(1)
Department of Paediatric Surgery and Urology, Sheffield Children’s NHS Trust, Sheffield, UK
Abstract
Advances in endourological techniques and their successful application in adult renal calculi over the last 30 years have led to a dramatic move from open surgery to minimally invasive techniques for pediatric urolithiasis. This chapter will focus on percutaneous nephrolithotomy (PCNL) and the tips and tricks in the procedure to achieve a successful outcome.
The online version of this chapter (doi:10.1007/978-1-4471-5394-8_28) contains supplementary material, which is available to authorized users.
Keywords
PediatricUrolithiasisPercutaneous nephrolithotomyMini percIntroduction
Pediatric urolithiasis has an overall incidence of 1–2 % of that observed in the adult population [1]. Urolithiasis is an endemic disease in the stone belt across the Middle East and Asian subcontinent. One report suggests an incidence of 17 % among children in Turkey [2]. Stones may be calcium oxalate stones which are reported to be the most frequent [3] or noncalcium-containing stones.
Over the last three decades with the successful results in the minimally invasive management of adult renal stones, there has been a shift from historical open surgery in children [4] to a minimally invasive approach. The minimally invasive techniques include extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL), and ureteroscopy (URS).
This chapter will describe the technique of PCNL the authors favor in management of pediatric urolithiasis.
Indications and Contraindications
Most children are suitable for PCNL irrespective of size/habitus (obesity) or abnormalities of the curvature of the spine (scoliosis).
The main indications for PCNL may be classified as:
1.
Stone size and location
(a)
Staghorn calculus
(b)
Multiple stones
(c)
Renal pelvic stone >2 cm
(d)
Lower pole >1 cm
(e)
Stone surrounding a foreign body
2.
Anatomy
(a)
Stone secondary to a UPJ obstruction
(b)
Infundibular stenosis
(c)
Stone within a calyceal diverticulum
The main contraindications are:
1.
Uncontrolled hypertension
2.
Active sepsis
3.
Coagulopathies
Preoperative Workup
The preoperative workup prior to a PCNL consists of determination of the size, number, location of the stones, anatomical configuration of the kidney, and the renal function.
The authors prefer the following workup:
1.
Plain X-ray KUB and renal ultrasound: Studies have shown that a combination of these two will detect up to 90 % of stones [5].
2.
DMSA: This gives information about the function of the kidney.
3.
An IVU may be used in some cases to determine the anatomy of the collecting system or where there is a strong index of suspicion of renal tract calculi not evident on the plain X-ray or ultrasound.
4.
In selected cases only, an unenhanced spiral CT scan (the gold standard for diagnosing renal tract calculi in adults) may be considered.
5.
Baseline blood hematology and biochemistry (FBC, creatinine, and electrolytes) and a group and save.
6.
A “spot” urine may be analyzed for metabolic analysis instead of the 24-h urine collection [6]. Where possible, the retrieved calculus should be sent for stone chemical analysis.
7.
Within 24 h of the surgery, the child should have another plain X-ray KUB and renal ultrasound scan to reconfirm location and number of calculi.
The Team
One of the most important requirements for a successful PCNL is the presence of a regular team who undertakes these procedures. In our institute, we have two pediatric urologists, two interventional pediatric radiologists, two pediatric anesthetists, and a pool of nursing staff who perform the PCNL. Our experience has shown that working as a team makes it more efficient and safe. A radiographer is also required for the procedure.
Instrumentation
For a PCNL, there is general equipment that is required and specific instrumentation for the PCNL. It is important to have all the instrumentation available to allow a choice of which instruments to use depending on the nature of the stone.
The General Equipment Requirements
1.
A fluoroscopy machine (C-arm) with monitor.
2.
A camera stack system: In our institute we have the benefit of OR-1 which allows for movement of multiple monitors to achieve the best ergonomic layout for a minimally invasive procedure.
3.
A general instrument trolley.
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