Original Paper
Urologia Internationalis
Received: August 6, 2013 Accepted after revision: October 11, 2013 Published online: March 1, 2014
Urol Int 2014;92:440–443 DOI: 10.1159/000356327
One Shot Tract Dilation for Percutaneous Nephrolithotomy: Is It Safe and Effective in Preschool Children? Seyed Reza Hosseini a Mohammad Ghasem Mohseni a Farshid Alizadeh b a Department of Urology, Tehran University of Medical Sciences, Tehran, and b Department of Urology, Isfahan University of Medical Sciences, Isfahan, Iran
Abstract Objective: To evaluate the safety and feasibility of percutaneous tract dilation by the one-stage method in preschool children. Methods: Between April 2009 and February 2013, all preschool ( 0.05) and 70.0 ± 8.9 s vs. 22.0 ± 5.6 s (p < 0.001), respectively. Postoperative compli-
© 2014 S. Karger AG, Basel 0042–1138/14/0924–0440$39.50/0 E-Mail [email protected] www.karger.com/uin
cations included one case of postoperative fever lasting less than 48 h in group I. Conclusions: Percutaneous tract dilation by the one-stage method is safe and effective. Also, it is associated with considerably less radiation exposure in preschool children. © 2014 S. Karger AG, Basel
Introduction
Percutaneous nephrolithotomy (PCNL) is the treatment of choice for many moderate- to large-sized renal stones. One of the most important steps of PCNL is establishing a safe percutaneous tract to the kidney and its dilation. Since the introduction of PCNL, several techniques have been developed to simplify it and to decrease the complications of tract creation and dilation. The current dilator devices include the semi-rigid multiple incremental Amplatz dilator set, metal telescopic dilators of the Alken type and one-stage balloon dilators [1–4]. The one-stage method was introduced by Frattini et al. [5]. In this procedure, tract dilation is performed in a single step using Amplatz dilators. Recent studies in adult patients have shown that this method is effective and acSeyed Reza Hosseini, MD, Assoc. Prof. Department of Urology Tehran University of Medical Sciences Tehran (Iran) E-Mail rhosseinim @ yahoo.com or srhoseini @ tums.ac.ir
Downloaded by: Universiteit Maastricht 137.120.4.50 - 7/9/2014 7:36:55 AM
Key Words One shot tract dilation · Percutaneous nephrolithotomy · Safety · Effectiveness · Preschool children
Materials and Methods Preoperative Protocol 62 children with kidney stone who underwent PCNL by a single surgeon (S.R.H.) at our center from April 2009 through February 2013 were enrolled. All patients were assessed preoperatively by non-contrast spiral computed tomography or intravenous pyelography. Routine blood tests and urine cultures were obtained. All procedures were done with the patient under general anesthesia in the prone position. Antibiotic prophylaxis with a first-generation cephalosporin was routinely administered to all patients with negative urine culture results. Patients with urinary tract infection received antibiotics according to sensitivity tests. Patients were assigned to one of the two intervention groups alternatively (every patient was allocated to a treatment group different from the previous one). In group I Alken telescopic dilators were employed to dilate the percutaneous tract, and in group II tract dilation was performed by the one-shot dilation procedure as explained by Frattini et al. [5]. Operative and Postoperative Protocol The patient was placed in the supine position. Cystoscopy was done after general anesthesia. A 4-F open-ended ureteral catheter was introduced into the renal pelvis and a Foley catheter was placed in the bladder. The patient was then turned to the prone position. Caliceal puncture was done using an 18-gauge angiographic needle under fluoroscopic guidance. After puncturing the caliceal system and with the urine coming out through the needle, an 0.089-cm guide wire was passed through the needle and threaded to the renal pelvis. The tract was initially dilated by insertion of an 8-F polyurethane dilator. In group I, the tract was dilated up to 24–26 F using sequential metallic dilators. In group II, a single 24or 26-F Amplatz dilator (based on the patient’s age) was passed on the Alken guide wire. In both groups, a 24- or 26-F working sheath was inserted after tract dilation. Rigid nephroscopy and calculus disintegration were performed in the conventional manner using a pneumatic lithotripter (Litho Crack, Sp. Swiss-Germany). Irrigation during the procedure was warm normal saline. After completion of lithotripsy and stone extraction, the status of residual stones was assessed by fluoroscopy. A 12- or 14-F nephrostomy tube was placed if indicated at the end of the operation. Patients were followed up in the clinic 2 weeks after operation with sonography and KUB. Stone-free patient was defined as anyone with residual stones ≤3 mm. Demographic, operative and postoperative data were collected prospectively. The primary endpoint of interest was fluoroscopy time. Secondary endpoints included tract creation and dilation time, success and complications. The ethics of the study was approved by the ethical committee of the Urology and Nephrology Research Center. The procedure was explained to parents and written informed consent was obtained.
One Shot Tract Dilation for Percutaneous Nephrolithotomy
Table 1. Demographic and perioperative data
Variables
Age, months Gender, male/female Side, left/right Stone size, mm1 Access number, single/multiple Access time, min Operation time, min Fluoroscopy time, s Hb before operation, mg/dl Hb after operation, mg/dl Stone-free patients Postoperative complications Postoperative hospital stay, days
Dilation technique
p value
one-shot
serial metallic
44.5 ± 14.9 22/9 21/10 20.0 ± 3.5 1/0
44.3 ± 16.5 18/13 17/14 17.0 ± 4.0 1/0
NS NS NS NS NS
5.9 ± 1.5 75 ± 15 22.0 ± 5.6 11.1 ± 0.7 10.4 ± 0.7 31 (100) 0 (0) 3.22 ± 1.70
7.3 ± 1.2 81 ± 9 70.0 ± 8.9 11.2 ± 0.6 10.4 ± 0.7 31 (100) 1 (3) 4.17 ± 1.06
NS NS
Urologia Internationalis
Received: August 6, 2013 Accepted after revision: October 11, 2013 Published online: March 1, 2014
Urol Int 2014;92:440–443 DOI: 10.1159/000356327
One Shot Tract Dilation for Percutaneous Nephrolithotomy: Is It Safe and Effective in Preschool Children? Seyed Reza Hosseini a Mohammad Ghasem Mohseni a Farshid Alizadeh b a Department of Urology, Tehran University of Medical Sciences, Tehran, and b Department of Urology, Isfahan University of Medical Sciences, Isfahan, Iran
Abstract Objective: To evaluate the safety and feasibility of percutaneous tract dilation by the one-stage method in preschool children. Methods: Between April 2009 and February 2013, all preschool ( 0.05) and 70.0 ± 8.9 s vs. 22.0 ± 5.6 s (p < 0.001), respectively. Postoperative compli-
© 2014 S. Karger AG, Basel 0042–1138/14/0924–0440$39.50/0 E-Mail [email protected] www.karger.com/uin
cations included one case of postoperative fever lasting less than 48 h in group I. Conclusions: Percutaneous tract dilation by the one-stage method is safe and effective. Also, it is associated with considerably less radiation exposure in preschool children. © 2014 S. Karger AG, Basel
Introduction
Percutaneous nephrolithotomy (PCNL) is the treatment of choice for many moderate- to large-sized renal stones. One of the most important steps of PCNL is establishing a safe percutaneous tract to the kidney and its dilation. Since the introduction of PCNL, several techniques have been developed to simplify it and to decrease the complications of tract creation and dilation. The current dilator devices include the semi-rigid multiple incremental Amplatz dilator set, metal telescopic dilators of the Alken type and one-stage balloon dilators [1–4]. The one-stage method was introduced by Frattini et al. [5]. In this procedure, tract dilation is performed in a single step using Amplatz dilators. Recent studies in adult patients have shown that this method is effective and acSeyed Reza Hosseini, MD, Assoc. Prof. Department of Urology Tehran University of Medical Sciences Tehran (Iran) E-Mail rhosseinim @ yahoo.com or srhoseini @ tums.ac.ir
Downloaded by: Universiteit Maastricht 137.120.4.50 - 7/9/2014 7:36:55 AM
Key Words One shot tract dilation · Percutaneous nephrolithotomy · Safety · Effectiveness · Preschool children
Materials and Methods Preoperative Protocol 62 children with kidney stone who underwent PCNL by a single surgeon (S.R.H.) at our center from April 2009 through February 2013 were enrolled. All patients were assessed preoperatively by non-contrast spiral computed tomography or intravenous pyelography. Routine blood tests and urine cultures were obtained. All procedures were done with the patient under general anesthesia in the prone position. Antibiotic prophylaxis with a first-generation cephalosporin was routinely administered to all patients with negative urine culture results. Patients with urinary tract infection received antibiotics according to sensitivity tests. Patients were assigned to one of the two intervention groups alternatively (every patient was allocated to a treatment group different from the previous one). In group I Alken telescopic dilators were employed to dilate the percutaneous tract, and in group II tract dilation was performed by the one-shot dilation procedure as explained by Frattini et al. [5]. Operative and Postoperative Protocol The patient was placed in the supine position. Cystoscopy was done after general anesthesia. A 4-F open-ended ureteral catheter was introduced into the renal pelvis and a Foley catheter was placed in the bladder. The patient was then turned to the prone position. Caliceal puncture was done using an 18-gauge angiographic needle under fluoroscopic guidance. After puncturing the caliceal system and with the urine coming out through the needle, an 0.089-cm guide wire was passed through the needle and threaded to the renal pelvis. The tract was initially dilated by insertion of an 8-F polyurethane dilator. In group I, the tract was dilated up to 24–26 F using sequential metallic dilators. In group II, a single 24or 26-F Amplatz dilator (based on the patient’s age) was passed on the Alken guide wire. In both groups, a 24- or 26-F working sheath was inserted after tract dilation. Rigid nephroscopy and calculus disintegration were performed in the conventional manner using a pneumatic lithotripter (Litho Crack, Sp. Swiss-Germany). Irrigation during the procedure was warm normal saline. After completion of lithotripsy and stone extraction, the status of residual stones was assessed by fluoroscopy. A 12- or 14-F nephrostomy tube was placed if indicated at the end of the operation. Patients were followed up in the clinic 2 weeks after operation with sonography and KUB. Stone-free patient was defined as anyone with residual stones ≤3 mm. Demographic, operative and postoperative data were collected prospectively. The primary endpoint of interest was fluoroscopy time. Secondary endpoints included tract creation and dilation time, success and complications. The ethics of the study was approved by the ethical committee of the Urology and Nephrology Research Center. The procedure was explained to parents and written informed consent was obtained.
One Shot Tract Dilation for Percutaneous Nephrolithotomy
Table 1. Demographic and perioperative data
Variables
Age, months Gender, male/female Side, left/right Stone size, mm1 Access number, single/multiple Access time, min Operation time, min Fluoroscopy time, s Hb before operation, mg/dl Hb after operation, mg/dl Stone-free patients Postoperative complications Postoperative hospital stay, days
Dilation technique
p value
one-shot
serial metallic
44.5 ± 14.9 22/9 21/10 20.0 ± 3.5 1/0
44.3 ± 16.5 18/13 17/14 17.0 ± 4.0 1/0
NS NS NS NS NS
5.9 ± 1.5 75 ± 15 22.0 ± 5.6 11.1 ± 0.7 10.4 ± 0.7 31 (100) 0 (0) 3.22 ± 1.70
7.3 ± 1.2 81 ± 9 70.0 ± 8.9 11.2 ± 0.6 10.4 ± 0.7 31 (100) 1 (3) 4.17 ± 1.06
NS NS
