Recent Trends in Percutaneous Nephrolithotomy in Pediatric Renal Stone Disease

Abstract

The first report of PCNL in children was published in 1985. Acceptance of the procedure, for treatment of renal calculi in pediatric patients was delayed because the authors used adult instruments and there was great concern about the deleterious effects of these large instruments on small pediatric kidneys. Then, development of new instruments, technical improvement and presence of endourologist with considerable experience in percutaneous surgery allowed widespread acceptance of PCNL for treating renal calculi in children. The current indications of PCNL in pediatric patients included large, complex, staghorn stones and those who are contraindicated to undergo SWL or failed SWL treatment. Preoperative radiological investigation of choice was NCCT using low dose protocols to reduce radiation exposure. Antibiotic prophylaxis is recommended by all major urological society guidelines and the procedure must be performed by an experienced team including endourologist, anesthiologist, nurses and technicians. An adequate operative room preparation and armamentarium of machines, scopes and instruments must be available. Percutaneous renal access is recommended to start at the posterior axillary line and enter the kidney through the top of a posterior calyx. There are many techniques and instruments used for dilatation and the size of the tract is also variable, the one-shot technique "The Pathway Access Sheath (PAS)" allows for simultaneous balloon tract dilation and percutaneous access sheath placement in one simple step with less fluoroscopy time and equal safety and efficacy. Intra-renal manipulations and lithotripsy should be performed in intelligent and delicate movements to achieve maximum stone clearance without high morbidity. Post-operative care and medications are as important as the operative steps. However, image evaluation of the success varies among reported series. The essential thing is to balance between high radiological exposure for the child and the value of information necessary for determination of stone-free status. Therefore, post-operative radiological investigations must be individualized for each case.