|Year : 2018 | Volume
| Issue : 2 | Page : 63-66
Supine percutaneous nephrolithotomy in children
Rajendra B Nerli1, Amit Mungarwadi2, Shridhar C Ghagane3, Neeraj S Dixit3, Murigendra B Hiremath4
1 Department of Urology, JN Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University); Department of Urology, KLES Kidney Foundation, KLES Dr. Prabhakar Kore Hospital and M. R. C, Belagavi, Karnataka, India
2 Department of Urology, JN Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), Belagavi, Karnataka, India
3 Department of Urology, KLES Kidney Foundation, KLES Dr. Prabhakar Kore Hospital and M. R. C, Belagavi, Karnataka, India
4 Department of Biotechnology and Microbiology, Karnatak University, Dharwad, Karnataka, India
|Date of Web Publication||10-Dec-2018|
Rajendra B Nerli
Department of Urology, KLES Kidney Foundation, KLES Dr. Prabhakar Kore Hospital and M. R. C, Nehru Nagar, Belagavi - 590 010, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: The stone disease in children shows wide geographic variations, and its incidence has increased worldwide in children of all ages. Percutaneous nephrolithotomy (PCNL) has gradually emerged as one of the standard treatment options for the management of renal stones >1.5 cm in pediatric cases. PCNL just like in adults has been performed in the prone position. Of late observing the successful use of supine position for PCNL in adults, pediatric urologists have been encouraged to use the supine access for PCNL in children. We report our early experience with supine PCNL in children. Materials and Methods: All children with symptomatic renal stones presenting to the pediatric urological services of our hospital were prospectively included into the study to undergo supine PCNL. Children with skeletal anomalies, bleeding diathesis, and active urinary tract infection were excluded from the study. Results: Ten children (six males and four females) with a mean age of 11.48 ± 2.08 years (9–18 years) underwent supine PCNL. The mean size of the stone was 22 mm (range 17–47 mm). The initial stone-free rate was 90% immediately after a single PCNL session. One child needed an additional extracorporeal shockwave lithotripsy session to clear a 7-mm fragment. The average operative time (from the beginning of the puncture trial to nephrostomy tube insertion) was 70 ± 5 min. Conclusions: Supine PCNL in children is feasible, safe, and an effective means for management of renal stones in the pediatric population.
Keywords: Percutaneous nephrolithotomy, renal calculi, supine
|How to cite this article:|
Nerli RB, Mungarwadi A, Ghagane SC, Dixit NS, Hiremath MB. Supine percutaneous nephrolithotomy in children. J Sci Soc 2018;45:63-6
| Introduction|| |
The removal of percutaneous stone has stood the test of time as the treatment of choice for large and/or complex renal stones even after 30 years and more. The prone position for percutaneous nephrolithotomy (PCNL) has been traditionally in use since Goodwin et al. gained their percutaneous renal access in 1955, and Fernstrom and Johansson described the percutaneous pyelolithotomy technique in 1976. There have been genuine concerns of the prone position, namely, the anesthetic concerns of the prone position (especially in morbidly obese patients, those with compromised cardiopulmonary status or skeletal deformities) and the difficulty of obtaining a combined antegrade and retrograde access to the renal cavities when needed.,
Valdivia Uria described his experience with the supine approach for PCNL in late 1980s, publishing consistent clinical data on the efficacy and safety of this technique; however, his results did not obtain the deserved consensus within the endourological community. The Galdakao-modified supine Valdivia (GMSV) position optimally supports endoscopic combined intrarenal surgery, a novel combined antegrade and retrograde approach to the upper urinary tract for the treatment of large and/or complex urolithiasis, involving the synergic use of rigid and flexible endoscopes, various accessories and lithotripsy energies, and a synergic cooperation among all the operators (two surgeons, anesthesiologist, scrub nurse, nurses, and radiology technician) with the relative armamentaries.,,,,,
Gamal et al. evaluated the safety and efficacy of supine PCNL in a total of 27 children (6 girls and 21 boys). A single lower calyceal access was used in all cases through which they could successfully remove even the upper calyceal stones. The average operative time (from the beginning of the puncture trial to nephrostomy tube insertion) was 41 ± 15 min. The initial stone free rate was 92.5%. The authors concluded that supine PCNL was a safe and effective method for the management of renal stones in children. We report our early experience with supine PCNL in children.
| Materials and Methods|| |
All children with symptomatic renal stones presenting to the pediatric urological services of our hospital were prospectively included into the study. The study was conducted with permission obtained from the institutional/university ethics committee. Laboratory tests, abdominal ultrasonography, plain X-ray of the kidneys, ureters, and urinary bladder (KUB) region, and either an intravenous urogram or contrast-enhanced computed tomography were done in all children [Figure 1]. Children with positive urine culture received appropriate antibiotics. Children with a single or multiple pelvic renal calculi, lower calyceal calculi of >1.5 cm, with no congenital anomaly of renal ascent, and fusion anomalies were included for supine PCNL. Similarly, children with skeletal anomalies, bleeding diathesis, and active urinary tract infection were excluded from the study.
|Figure 1: (a) Plain X-ray of kidneys, ureters, and urinary bladder showing bilateral renal calculi. (b and c) Computed tomography showing bilateral renal calculi|
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Positioning of the child
The posterior axillary line was drawn on the skin with the child standing; subsequently, the child was given general anesthesia in the supine position [Figure 2]. The side or flank to be operated upon was made to lean out of the border of the operating table and was raised and slightly rotated by a single underlying cushion or by two separated jelly pillows put under the thorax and the ankle. The ipsilateral arm was laid on the thorax, while the venous access was assured on the contralateral arm; the remaining landmarks, i.e., 12th rib and iliac crest, were then drawn on the skin. The lower limbs were arranged in a modified lithotomy position, typical of the GMSV position, with the leg of the side to be operated extended and the contralateral one well abducted. Care was taken to prevent pressure injuries and by padding the legs stirrups. Once the child was correctly positioned, the part was prepared and draped preferably using a single sterile draping, standardized according to the individual requirements. The position permitted both percutaneous and retrograde accesses simultaneously, the movements of the endoscopic instruments remained unhindered, and all the monitors (endoscopic, ultrasound, and fluoroscopic) were visible by surgeons, nurses, and residents, and the rest of the armamentarium such as lithotripsy and energy sources were handy for the operators.
|Figure 2: (a) The marking of the posterior axillary line on the child. (b) The modified supine position|
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Preliminary retrograde ureterographic evaluation
An appropriate-sized cystoscope was used to perform the initial cystourethroscopy, examination of the ureteric orifices, selective catheterization of the ureter using a ureteric catheter, performing retrograde ureterogram, and positioning of the guidewire. The delineation of the ureteric anatomy on ureterogram would be useful if simultaneous ureteroscopic examination and procedure was necessary. Ureteroscopy may also be useful in providing endovision-assisted fluoroscopic and ultrasound-guided renal puncture, with the possibility of controlling/correcting the exiting of the needle through the tip of the renal papilla after passing through the Brodel's avascular line, thus minimizing the risk of bleeding. Ureteroscopic endovision would also be useful in assisting percutaneous tract dilation and Amplatz sheath application, thereby minimizing radiation exposure.
The first step was the insertion of a retrograde 5 Fr ureteric catheter. Under fluoroscopic guidance, an initial puncture was made using an 18-gauge puncture needle [Figure 3]. The puncture was medial to posterior axillary line and was directed horizontally or with slight upward needle inclination toward the operating table. The fluoroscopy was maintained perpendicular to the access tract throughout the duration of the procedures. After a successful puncture, a 0.035 Fr Super Stiff guidewire was inserted either straight down to the ureter or to another calyx. The tract was dilated up to 22 Fr and the Amplatz tube was inserted. Hypothermia was avoided using a warming mattress, appropriate air-conditioning, and covering the child's extremities with a warming blanket.
|Figure 3: (a) Under fluoroscopic guidance, an initial puncture was made using an 18-gauge puncture needle. (b) The tract was dilated up to 22 Fr|
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A sheathless 19 Fr Richard Wolf rigid nephroscope or an 18 Fr Storz rigid nephroscope was used in all cases, and the stones were disintegrated using either pneumatic lithotripsy or holmium laser [Figure 4]. The procedure was terminated after complete stone clearance as confirmed on fluoroscopy and endoscopy. At the end of the procedure, a 14 Fr nephrostomy tube was placed within the tract and clamped for 12 h or overnight. The following morning plain X-ray of KUB region and abdominal ultrasonography was done to ensure complete clearance. The nephrostomy was removed in the absence of residual significant stone fragments. The child was discharged 48–72 h after surgery. The child was called for follow-up after 2 weeks. The treatment success was defined as the child being free of any stone fragments (>4 mm) by 30 days posttreatment. The complications (intra- and postoperative) were evaluated postoperatively. Stone analysis was performed in all cases.
|Figure 4: (a and b) The stones were disintegrated using either pneumatic lithotripsy or holmium laser|
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| Results|| |
During this prospective study (January 2016–December 2016), ten children (six males and four females) with a mean age of 11.48 ± 2.08 years (9–18 years) underwent supine PCNL. The presenting symptoms in these children included pain in abdomen (90%), hematuria (40%), fever (30%), and discomfort (20%). The renal stones were single pelvic stone in 4 (40%), multiple pelvic calculi in 2 (20%), single pelvic stone with lower calyceal stones in 2 (20%), and bilateral single pelvic stone in 2 (20%) children. All the stones were radiopaque. Five children had right-sided stones, three had left-sided stones, and the remaining two had bilateral renal calculi. One of these children had a history of undergoing extracorporeal shockwave lithotripsy treatment (ESWL) previously. The mean size of the stone was 22 mm (range 17–47 mm) on measuring the longest diameter (solitary stone) and in the case of multiple stones (sum of the longest diameters of all the stones). The initial stone-free rate was (90%) immediately after a single PCNL session. One child needed an additional ESWL session to clear a 7-mm fragment.
The average operative time (from the beginning of the puncture trial to nephrostomy tube insertion) was 70 ± 15 min. A single lower calyceal tract was successfully applied in all cases, and all the punctures were subcostal. We did not encounter any access difficulties; hypermobility of the kidney encountered during the tract dilatation was overcome by anterior abdominal wall support by the assistant in two children. The tract was dilated up to 22 Fr in all ten children. None of the children needed either intra- or postoperative blood transfusions. The calculated blood loss ranged between 50 and 100 ml (mean 60 ml). There were no instances of intraoperative hypothermia or volume overload reported. Three of the children had perinephrostomy tube leak, lasting for 12–24 h, but stopped on own. One child had mild fever needing antipyretics for 24 h. There were no major postoperative complications in the form of urinary leak or postoperative bleeding. All the children were discharged home within 72 h postoperatively. Stone analysis revealed calcium oxalate plus uric acid in 5 (50%) cases, calcium oxalate in 4 (40%) cases, and calcium ammonium phosphate in 1 (10%) case.
| Discussion|| |
The technique of PCNL has changed significantly in recent years. Miniaturization of nephroscopes, improvement in the lithotripsy devices, and new retrieval tools have resulted in growth of pediatric PCNL. Since its inception, PCNL has been performed in the prone position. Urologists have been very familiar with this access, and moreover, this access provides a wide operative field for manipulation of the instrumentation and a wide distended pelvicalyceal system with a high success rate and acceptable complication rates. Despite its popularity, prone PCNL has its disadvantages, including cervical spine trauma from excessive extension or flexion  and difficulty in continuous monitoring of the endotracheal tube to avoid kinking or slippage in addition to the ventilatory difficulty caused by restricted mobility of thorax and abdomen.,, Moreover, it is difficult for an anesthetist to observe the child in the prone position, and if an emergency occurred, such as cardiac arrest, resuscitation may be impossible. All these issues associated with the prone position in the pediatric population has created an interest in supine PCNL among the pediatric urologists.
Valdivia Uría et al. performed the first supine PCNL in an adult in the year 1987. Gamal et al. advised that supine PCNL in children should follow the same principle as in adult supine PCNL with elevation of the ipsilateral shoulder and hip to widen the surface area for renal access. They reported an initial stone-free rate of 92.5%, which is comparable with many reported pediatric prone PCNL series (86% to up to 98%).,, The initial stone free rate in our series too is 90%. Gamal et al. reported no cases of hypothermia in their series. In supine PCNL, the tract is horizontal or with slight upward inclination toward the operative table, allowing most of the irrigation fluid to fall away from the child, thus decreasing the incidence of hypothermia, which is critical in pediatric population. Another advantage of the horizontal tract of supine PCNL is that most of the wash goes out, causing a collapsed pelvicalyceal system ensuring a low-pressure PCNL procedure and decreasing the incidence of urosepsis, which is also critical in the pediatric population. This probably explains the low incidence of postoperative fever in our series when compared with other series of prone pediatric PCNL in which postoperative fever reaches 30%–40%.
A number of potential advantages of supine pediatric PCNL have been outlined in the literature: (1) it is comfortable for the surgeon as he works in sitting position; (2) it is very comfortable for the anesthetist, especially in this critical age group, as it allows easy follow-up of the endotracheal tubes, and easy intervention in case of emergency, nonrestricted respiratory and abdominal movements; and (3) it is more comfortable for the child as there are fewer incidences of colonic injury, sepsis, hypothermia, volume overload, and less manipulation in repositioning.
As of now, there are a few shortcomings of the supine position. This is not familiar to most urologists, but this could be overcome by initiating training and protocols for the new residents/beginners., This access has a small field of operation; however, this could be overcome with the use of flank elevation by bags below the ipsilateral hip and shoulder. The hypermobility of the kidney during tract dilation might be encountered, and this can be overcome easily by anterior abdominal wall support by the assistant. Our study includes small numbers and is just an initial experience; however, larger series should prove the advantages of supine PCNL in comparison with prone PCNL.
| Conclusions|| |
Supine PCNL in children is feasible, safe, and an effective means for the management of renal stones in the pediatric population. It carries the advantages for the surgeon who can perform in a sitting down position, avoids changing of position at the beginning and end of PCNL, is associated with less chance of hypothermia and fluid absorption, and offers the anesthetist easy monitoring.
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Conflicts of interest
There are no conflicts of interest.
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