Surgical Technique of Supine Percutaneous Nephrolithotomy in Children

Abstract

Percutaneous nephrolithotomy (PCNL) in children has become more widely used due to its high efficacy and safety and to the development of miniaturized instruments. A supine approach is promising due to advantages such as better ventilation, reproducibility, and ergonomics. The purpose of the present study is to describe our surgical technique with special considerations in the pediatric population. We used an oblique supine position supported by one silicone gel positioning pad under the hip and another under the ipsilateral flank. The anatomical landmarks used to guide the puncture were the 11^th and 12^th ribs, the posterior axillary line, and the iliac crest. Initially, a ureteral catheter was introduced endoscopically. A retrograde pyelography was performed to guide the puncture, which was performed using a biplanar technique. A hydrophilic guide wire was then advanced through the needle. Dilation was performed with Alken telescopic dilators until 14 Ch. Fragmentation was performed either with a 13 Ch semirigid cystoscope or a flexible ureteroscope using a holmium: yttrium aluminum garnet (Ho:Yag) laser. We left a double J catheter. Supine PCNL in the pediatric population has comparable efficacy in terms of stone free rate to that of the prone approach as well as less complications. Certain considerations in children are careful padding and placement of the patient close to the edge of the table. Puncture should be guided by ultrasound to reduce radiation exposure. Miniaturized equipment is not widely available, so adaptation of adult equipment for the pediatric population is sometimes necessary.

Resumen

La nefrolitotomía percutánea en niños se ha vuelto ampliamente utilizada por su alta efectividad, seguridad, y por la miniaturización de los instrumentos endoscópicos. El abordaje en supino es prometedor por sus ventajas, como mejor ventilación, reproducibilidad, y ergonomía. El propósito es describir nuestra técnica quirúrgica con las consideraciones especiales a tener en cuenta en la población pediátrica. Todos nuestros pacientes han sido intervenidos bajo la siguiente técnica quirúrgica: en una posición oblicua en supino, utilizando soportes de silicona ubicados debajo de la cadera y del flanco ipsilateral, se marcan los reparos anatómicos: las costillas once y doce, la línea axilar posterior y la cresta ilíaca. Inicialmente se introduce un cateter ureteral por vía endoscópica, con el cual se realiza una pielografía retrógrada para guiar la punción con una técnica biplanar. Se avanza una guía hidrofílica y, sobre esta, los dilatadores telescopados de Alken hasta un tracto de 14 Ch. Se realiza la fragmentación con un cistoscopio semirígido de 13 Ch o con un ureteroscopio flexible utilizando el láser Ho:Yag. Se deja un cateter JJ. La nefrolitotomía percutánea en la población pediátrica es comparable en términos de tasa libre de cálculos al abordaje en prono, con menos complicaciones. Una consideración importante en niños es una adecuada posición, cerca al eje de la mesa. La punción debe ser guiada por ultrasonido para disminuir la exposición a radiación. La disponibilidad de equipos miniaturizados es limitada, por lo cual usualmente es necesario adaptar los equipos de adultos.

Keywords

percutaneous nephrolithotomy - pediatrics - supine approach - stone disease - nephrolithiasis

Palabras Clave

nefrolitotomía percutánea - pediatría - posición supina - urolitíasis - nefrolitíasis - miniaturización

Ethical Responsibilities

The present study complies with the World Medical Association (WMA) Declaration of Helsinki Ethical Principles for Medical Research involving Human Subjects, initially developed in 1964 and amended in October 2013. The authors declare there are no conflicts of interest to disclose in the publication of this study. All confidentiality policies have been applied. The current study represents no risk according to the resolution 8430 of 1993 because it is a study that employs “techniques and methods of retrospective documental investigation and those in which no intervention is performed or intentioned modification of the biologic, physiologic, psychologic, or social variables of the individuals who participate in the study.”

Patients' confidentiality was respected at all moments, no data that can identify patients have been used, complying with the law 1581 of 2012. The ethical principles of autonomy, beneficence, nonmaleficence, and justice have been respected. Due to what was previously exposed, no informed consent was needed.

Financial Aid

No financial aid by any institution was required

Publication History

Received: 29 June 2020

Accepted: 02 July 2021

Article published online:
22 December 2021

• References

• 1 Tekgül S, Riedmiller H, Gerharz E. et al. EAU Guidelines on paediatric urology. Eur Soc Paediatr Urol Assoc Urol.. 2009: 1-72
• 2 Dogan HS, Kilicarslan H, Kordan Y, Celen S, Oktay B. Percutaneous nephrolithotomy in children: does age matter?. World J Urol 2011; 29 (06) 725-729
• 3 Valdivia JG, Scarpa RM, Duvdevani M. et al; Croes PCNL Study Group. Supine versus prone position during percutaneous nephrolithotomy: a report from the clinical research office of the endourological society percutaneous nephrolithotomy global study. J Endourol 2011; 25 (10) 1619-1625
• 4 Ozdemir H, Erbin A, Sahan M. et al. Comparison of supine and prone miniaturized percutaneous nephrolithotomy in the treatment of lower pole, middle pole and renal pelvic stones: A matched pair analysis. Int Braz J Urol 2019; 45 (05) 956-964
• 5 Gamal W, Moursy E, Hussein M, Mmdouh A, Hammady A, Aldahshoury M. Supine pediatric percutaneous nephrolithotomy (PCNL). J Pediatr Urol 2015; 11 (02) 78.e1-78.e5
• 6 Loukas M, El-Zammar D, Shoja MM. et al. The clinical anatomy of the triangle of Grynfeltt. Hernia 2008; 12 (03) 227-231
• 7 Loukas M, Tubbs RS, El-Sedfy A. et al. The clinical anatomy of the triangle of Petit. Hernia 2007; 11 (05) 441-444
• 8 Figueroa VH, Torres L, Pérez JF, García CF, Prada S. Experiencia quirúrgica en el manejo de litiasis urinaria en la población pediátrica: estudio multicéntrico Surgical Experience in Management of Urinary Lithiasis in Pediatric Population: Multicentric Study. Urol Colomb 2018; 27 (03) 277-281
• 9 Cox RG, Ewen A, Bart BB. The prone position is associated with a decrease in respiratory system compliance in healthy anaesthetized infants. Paediatr Anaesth 2001; 11 (03) 291-296
• 10 Guven S, Frattini A, Onal B. et al; CROES PCNL Study Group. Percutaneous nephrolithotomy in children in different age groups: data from the Clinical Research Office of the Endourological Society (CROES) Percutaneous Nephrolithotomy Global Study. BJU Int 2013; 111 (01) 148-156
• 11 Bujons A, Millán F, Centeno C. et al. Mini-percutaneous nephrolithotomy with high-power holmium YAG laser in pediatric patients with staghorn and complex calculi. J Pediatr Urol 2016; 12 (04) 253.e1-253.e5 DOI: 10.1016/j.jpurol.2016.04.027. [Internet]
• 12 Desoky EAE, ElSayed ER, Eliwa A. et al; Flank-free Modified Supine Percutaneous Nephrolithotomy in Pediatric Age Group. Flank-free Modified Supine Percutaneous Nephrolithotomy in Pediatric Age Group. Urology 2015; 85 (05) 1162-1165