dL 12.67 ± 1.7 12.71 ± 1.9 .95 Postoperative Hb, g/dL 11.39 ± 1.6 .65 Pre-operative Cr, mg/dL 0.73 ± 0.19 .60 Postoperative Cr, mg/dL 0.63 ± 0.19 .11 Mean Hb drop, g/dL 1.5 ± 0.69 .24 Mean hospital stay, day 3.5 ± 1.1 5 ± 1.6 .001 Endourology and Stone Disease 469Vol. 9 | No. 2 | Spring 2012 |U R O LO G Y J O U R N A L to avoid the associated complications. On the oth- er hand, attempts to extract staghorn stones from a single tract can result in nephroscope torque on the renal parenchyma and inadvertent injury and bleeding; therefore, we did not stress on this ma- neuver. In an effort to decrease renal damage, Jackman and colleagues introduced the “mini-perc” tech- nique using a 15F peel-away vascular sheath that needs a smaller skin incision and smaller tract size, and low complication rates and less pain were re- ported. Gunes and associates reported a higher incidence of complications, such as bleeding, in children younger than 7 years with adult sized instruments and standard PCNL. Although we did not use the mini-perc technique, our study did - tal stay. The reason for lower complications at our center may be that pediatric PCNL is only per- formed by experienced surgeons. Wadhwa and coworkers showed marginal renal function improvement after stone removal on isotope scan. Although creatinine level is not a sensetive indicator for small parenchymal dam- age, access to patients’ renal radioisotope scans was limited due to the retrospective nature of the study; thus, we used increasing serum levels of creatinine as a proxy for renal function. There pre and postoperatively in our subjects. Despite encouraging results, concern remains regarding safety of endourologic treatment in pediatric pa- tients and its subsequent effects on the growing kidney. candidates for pediatric PCNL had UTI in the past. A history of documented UTI was positive in 13.3% of our patients probably because of the general use of antibiotics without any evaluation in febrile children. result in overload and hyponatremia; hence, a should be used to prevent this complication. At the same time, irrigation solutions must be warmed to prevent hypothermia, which can only one subject, who had a prolonged operative time because of a staghorn stone. We had no case of hypothermia, and assume that we can use re- versed osmosis sterile water for irrigation in chil- dren without fear of hyponatremia, especially in patients with small stone burden. drop and transfusion rate were number and size of the tract. Mean Hb decrease in our study was - ference in Hb drop between tubeless and nephros- tomy cases or those done with two different Am- platz sheath sizes. Zeren and associates reported operative time and larger Amplatz sheath and stone burden were associated with greater trans- fusion rates. In line with other studies, the most common complication in our study was fever, which per- st postopera- tive day. Only one of our patients with a large culture had fever for 6 days. All the patients with fever were managed conservatively without any intervention. Samad and colleagues reported a stone-free rate of 59% with PCNL monotherapy and a 3.6% transfusion rate. Only one of our patients or our patients’ higher levels of pre-operative Hb. Tubeless PCNL is less painful and less trouble- some for adults and it shortens their hospital stay. The literature on this subject in the pediatric population is scant. Our study showed that Percutaneous Nephrolithotomy with Adult Instruments | Etemadian et al 470 | - less group compared to the standard group. In the pediatric population, urolithiasis is more preva- ratio; this may be because of the higher incidence of anatomical abnormalities in the male gender. This study has some limitations, such as lack of a control group, short follow-up period, and low sample size. CONCLUSION In our study, PCNL using adult sized instruments appeared to be safe and effective. However, fur- ther prospective randomized studies with larger sample sizes are needed to compare mini-perc with adult sized instruments used in PCNL. CONFLICT OF INTEREST None declared. REFERENCES 1. Hiatt RA, Dales LG, Friedman GD, Hunkeler EM. Frequency of urolithiasis in hospital discharge diagnosis in the United 2. Schultz-Lampel D, Lampel A. The surgical management of 3. Kroovand RL. Pediatric urolithiasis. Urol Clin North Am. 4. Lottmann HB, Traxer O, Archambaud F, Mercier-Pageyral B. Monotherapy extracorporeal shock wave lithotripsy for the treatment of staghorn calculi in children. J Urol. 5. Fernstrom I, Johansson B. Percutaneous pyelolithotomy. A new extraction technique. Scand J Urol Nephrol. 6. Woodside JR, Stevens GF, Stark GL, Borden TA, Ball WS. Percutaneous stone removal in children. J Urol. 7. Jackman SV, Hedican SP, Peters CA, Docimo SG. Percutane- ous nephrolithotomy in infants and preschool age children: 701. Moskovitz B, Halachmi S, Sopov V, et al. Effect of percutane- ous nephrolithotripsy on renal function: assessment with quantitative SPECT of (99m)Tc-DMSA renal scintigraphy. J 9. Wadhwa P, Aron M, Bal CS, Dhanpatty B, Gupta NP. Critical prospective appraisal of renal morphology and function in children undergoing shockwave lithotripsy and percutane- 10. Mor Y, Elmasry YE, Kellett MJ, Duffy PG. The role of percu- taneous nephrolithotomy in the management of pediatric 11. Dawaba MS, Shokeir AA, Hafez AT, et al. Percutaneous nephrolithotomy in children: early and late anatomical and 12. Li LY, Gao X, Yang M, et al. Does a smaller tract in percutane- ous nephrolithotomy contribute to less invasiveness? A 13. Gupta NP, Mishra S, Suryawanshi M, Seth A, Kumar R. Com- parison of standard with tubeless percutaneous nephroli- 14. Samad L, Aquil S, Zaidi Z. Paediatric percutaneous nephro- 15. Sahin A, Tekgul S, Erdem E, Ekici S, Hascicek M, Kendi S. Percutaneous nephrolithotomy in older children. J Pediatr 16. Zeren S, Satar N, Bayazit Y, Bayazit AK, Payasli K, Ozkeceli R. Percutaneous nephrolithotomy in the management of 17. Mahmud M, Zaidi Z. Percutaneous nephrolithotomy in chil- dren before school age: experience of a Pakistani centre. Jackman SV, Docimo SG, Cadeddu JA, Bishoff JT, Kavoussi LR, Jarrett TW. The "mini-perc" technique: a less invasive alternative to percutaneous nephrolithotomy. World J Urol. 19. Gunes A, Yahya Ugras M, Yilmaz U, Baydinc C, Soylu A. Percutaneous nephrolithotomy for pediatric stone disease- -our experience with adult-sized equipment. Scand J Urol 20. Schuster TK, Smaldone MC, Averch TD, Ost MC. Percutane- 705. 21. during percutaneous nephrolithotomy: does it matter? J Endourology and Stone Disease 471Vol. 9 | No. 2 | Spring 2012 |U R O LO G Y J O U R N A L 22. Docimo SG, Peters CA. Pediatric Endourology and Laparos- copy. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds. Campbell-Walsh Urology. Vol 4. 9 ed. Philadelphia: 23. nephrolithotomy for complex pediatric renal calculus 24. Kapoor R, Solanki F, Singhania P, Andankar M, Pathak HR. Percutaneous Nephrolithotomy with Adult Instruments | Etemadian et al