Pediatric Urology Flank-free Modified Supine Percutaneous Nephrolithotomy in Pediatric Age Group Esam A. E. Desoky, Ehab R. ElSayed, Ahmed Eliwa, Mohamed Sleem, Waleed Shabana, Tamer Dawood, Mohamed Teleb, and Salem Khalil OBJECTIVE
PATIENTS AND METHODS
RESULTS
CONCLUSION
To evaluate the safety and efficacy of pediatric percutaneous nephrolithotomy (PCNL) in the flank-free modified supine position (FFMSP). PCNL in the supine position is increasingly and successfully used in pediatric age group. Different modifications of supine positions have been described; however, the best supine position is not well established and remains a matter of debate. This prospective study included 22 children presenting with single renal pelvis stone (2-3 cm) in the period between May 2012 and April 2014. Diagnosis was set by plain x-ray and computed tomography in all patients. PCNL was performed with the patients placed in the FFMSP. The operative time and hospital stay were estimated. The outcome and any perioperative complications or conflicts were recorded. The study included 22 children (15 boys and 7 girls) with a solitary renal pelvis stone. Mean standard deviation age of the patients was 9.5 3.2 years (range, 3-15.5 years). Stone length, operative time, and hospital stay had mean standard deviation of 2.4 0.23 cm, 65.1 18.7 minutes, and 4.4 0.9 days. Stone-free rate was 90.9% after 1 session of PCNL. One patient (4.5%) needed a second-look PCNL. Shock wave lithotripsy was performed for another patient. Postoperative fever occurred in 4 patients (18.2%). One patient received postoperative blood transfusion. Postoperative transient urinoma occurred in 2 patients (9.1%). PCNL in pediatric age group via FFMSP was proved to be safe and effective in management of renal pelvis stones of size 2-3 cm. It provides stone clearance rate comparable with that reported of conventional PCNL in the prone position. UROLOGY 85: 1162e1165, 2015. 2015 Elsevier Inc.
I
ncidence of pediatric urolithiasis varies from 5%-15% in developing countries to 1%-5% in the developed ones. It is usually associated with urinary tract infection, anatomic, and metabolic abnormalities. Therefore, it has a high 5-year recurrence rate of about 55% (range, 38%-70%).1,2 Pediatric urolithiasis may be associated with underlying metabolic, enzymatic, or anatomic abnormalities, which may lead to a high chance of stone recurrence.2 In the last decades, management of pediatric upper tract stones has evolved rapidly. Open surgery is now limited to only a few indications, whereas minimally invasive shock wave lithotripsy (SWL) is the preferred treatment. SWL limitations include lower efficacy for large and multiples stones, potential long-term effects on developing kidneys, and the probability of requiring multiple sessions under anesthesia.3 The first pediatric percutaneous nephrolithotomy (PCNL) was performed by Woodside et al in 1985.4 The technique of
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, Zagazig University, Zagazig, Sharkia, Egypt Address correspondence to: Ehab R. ElSayed, M.D., Department of Urology, Zagazig University, 11 Mahmoud Hashim Street, Zagazig, Sharkia 44111, Egypt. E-mail: [email protected] Submitted: December 26, 2014, accepted (with revisions): January 27, 2015
1162
ª 2015 Elsevier Inc. All Rights Reserved
PCNL has been modified over the last years, and it is now a well-established less-invasive procedure for pediatric nephrolithiasis.2 PCNL is traditionally performed in the prone position,5 but the supine position has proven a good option with several advantages.6,7 PCNL in the supine position has a similar success rate and a shorter operative time than conventional PCNL.8 In the supine position, Amplatz sheath (Cook Medical, Bloomington, IN) is oriented downward, maintaining a low pressure in the renal pelvis and reducing the risk of fluid absorption.9 Furthermore, the supine position is easier for the anesthesiologist to control the airway and carry a lower chance of neural and ophthalmologic pressure lesions than the prone position.10 Desoky et al11 in 2012 described the flank-free modified supine position (FFMSP) and claimed that this position overcomes the mechanical limitation of ordinary supine position because of ample space for puncture, dilatation, multiple tracts, and maneuverability of the system with the nephroscope. One year later, the same authors published a comparative study between FFMSP and prone position in adult and concluded that FFMSP has a similar efficacy and safety to the standard prone position for PCNL and offers a significantly less-operative time.12 Herein, we tried to http://dx.doi.org/10.1016/j.urology.2015.01.030 0090-4295/15
evaluate the safety and efficacy of pediatric PCNL in the FFMSP.
PATIENTS AND METHODS Between May 2012 and April 2014, a prospective study was conducted on 22 children presenting with single renal pelvis stone (2-3 cm). Diagnosis was set by plain x-ray and computed tomography in all patients. Exclusion criteria were renal anomalies, single kidney, and uncontrolled coagulopathy. An informed consent was obtained from the parents of all patients after approval of our local ethical committee. Preoperative laboratory investigations included complete blood count, bleeding and clotting time, urine analysis, urine culture (in case of pyuria), and renal function tests.
Figure 1. The figure shows the flank-free modified supine position. (Color version available online.) Table 1. Patients and stone criteria plus operative data
Operative Technique First, we mark the ipsilateral posterior axillary line while the patient is standing. General anesthesia was introduced in 17 patients, and 5 patients received regional (spinal or epidural) anesthesia. After the patient is placed in the lithotomy position, 0.025-inch guide wire was inserted in the ipsilateral ureter to safely negotiate 5F or 6F open-tipped ureteral catheter under fluoroscopy. Then, the patient was placed in the FFMSP by putting a suitable cushion (according to body mass) under the ipsilateral shoulder, the ipsilateral arm was placed over the thorax, and the ipsilateral leg was extended and crossed over the flexed contralateral leg (Fig. 1). All pressure points were well padded, and proper water seal draping of the child was used. Under fluoroscopic guidance and after opacification of the pyelocalyceal system, renal access was achieved through a subcostal puncture in the posterior axillary line. Coaxial Alken dilators were used for tract dilatation. A 20F Amplatz sheath (Cook Medical) was inserted allowing the introduction of an 18F nephroscope without its outer sheath or short ureteroscope. A pneumatic or laser lithotripsy device was used to fragment the stone, and the fragments were retrieved through the Amplatz sheath (Cook Medical). At the end of the procedure, a 16F nephrostomy tube was fixed and clamped for 6 hours postoperatively for homeostasis. The operative time (from the introduction of the endoscope till fixation of the nephrostomy tube) was estimated. After 24 hours, patients were assessed with kidney, ureter, and bladder and abdominopelvic ultrasonography. Then, the nephrostomy tube was removed, if there was no indication for a second look, and the patients had no fever or urinoma. One day later, the urethral and ureteric catheters were removed. In patients with postoperative urinoma or residual stones scheduled for SWL, the ureteric catheter was replaced by a double-J stent. Prophylactic parenteral broad-spectrum antibiotics were continued after surgery until all tubes were removed. The outcome was considered as successful if the patient became stone free or had residual fragments of
PATIENTS AND METHODS
RESULTS
CONCLUSION
To evaluate the safety and efficacy of pediatric percutaneous nephrolithotomy (PCNL) in the flank-free modified supine position (FFMSP). PCNL in the supine position is increasingly and successfully used in pediatric age group. Different modifications of supine positions have been described; however, the best supine position is not well established and remains a matter of debate. This prospective study included 22 children presenting with single renal pelvis stone (2-3 cm) in the period between May 2012 and April 2014. Diagnosis was set by plain x-ray and computed tomography in all patients. PCNL was performed with the patients placed in the FFMSP. The operative time and hospital stay were estimated. The outcome and any perioperative complications or conflicts were recorded. The study included 22 children (15 boys and 7 girls) with a solitary renal pelvis stone. Mean standard deviation age of the patients was 9.5 3.2 years (range, 3-15.5 years). Stone length, operative time, and hospital stay had mean standard deviation of 2.4 0.23 cm, 65.1 18.7 minutes, and 4.4 0.9 days. Stone-free rate was 90.9% after 1 session of PCNL. One patient (4.5%) needed a second-look PCNL. Shock wave lithotripsy was performed for another patient. Postoperative fever occurred in 4 patients (18.2%). One patient received postoperative blood transfusion. Postoperative transient urinoma occurred in 2 patients (9.1%). PCNL in pediatric age group via FFMSP was proved to be safe and effective in management of renal pelvis stones of size 2-3 cm. It provides stone clearance rate comparable with that reported of conventional PCNL in the prone position. UROLOGY 85: 1162e1165, 2015. 2015 Elsevier Inc.
I
ncidence of pediatric urolithiasis varies from 5%-15% in developing countries to 1%-5% in the developed ones. It is usually associated with urinary tract infection, anatomic, and metabolic abnormalities. Therefore, it has a high 5-year recurrence rate of about 55% (range, 38%-70%).1,2 Pediatric urolithiasis may be associated with underlying metabolic, enzymatic, or anatomic abnormalities, which may lead to a high chance of stone recurrence.2 In the last decades, management of pediatric upper tract stones has evolved rapidly. Open surgery is now limited to only a few indications, whereas minimally invasive shock wave lithotripsy (SWL) is the preferred treatment. SWL limitations include lower efficacy for large and multiples stones, potential long-term effects on developing kidneys, and the probability of requiring multiple sessions under anesthesia.3 The first pediatric percutaneous nephrolithotomy (PCNL) was performed by Woodside et al in 1985.4 The technique of
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, Zagazig University, Zagazig, Sharkia, Egypt Address correspondence to: Ehab R. ElSayed, M.D., Department of Urology, Zagazig University, 11 Mahmoud Hashim Street, Zagazig, Sharkia 44111, Egypt. E-mail: [email protected] Submitted: December 26, 2014, accepted (with revisions): January 27, 2015
1162
ª 2015 Elsevier Inc. All Rights Reserved
PCNL has been modified over the last years, and it is now a well-established less-invasive procedure for pediatric nephrolithiasis.2 PCNL is traditionally performed in the prone position,5 but the supine position has proven a good option with several advantages.6,7 PCNL in the supine position has a similar success rate and a shorter operative time than conventional PCNL.8 In the supine position, Amplatz sheath (Cook Medical, Bloomington, IN) is oriented downward, maintaining a low pressure in the renal pelvis and reducing the risk of fluid absorption.9 Furthermore, the supine position is easier for the anesthesiologist to control the airway and carry a lower chance of neural and ophthalmologic pressure lesions than the prone position.10 Desoky et al11 in 2012 described the flank-free modified supine position (FFMSP) and claimed that this position overcomes the mechanical limitation of ordinary supine position because of ample space for puncture, dilatation, multiple tracts, and maneuverability of the system with the nephroscope. One year later, the same authors published a comparative study between FFMSP and prone position in adult and concluded that FFMSP has a similar efficacy and safety to the standard prone position for PCNL and offers a significantly less-operative time.12 Herein, we tried to http://dx.doi.org/10.1016/j.urology.2015.01.030 0090-4295/15
evaluate the safety and efficacy of pediatric PCNL in the FFMSP.
PATIENTS AND METHODS Between May 2012 and April 2014, a prospective study was conducted on 22 children presenting with single renal pelvis stone (2-3 cm). Diagnosis was set by plain x-ray and computed tomography in all patients. Exclusion criteria were renal anomalies, single kidney, and uncontrolled coagulopathy. An informed consent was obtained from the parents of all patients after approval of our local ethical committee. Preoperative laboratory investigations included complete blood count, bleeding and clotting time, urine analysis, urine culture (in case of pyuria), and renal function tests.
Figure 1. The figure shows the flank-free modified supine position. (Color version available online.) Table 1. Patients and stone criteria plus operative data
Operative Technique First, we mark the ipsilateral posterior axillary line while the patient is standing. General anesthesia was introduced in 17 patients, and 5 patients received regional (spinal or epidural) anesthesia. After the patient is placed in the lithotomy position, 0.025-inch guide wire was inserted in the ipsilateral ureter to safely negotiate 5F or 6F open-tipped ureteral catheter under fluoroscopy. Then, the patient was placed in the FFMSP by putting a suitable cushion (according to body mass) under the ipsilateral shoulder, the ipsilateral arm was placed over the thorax, and the ipsilateral leg was extended and crossed over the flexed contralateral leg (Fig. 1). All pressure points were well padded, and proper water seal draping of the child was used. Under fluoroscopic guidance and after opacification of the pyelocalyceal system, renal access was achieved through a subcostal puncture in the posterior axillary line. Coaxial Alken dilators were used for tract dilatation. A 20F Amplatz sheath (Cook Medical) was inserted allowing the introduction of an 18F nephroscope without its outer sheath or short ureteroscope. A pneumatic or laser lithotripsy device was used to fragment the stone, and the fragments were retrieved through the Amplatz sheath (Cook Medical). At the end of the procedure, a 16F nephrostomy tube was fixed and clamped for 6 hours postoperatively for homeostasis. The operative time (from the introduction of the endoscope till fixation of the nephrostomy tube) was estimated. After 24 hours, patients were assessed with kidney, ureter, and bladder and abdominopelvic ultrasonography. Then, the nephrostomy tube was removed, if there was no indication for a second look, and the patients had no fever or urinoma. One day later, the urethral and ureteric catheters were removed. In patients with postoperative urinoma or residual stones scheduled for SWL, the ureteric catheter was replaced by a double-J stent. Prophylactic parenteral broad-spectrum antibiotics were continued after surgery until all tubes were removed. The outcome was considered as successful if the patient became stone free or had residual fragments of
