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Extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy in children
Extracorporeal Shock Wave Lithotripsy and Percutaneous Nephrolithotolny in Children By S-A.M. Boddy, M.J. Kellett, M.S. Fletcher, P.G. Ransley, A.M.I. Paris, H.N. Whitfield, and J.E.A, Wickham London, England 9 The possibilities for treating children with renal stone disease by extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrolithotomy (PCNL) have not been widely explored. W e report ten children, aged between 5 and 16 years, treated by PCNL, and six children, aged between 6 and 15 years, treated by ESWL alone. A 16-year-old spina bifida child with a staghorn calculus was treated electively by a combination of the t w o methods. Hospital stay was 3 to 8 days for treatment by PCNL or ESWL, and was only 11 days for the combination treatment. Complete stone clearance was achieved in 12 children followed for 3 months. No significant complications occurred. ESWL and PCNL are suitable methods for the management of renal calculi in children. 9 1987 by Grune & Stratton. Inc. INDEX WORDS: Extracorporeal shock wave lithotripsy, percutaneous nephrolithotomy.
' R I N A R Y C A L C U L I in children are rare in industrialized countries. There are approximately 100 new cases per year in the United Kingdom; 85 of whom have a renal calculus, 90% of which are secondary to infection. According to Innes Williams and Johnston, 1 there is no place for conservative management of renal calculi in children. The possibility of avoiding operation by treating children with renal stone disease by percutaneous nephrolithomy (PCNL) or extracorporeal shock wave lithotripsy (ESWL) has not been widely explored. 2~ We report 17 children treated by PCNL, E S W L or by a combination of the two methods.
U
MATERIALS AND METHODS
Percutaneous Nephrolithotomy Ten children (8 girls and 2 boys), aged 5 to 16 years underwent percutaneous stone removal. Although eight of the children were over 40 kg in weight, two were 20 and 15 kg, respectively. One child had a large cystine stone occupying the renal pelvis and a lower calyx; two children had primary hyperoxaluria, one with multiple stones and one with a recurrent 7 mm calculus, A fourth child had had a previous pyeloplasty and presented with multiple calculi. Of the other six who presented with a single calculus, one had had a previous open nephrolithotomy and two had had numerous operations for bladder extrophy (Fig 1). Under general anesthesia and oral antibiotic cover, the children were cystoscoped. An ipsilateral retrograde ureterogram was performed using contrast mixed with methylene blue. The child was then turned prone and, under x-ray control, a needle nephrostomy was inserted. Puncture of the collecting system was ascertained by the flow of methylene blue-stained contrast and correct positioning of the needle track was confirmed radiologically. Graded Teflon dilators up to 24 to 26 French were passed over a guide wire, and an
Journal of Pediatric Surgery, Vol 22, No 3 (March), 1987: pp 223-227
Amplatz sheath (Cook, England) was then inserted. In six children the stones were extracted intact with grasping forceps under direct vision through a nephroscope in a single-stage procedure, and no nephrostomy tube was left in situ, One of these children required two punctures in order to gain access to all the stones. In the four other children, ultrasonic disintegration of the stone was required. In two this was a single-stage procedure and a 24 Fr nephrostomy tube was left in for two days, to aid passage of stone fragments. A planned second session was performed in the other two children to remove stone fragments. In the case of the child with the cystine stone, further ultrasonic disintegration was required, which caused bleeding. The final stone fragments and the nephrostomy tube were removed at a third session.
PCNL and ESWL A 16-year-old spina bifida boy who was wheelchair bound, who had had numerous previous operations including a Dwyers procedure for his kyphosis, and who required manual bladder expression, had one of his bilateral staghorn calculi electively treated with intitial percutaneous nephrolithotomy and debulking of the calculus prior to ESWL (Fig 2). His nephrostomy tube was left in situ for 2 months.
Extracorporeal Shock Wave Lithotripsy A shockwave is generated by passing an ultrashort high tension electrical discharge underwater to form an arc between two electrodes. The fluid surrounding the arc path vaporizes to produce a rapidly expanding gas bubble. As a result of this rapid expansion, a shockwave is created in the surrounding fluid, which radiates from the focus in a circular manner. The shockwave is generated by an electrode placed in first focus of an ellipse in a hemiellipsoidal reflector. The shockwaves are accurately focused to produce a high tensile pressure precisely at the small area of the second focus. For treatment by ESWL the calculus is localized at the second focus using biplanar radiography. The manufacturer's specification states that only patients under 135 kg and those over 135 cm can be treated on the machine. A report last year from Germany 4 included a 6-year-old child treated by lithotripsy. They concluded that children taller than 120 cm were suitable for treatment on the lithotripter but they felt that smaller children had to be excluded because they could not be positioned on the patient support. Six children have been treated with ESWL using general anesthesia and with parenteral antibiotics at induction. They were aged
From The London Stone Clinic and Lithotripter Centre and The Institute of Urology, London. Presented at the 33nd Annual Congress of the British Association of Paediatric Surgeons, Birmingham, England, July 16-18, 1986. Address reprint requests to S-A.M. Boddy, FRCS, Department of Urology, St Bartholomew's Hospital, West Smithfield, London ECIA 7BE England. 9 1987 by Grune & Stratton, Inc. 0022-3468/87/2203-t9010503.00/0
223
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BODDY ET AL
Fig 1. (A) Preoperative plain film shows calculus in right kidney. (B) IVU shows previous transureterouretarostomy and bladder augmentation. (C) Amplatz sheath and guide wire in place.
Fig 2. (A) Preoperative plain film shows bilateral staghorn calculi, and Dwyers operation for kyphosis. (B) X-ray immediately post PCNL and ESWL to left staghorn: the nephrostomy tube is still in situ.
Fig 3.
(A) Child on adapted hoist. (B) Child in lithotripter bath.
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between 6 and 15 years, (6 boys and 1 girl). Three of the children were over 50 kg. The other three were 32, 20, and 18 kg and their heights were 139, 119, and 106 cm, respectively. The restraint system that normally prevents patients from floating off the cradle was adjusted so that the belts acted as a sling on which the child was supported (Fig 3). Three of the children had had previous bilateral renal surgery for calculi, one having had bilateral recurrent cystine stones. A fourth child had multiple recurrent stones following a previous staghorn calculus. These four all had persistent urinary tract infections. The other two children had single calculi and hematuria (Fig 4). The children received between 500 and 2,000 shocks depending on the size and composition of the calculus. The girl with bilateral recurrent cystine stones was treated with 1,000 shocks to each kidney in one treatment,
BODDY ET AL
RESULTS
The hospital stay for the ten treated with P C N L alone was 3 to 8 days, for the six treated with ESWL alone 3 to 5 days, and for the combined treatment the hospital stay was 11 days. Nine of the ten children treated with P C N L were cleared of stones. One child has residual small fragments. The boy treated with both P C N L and E S W L for a staghorn calculus requires further P C N L for a few residual fragments. Three of the children treated by E S W L alone were found to be cleared of stones at 3 month follow-up. One
Fig 4. (A) Preoperative plain film shows calculus in right kidney. (B) X-ray 24 hours after ESWL shows good fragmentation of stones. (C) X-ray ten days after ESWL. All stone fragments have passed,
ESWL AND PERCUTANEOUS NEPHROLITHOTOMY
227
had residual fragments at 3 months that were under 2 m m in size. Two children have been treated too recently to assess stone clearance fully.
Complications Minor complications occurred with both procedures. Intrarenal bleeding occurred in one child treated by P C N L , and the removal of further fragments had to be deferred to another session. No transfusion was required. During E S W L treatment two children had a marked tachycardia and ventricular ectopic beats that did not require treatment and resolved immediately after ESWL. Two children had entry bruises. One child required intravenous fluids for three days because of persistent nausea and vomiting, and another child required readmission four days after treatment because of pain on passing the aggregated stone fragments. DISCUSSION
There are three advantages of these techniques over existing open surgical procedures. First, there is a much shorter hospital stay. Second, the convalescent period is greatly reduced: most children being able to return to normal activity immediately after leaving the hospital. Third, in experienced hands, the complication
rate for both procedures is significantly reduced in comparison with open surgery in children who have previously had open renal operations. Since 33% of children presenting with renal calculus disease will have an underlying urologic abnormality, the less invasive P C N L or E S W L make a subsequent operation less hazardous. CONCLUSIONS
We have shown that percutaneous removal of renal calculi in children over 5 years of age can be accomplished safely with the currently available instruments, and that the patient hoist on the lithotripter can be easily adapted so that children over 100 cm in height can be safely treated. Since 75% of the children with urinary calculi are under 5 years old, with the currently available instruments and hoist most children with calculi will necessarily be excluded. However, we believe that with the advent of percutaneous techniques and E S W L , certain calculi in children can be managed without open operation. ACKNOWLEDGMENT
I gratefully acknowledge the generous support of the Joint Research Board, St. Bartholomew'sHospital, and I am very grateful to Betty Taylor, Superintendant Radiographer, St Paul's Hospital, London, for all her assistance.
REFERENCES
1. Innes Williams D, Johnston JH: Paediatric Urology (ed 2). London, Butterworth, 1982, p 354 2. Hulbert JC, Reddy PK, Gonzales R, et al: Percutaneous nephrostolithotomy: An alternative approach to the management of paediatric calculus disease. Paediatrics 76:610-612, 1985
3. WoodsideJR, Stevens GF, Stark GL, et al: Percutaneous stone removal in children. J Urol 134:1166-1167, 1985 4. Eisenberger F, Fuchs G, Miller K, et al: Extracorporeal shockwavelithotripsy(ESWL)and endourology:An ideal combination for the treatment of kidney stones. World J Urol 3: 41~,7, 1985
' R I N A R Y C A L C U L I in children are rare in industrialized countries. There are approximately 100 new cases per year in the United Kingdom; 85 of whom have a renal calculus, 90% of which are secondary to infection. According to Innes Williams and Johnston, 1 there is no place for conservative management of renal calculi in children. The possibility of avoiding operation by treating children with renal stone disease by percutaneous nephrolithomy (PCNL) or extracorporeal shock wave lithotripsy (ESWL) has not been widely explored. 2~ We report 17 children treated by PCNL, E S W L or by a combination of the two methods.
U
MATERIALS AND METHODS
Percutaneous Nephrolithotomy Ten children (8 girls and 2 boys), aged 5 to 16 years underwent percutaneous stone removal. Although eight of the children were over 40 kg in weight, two were 20 and 15 kg, respectively. One child had a large cystine stone occupying the renal pelvis and a lower calyx; two children had primary hyperoxaluria, one with multiple stones and one with a recurrent 7 mm calculus, A fourth child had had a previous pyeloplasty and presented with multiple calculi. Of the other six who presented with a single calculus, one had had a previous open nephrolithotomy and two had had numerous operations for bladder extrophy (Fig 1). Under general anesthesia and oral antibiotic cover, the children were cystoscoped. An ipsilateral retrograde ureterogram was performed using contrast mixed with methylene blue. The child was then turned prone and, under x-ray control, a needle nephrostomy was inserted. Puncture of the collecting system was ascertained by the flow of methylene blue-stained contrast and correct positioning of the needle track was confirmed radiologically. Graded Teflon dilators up to 24 to 26 French were passed over a guide wire, and an
Journal of Pediatric Surgery, Vol 22, No 3 (March), 1987: pp 223-227
Amplatz sheath (Cook, England) was then inserted. In six children the stones were extracted intact with grasping forceps under direct vision through a nephroscope in a single-stage procedure, and no nephrostomy tube was left in situ, One of these children required two punctures in order to gain access to all the stones. In the four other children, ultrasonic disintegration of the stone was required. In two this was a single-stage procedure and a 24 Fr nephrostomy tube was left in for two days, to aid passage of stone fragments. A planned second session was performed in the other two children to remove stone fragments. In the case of the child with the cystine stone, further ultrasonic disintegration was required, which caused bleeding. The final stone fragments and the nephrostomy tube were removed at a third session.
PCNL and ESWL A 16-year-old spina bifida boy who was wheelchair bound, who had had numerous previous operations including a Dwyers procedure for his kyphosis, and who required manual bladder expression, had one of his bilateral staghorn calculi electively treated with intitial percutaneous nephrolithotomy and debulking of the calculus prior to ESWL (Fig 2). His nephrostomy tube was left in situ for 2 months.
Extracorporeal Shock Wave Lithotripsy A shockwave is generated by passing an ultrashort high tension electrical discharge underwater to form an arc between two electrodes. The fluid surrounding the arc path vaporizes to produce a rapidly expanding gas bubble. As a result of this rapid expansion, a shockwave is created in the surrounding fluid, which radiates from the focus in a circular manner. The shockwave is generated by an electrode placed in first focus of an ellipse in a hemiellipsoidal reflector. The shockwaves are accurately focused to produce a high tensile pressure precisely at the small area of the second focus. For treatment by ESWL the calculus is localized at the second focus using biplanar radiography. The manufacturer's specification states that only patients under 135 kg and those over 135 cm can be treated on the machine. A report last year from Germany 4 included a 6-year-old child treated by lithotripsy. They concluded that children taller than 120 cm were suitable for treatment on the lithotripter but they felt that smaller children had to be excluded because they could not be positioned on the patient support. Six children have been treated with ESWL using general anesthesia and with parenteral antibiotics at induction. They were aged
From The London Stone Clinic and Lithotripter Centre and The Institute of Urology, London. Presented at the 33nd Annual Congress of the British Association of Paediatric Surgeons, Birmingham, England, July 16-18, 1986. Address reprint requests to S-A.M. Boddy, FRCS, Department of Urology, St Bartholomew's Hospital, West Smithfield, London ECIA 7BE England. 9 1987 by Grune & Stratton, Inc. 0022-3468/87/2203-t9010503.00/0
223
224
BODDY ET AL
Fig 1. (A) Preoperative plain film shows calculus in right kidney. (B) IVU shows previous transureterouretarostomy and bladder augmentation. (C) Amplatz sheath and guide wire in place.
Fig 2. (A) Preoperative plain film shows bilateral staghorn calculi, and Dwyers operation for kyphosis. (B) X-ray immediately post PCNL and ESWL to left staghorn: the nephrostomy tube is still in situ.
Fig 3.
(A) Child on adapted hoist. (B) Child in lithotripter bath.
226
between 6 and 15 years, (6 boys and 1 girl). Three of the children were over 50 kg. The other three were 32, 20, and 18 kg and their heights were 139, 119, and 106 cm, respectively. The restraint system that normally prevents patients from floating off the cradle was adjusted so that the belts acted as a sling on which the child was supported (Fig 3). Three of the children had had previous bilateral renal surgery for calculi, one having had bilateral recurrent cystine stones. A fourth child had multiple recurrent stones following a previous staghorn calculus. These four all had persistent urinary tract infections. The other two children had single calculi and hematuria (Fig 4). The children received between 500 and 2,000 shocks depending on the size and composition of the calculus. The girl with bilateral recurrent cystine stones was treated with 1,000 shocks to each kidney in one treatment,
BODDY ET AL
RESULTS
The hospital stay for the ten treated with P C N L alone was 3 to 8 days, for the six treated with ESWL alone 3 to 5 days, and for the combined treatment the hospital stay was 11 days. Nine of the ten children treated with P C N L were cleared of stones. One child has residual small fragments. The boy treated with both P C N L and E S W L for a staghorn calculus requires further P C N L for a few residual fragments. Three of the children treated by E S W L alone were found to be cleared of stones at 3 month follow-up. One
Fig 4. (A) Preoperative plain film shows calculus in right kidney. (B) X-ray 24 hours after ESWL shows good fragmentation of stones. (C) X-ray ten days after ESWL. All stone fragments have passed,
ESWL AND PERCUTANEOUS NEPHROLITHOTOMY
227
had residual fragments at 3 months that were under 2 m m in size. Two children have been treated too recently to assess stone clearance fully.
Complications Minor complications occurred with both procedures. Intrarenal bleeding occurred in one child treated by P C N L , and the removal of further fragments had to be deferred to another session. No transfusion was required. During E S W L treatment two children had a marked tachycardia and ventricular ectopic beats that did not require treatment and resolved immediately after ESWL. Two children had entry bruises. One child required intravenous fluids for three days because of persistent nausea and vomiting, and another child required readmission four days after treatment because of pain on passing the aggregated stone fragments. DISCUSSION
There are three advantages of these techniques over existing open surgical procedures. First, there is a much shorter hospital stay. Second, the convalescent period is greatly reduced: most children being able to return to normal activity immediately after leaving the hospital. Third, in experienced hands, the complication
rate for both procedures is significantly reduced in comparison with open surgery in children who have previously had open renal operations. Since 33% of children presenting with renal calculus disease will have an underlying urologic abnormality, the less invasive P C N L or E S W L make a subsequent operation less hazardous. CONCLUSIONS
We have shown that percutaneous removal of renal calculi in children over 5 years of age can be accomplished safely with the currently available instruments, and that the patient hoist on the lithotripter can be easily adapted so that children over 100 cm in height can be safely treated. Since 75% of the children with urinary calculi are under 5 years old, with the currently available instruments and hoist most children with calculi will necessarily be excluded. However, we believe that with the advent of percutaneous techniques and E S W L , certain calculi in children can be managed without open operation. ACKNOWLEDGMENT
I gratefully acknowledge the generous support of the Joint Research Board, St. Bartholomew'sHospital, and I am very grateful to Betty Taylor, Superintendant Radiographer, St Paul's Hospital, London, for all her assistance.
REFERENCES
1. Innes Williams D, Johnston JH: Paediatric Urology (ed 2). London, Butterworth, 1982, p 354 2. Hulbert JC, Reddy PK, Gonzales R, et al: Percutaneous nephrostolithotomy: An alternative approach to the management of paediatric calculus disease. Paediatrics 76:610-612, 1985
3. WoodsideJR, Stevens GF, Stark GL, et al: Percutaneous stone removal in children. J Urol 134:1166-1167, 1985 4. Eisenberger F, Fuchs G, Miller K, et al: Extracorporeal shockwavelithotripsy(ESWL)and endourology:An ideal combination for the treatment of kidney stones. World J Urol 3: 41~,7, 1985