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Management of calculus anuria in children: Experience of 54 cases
Journal of Pediatric Urology (2009) 5, 462e465
Management of calculus anuria in children: Experience of 54 cases* Mohammed A. Elgammal a,*, Mohammed S. Abdel-kader a, Adel Kurkar a, Omima A. Mohammed b, Hisham M. Hammouda a a b
Department of Urology, Section Pediatric Urology, Assiut University Hospital, Assiut 71526, Egypt Department of Pediatrics, Section Pediatric Nephrology, Assiut University Hospital, Assiut 71526, Egypt
Received 10 February 2009; accepted 25 March 2009 Available online 15 May 2009
KEYWORDS Anuria; Calculus; Children
Abstract Objective: To evaluate the outcome of different treatment plans for calculus anuria in children. Patients and methods: Patients were subdivided into three groups, A, B and C. Group A included patients who were critically ill, had serum creatinine 3.5 mg/dl, blood urea 100 mg/dl, serum potassium 7 meq/l and/or blood pH 7.1; and they were treated initially by peritoneal dialysis. Patients in groups B and C were stable with serum creatinine < 3.5 mg/dl, blood urea < 100 mg/dl, serum potassium level < 7 meq/l and blood pH > 7.1. In group B, the obstructing stone could not be localized, and they were treated either by percutaneous nephrostomy or JJ stent. In group C, stone level was confidently determined and patients were treated by open surgery. Results: Fifty-four patients were included. All patients regained normal serum creatinine levels within 72e120 h. Overall complication rate in groups A and C was 26% and 13%, respectively. In group B, overall complication rate was 66% for percutaneous nephrostomy and 50% for internal stent. Conclusions: Urinary diversion in children is associated with a high complication rate while dialysis is highly effective in children. Formal surgery in compensated children is associated with a low complication rate with good outcome and early recovery. ª 2009 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction *
The protocol for the research project has been approved by IRD (Institutional Review Board) of faculty of medicine at Assiut University. * Corresponding author. Tel.: þ20105212163 (mobile); fax: þ20882333327. E-mail address: [email protected] (M.A. Elgammal).
Acute renal failure due to calculus disease is a urological emergency. Management in the form of urinary diversion (percutaneous nephrostomy), acute peritoneal dialysis, hemodialysis and definitive surgical treatment can save the patient from developing chronic renal failure. In children, it
1477-5131/$36 ª 2009 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2009.03.024
Management of calculus anuria in children
463
is a catastrophic, life-threatening event with significantly increased morbidity and mortality rates. Post-renal acute renal failure (5% of acute renal failure cases) requires immediate treatment. Most children regain normal kidney function if the condition is reversed promptly [1]. There are many problems during management of anuria in children. Children are at greater risk of acute renal failure complications (sepsis and electrolyte imbalance). Stone location is difficult to determine accurately, especially if the stone is present in the ureter. Lastly, the risk of de-compensation from anesthesia during intervention is high. We report our experience in the management of calculus anuria in children to identify the optimal time of interference, and the indication and complications of each treatment line (dialysis, surgery and urinary drainage).
Group A (dialysis group)
Patients and methods
As regards patients treated with percutaneous nephrostomy, serum creatinine improved within 3 days (Fig. 1). The overall complication rate was 66% (Table 1). Major complications were slipped tube in two (33%) patients, febrile UTI in two (33%) patients and primary hemorrhage in one (16%) patient. Minor complications were leakage around the tube in two (33%) patients, mild hematuria in one (16%) patient and transient tube obstruction in three (50%) patients. In patients treated with internal stenting, the creatinine level improved within 3 days (Fig. 1). The overall complication rate was 50% (Table 1). The major complication was febrile UTI in two (33%) patients. A minor complication was a difficult introduction in two (33%) patients. Immediate relief of anuria occurred in four children while in the other two children anuria was relieved after 24e48 h.
We reviewed the charts of children who were treated for calculus anuria in our urology and pediatric nephrology departments in the period from December 2004 to June 2007. Patients were initially evaluated in the nephrology subunit of the pediatric department. Every child was subjected first to a general examination to exclude signs of acidosis, sepsis or fluid retention. A venous blood sample was taken to determine levels of serum electrolytes, serum creatinine and blood urea. An arterial blood sample was taken to determine the level of blood gases. Abdominal ultrasound and plain urinary tract imaging were done to determine degree and level of obstruction. Patients were subdivided into three groups, A, B and C, according to the clinical findings and type of treatment. The treatment decision was based on the patient’s general condition, basic metabolic panel and stone localization. Group A included patients who were critically ill, had serum creatinine 3.5 mg/dl, blood urea nitrogen 100 mg/dl, serum potassium 7 meq/l and/or blood pH 7.1. This group was treated initially by peritoneal dialysis, followed by our standard protocol of management, in which open surgery or drainage would be chosen according to the stone level determined. Patients in groups B and C were stable with serum creatinine < 3.5 mg/dl, blood urea nitrogen < 100 mg/dl, serum potassium level < 7 meq/l and blood pH > 7.1. In group B, the obstructing stone could not be localized and patients were treated either by percutaneous nephrostomy or JJ stent. If the decision was percutaneous nephrostomy then we chose the side to operate according to the priority of infection and the more dilated pelvis. In group C, stone level was confidently determined and patients were treated by open surgery, choosing the side where there were fewer stones. Follow-up tools included urine output and basic metabolic panel. Complications were recorded for each treatment line. Time for blood chemistry to return to normal was also recorded.
All children regained normal blood urea, serum creatinine (Fig. 1) and electrolyte levels within 48 h (after one run of dialysis). Eight children (42%) in this group were relieved of anuria during dialysis due to either stone expulsion (through urethra or to the bladder) or dis-impaction. The overall complication rate was 26% (Table 1). Hypokalemia was recorded in three children (15%) and sepsis in two children (10%). Both conditions were managed by replacement therapy and antibiotics. Children with persistent anuria after dialysis (11) were managed by open pyelolithotomy in eight, internal stenting in two and percutaneous nephrostomy in one.
Group B (urinary drainage group)
Group C (open surgery group) Pyelolithotomy was done in 16 patients (69.5%) and ureterolithotomy in seven patients. Serum creatinine improved rapidly within 3 days (Fig. 1). The overall complication rate was 13% (Table 1). Secondary hemorrhage occurred in one child (4%) and was managed conservatively by blood transfusion and parental antibiotics. Other complications were minor: persistent leakage in two (8%) patients (stopped spontaneously within 6 days), low-grade fever in two (8%) patients and wound infection in two (8%) patients.
Results Fifty-four patients were included. Age ranged from 1 to 8 years. Nineteen patients (35.2%) fell in the group A category, 12 patients (22.2%) were group B and 23 patients (42.6%) were group C. All children had bilateral urinary stones.
Figure 1 Graph showing drop in serum creatinine level over time for each treatment line.
464 Table 1
M.A. Elgammal et al. Complications reported with different treatment lines.
Line of management
Major complication
Peritoneal dialysis Percutaneous nephrostomy
Hypokalemia Slippage Febrile UTI Primary hemorrhage Febrile UTI Secondary hemorrhage
Internal stenting Open surgery
Discussion Acute renal failure is the most important condition in pediatric nephrology seen in hospital practice. The causes and outcome vary from place to place and have shown changes with time. Dialysis therapy has changed the outlook for this condition somewhat; however, dialysis, especially hemodialysis, is not as easy a proposition in children at centers with limited resources and inadequate expertise [2]. Peritoneal dialysis is most often used in children with acute renal failure. It is a technically simple procedure not requiring specialized personnel. The procedure is well tolerated in the hemo-dynamically compromised child since fluid and solute removal occurs gradually over the course of the day, rather than during a short hemodialysis treatment when the risk of hypotension or dialysis disequilibrium would be much greater. Solute and fluid removal across the peritoneal membrane is efficient in children; the surface area of the peritoneal membrane correlates with the body surface area rather than the body mass, and this ratio is most favorable in infants and young children. Also, this form of dialysis is somewhat less expensive to perform [2,3]. Another advantage of peritoneal dialysis in our study was that stone expulsion (through urethra or to the bladder) or dis-impaction was encountered in 42% of children in this group, relieving of the anuria and converting the condition from an urgent to an elective one. Sepsis occurred in 10% of children under dialysis and was successfully treated using parental antibiotic therapy. Percutaneous nephrostomy has come a long way since the time of William Goodwin, who inadvertently punctured the renal pelvis attempting a translumbar aortogram [4]. Although percutaneous nephrostomy was developed using fluoroscopic guidance, ultrasound-guided procedures are now safe, easy and effective [5e7]. The procedure is usually performed when retrograde stenting is not possible, due to difficult anatomy or lack of technical expertise. Comparative studies have been carried out between percutaneous nephrostomy and retrograde ureteric stenting. Pearle et al. found no difference in clinical efficacy between the two procedures and concluded that the choice of procedure may be based on the particular circumstances of the patient and availability of facilities to carry it out [8]. A similar study however found percutaneous nephrostomy to be superior to retrograde stenting; the results demonstrated that percutaneous nephrostomy is tolerated better by patients and has less influence on the quality of
Minor complication 3 2 2 1 2 1
(15%) (33%) (33%) (16%) (33%) (4%)
Sepsis Leakage Mild hematuria Transient obstruction Difficult introduction Persistent leakage Low-grade fever Wound infection
2 2 1 3 2 2 2 2
(10%) (33%) (16%) (50%) (33%) (8%) (8%) (8%)
life than ureteral stents [9]. Mhiri and co-workers recommended percutaneous nephrostomy as an emergency measure followed by cold nephrolithotripsy, and considered it the first step of in situ treatment of the stone [10,11]. We observed a 65% complication rate in children treated by nephrostomy. As regards major complications of this procedure, primary hemorrhage occurred in 16%, tube displacement in 33%, for which re-nephrostomies had to be performed, and febrile UTI in 16%. Minor complications were post-procedure urine leak in 33%, mild hematuria in 16% and intermittent tube obstruction in 50%. clayman et al. summarized early complications inherent to fluoroscopy-guided percutaneous nephrostomy, the most common being acute bleeding requiring transfusion (<5%), failed access (<5%), adjacent organ (bowel, spleen, lung) injury (<1%) and septicemia (<1) [12]. Cochran et al. stated that risk of procedure-related sepsis is a major concern [13]. The incidence of sepsis is reported to be 0e5% [14e16], although one study showed a higher incidence of 21%. In that same study, the incidence of sepsis decreased to 9% when antibiotics were administered [13]. To our mind, primary hemorrhage was the most serious complication because the anuric kidney is edematous and congested, so the risk of cortical bleeding is high, especially with multiple punctures to access the relatively small-sized pelvi-caliceal system. As regards ureteral stenting, we observed a complication rate of 50%. Only febrile UTI was encountered as a major complication, with an incidence of 33%. Normalization of serum creatinine was reached after 5 days of the procedure. With other methods of treatment normalization of serum creatinine was reached after a maximum of 3 days. Two children in this study were not relieved of their anuria immediately after ureteric stenting. This might be due to the stents used being of narrow caliber (3e4 Fr) and therefore at risk of obstruction with ureteric edema or small clots/debris. A previous study by Li et al. compared percutaneous nephrostomy and open surgery in treating patients with post-renal acute renal failure. They concluded that percutaneous nephrostomy is preferable because of minimal trauma, less blood loss, as well as rapid recovery and better effect on recovery of renal function [17]. We think that this is true as regards adult patients, but in the pediatric population percutaneous nephrostomy may add another risk for an already critically ill child if it is complicated. The risk of anesthesia and difficulties of doing the procedure in a relatively small non-dilated kidney
Management of calculus anuria in children should be considered before taking the decision of percutaneous nephrostomy. Open surgery in our study had the lowest complication rate (13%). All children subjected to open surgery were in the group of non-critically ill children and had their stone level definitively determined by imaging study.
Conclusion Urinary diversion in children is associated with a high complication rate, while dialysis is highly effective in children rather than adults, with a lower complication rate and high incidence of spontaneous relief of anuria during peritoneal dialysis. Formal surgery in compensated children is associated with a low complication rate, with a good outcome and early recovery.
Conflict of interest All authors have no conflict of interest.
Funding No financial support or incentive has been provided for this manuscript.
Authors’ contribution All authors of this manuscript have directly participated in planning, execution, and/or analysis of this study. The contents of this manuscript have not been copyrighted or published previously. The contents of this manuscript are not now under consideration for publication elsewhere. The contents of this manuscript will not be copyrighted, submitted, or published elsewhere while acceptance by clinical Pediatric Urology Journal is under consideration. There are no directly related manuscripts or abstracts, published or unpublished, by any authors of this manuscript.
References [1] Brady HR, Brenner BM. Acute renal failure. In: Kasper DL, editor. Harrison’s principles of internal medicine. 16th ed.; 2005. p. 1644e53.
465 [2] Gallego N, Gallego A, Pascual J, Liano F, Estepa R, Ortuno J. Prognosis of children with acute renal failure: a study of 138 cases. Nephron 1993;64:399e404. [3] Reznik VM, Griswold WR, Peterson BM, Rodarte A, Ferris ME, Mendoza SA. Peritoneal dialysis for acute renal failure in children. Pediatr Nephrol 1991;5:715e7. [4] Goodwin WE, Casey WC, Woolf W. Percutaneous trocar (needle) nephrostomy in hydronephrosis. J Am Med Assoc 1955; 157:891e4. [5] Gupta S, Gulati M, Uday Shankar K, Rungta U, Suri S. Percutaneous nephrostomy with real-time sonographic guidance. Acta Radiol 1997;38:454e7. [6]. Kehinde EO, Newland CJ, Terry TR, Watkin EM, Butt Z. Percutaneous nephrostomies. Br J Urol 1993;71:664e6. [7] Martino P. Ultrasound-guided percutaneous nephrostomy. Arch Ital Urol Androl 2000;72:324e7. [8] Pearle MS, Pierce HL, Miller GL, Summa JA, Mutz JM, Petty BA, et al. Optimal method of urgent decompression of the collecting system for obstruction and infection due to ureteral calculi. J Urol 1998;160:1260e4. [9] Mokhmalji H, Braun PM, Martinez Portillo FJ, Siegsmund M, Alken P, Kohrmann KU. Percutaneous nephrostomy versus ureteral stents for diversion of hydronephrosis caused by stones: a prospective, randomized clinical trial. J Urol 2001;165:1088e92. [10] Mhiri MN. Significance of percutaneous nephrostomy in calculous anuria in children. Apropos of 3 cases. Chir Pediatr 1989;30:205e8. [11] Mhiri MN, Hachicha M, Chaabouni MN, Triki A, Smida ML. Calculous anuria in children. Apropos of 12 cases. Ann Urol (Paris) 1990;24:451e4. [12] Clayman RV, McDougall EM, Nakada SY. Endourology of the upper urinary tract: percutaneous renal and ureteral procedures. In: Walsh PC, Retik AB, Vaughan ED, Wein AJ, editors. Campbell’s urology. Philadelphia: WB Saunders; 1998. p. 2791e800. [13] Cochran ST, Barbaric ZL, Lee JJ, Kashfian P. Percutaneous nephrostomy tube placement: an outpatient procedure? Radiology 1991;179:843e7. [14] Ball Jr WS, Towbin R, Strife JL, Spencer R. Interventional genitourinary radiology in children: a review of 61 procedures. AJR Am J Roentgenol 1986;147:791e6. [15] Irving HC, Arthur RJ, Thomas DF. Percutaneous nephrostomy in paediatrics. Clin Radiol 1987;38:245e8. [16] Stanley P, Diament MJ. Pediatric percutaneous nephrostomy: experience with 50 patients. J Urol 1986;135: 1223e6. [17] Li CG, Fan ZL, Liu H, Sun WB, Liu YJ, Li ML. A comparison of curative effects of percutaneous nephrostomy and open surgery in the management of postrenal acute renal failure. Zhongguo Wei Zhong Bing Ji Jiu Yi Xue 2008;20: 565e7.
Management of calculus anuria in children: Experience of 54 cases* Mohammed A. Elgammal a,*, Mohammed S. Abdel-kader a, Adel Kurkar a, Omima A. Mohammed b, Hisham M. Hammouda a a b
Department of Urology, Section Pediatric Urology, Assiut University Hospital, Assiut 71526, Egypt Department of Pediatrics, Section Pediatric Nephrology, Assiut University Hospital, Assiut 71526, Egypt
Received 10 February 2009; accepted 25 March 2009 Available online 15 May 2009
KEYWORDS Anuria; Calculus; Children
Abstract Objective: To evaluate the outcome of different treatment plans for calculus anuria in children. Patients and methods: Patients were subdivided into three groups, A, B and C. Group A included patients who were critically ill, had serum creatinine 3.5 mg/dl, blood urea 100 mg/dl, serum potassium 7 meq/l and/or blood pH 7.1; and they were treated initially by peritoneal dialysis. Patients in groups B and C were stable with serum creatinine < 3.5 mg/dl, blood urea < 100 mg/dl, serum potassium level < 7 meq/l and blood pH > 7.1. In group B, the obstructing stone could not be localized, and they were treated either by percutaneous nephrostomy or JJ stent. In group C, stone level was confidently determined and patients were treated by open surgery. Results: Fifty-four patients were included. All patients regained normal serum creatinine levels within 72e120 h. Overall complication rate in groups A and C was 26% and 13%, respectively. In group B, overall complication rate was 66% for percutaneous nephrostomy and 50% for internal stent. Conclusions: Urinary diversion in children is associated with a high complication rate while dialysis is highly effective in children. Formal surgery in compensated children is associated with a low complication rate with good outcome and early recovery. ª 2009 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Introduction *
The protocol for the research project has been approved by IRD (Institutional Review Board) of faculty of medicine at Assiut University. * Corresponding author. Tel.: þ20105212163 (mobile); fax: þ20882333327. E-mail address: [email protected] (M.A. Elgammal).
Acute renal failure due to calculus disease is a urological emergency. Management in the form of urinary diversion (percutaneous nephrostomy), acute peritoneal dialysis, hemodialysis and definitive surgical treatment can save the patient from developing chronic renal failure. In children, it
1477-5131/$36 ª 2009 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jpurol.2009.03.024
Management of calculus anuria in children
463
is a catastrophic, life-threatening event with significantly increased morbidity and mortality rates. Post-renal acute renal failure (5% of acute renal failure cases) requires immediate treatment. Most children regain normal kidney function if the condition is reversed promptly [1]. There are many problems during management of anuria in children. Children are at greater risk of acute renal failure complications (sepsis and electrolyte imbalance). Stone location is difficult to determine accurately, especially if the stone is present in the ureter. Lastly, the risk of de-compensation from anesthesia during intervention is high. We report our experience in the management of calculus anuria in children to identify the optimal time of interference, and the indication and complications of each treatment line (dialysis, surgery and urinary drainage).
Group A (dialysis group)
Patients and methods
As regards patients treated with percutaneous nephrostomy, serum creatinine improved within 3 days (Fig. 1). The overall complication rate was 66% (Table 1). Major complications were slipped tube in two (33%) patients, febrile UTI in two (33%) patients and primary hemorrhage in one (16%) patient. Minor complications were leakage around the tube in two (33%) patients, mild hematuria in one (16%) patient and transient tube obstruction in three (50%) patients. In patients treated with internal stenting, the creatinine level improved within 3 days (Fig. 1). The overall complication rate was 50% (Table 1). The major complication was febrile UTI in two (33%) patients. A minor complication was a difficult introduction in two (33%) patients. Immediate relief of anuria occurred in four children while in the other two children anuria was relieved after 24e48 h.
We reviewed the charts of children who were treated for calculus anuria in our urology and pediatric nephrology departments in the period from December 2004 to June 2007. Patients were initially evaluated in the nephrology subunit of the pediatric department. Every child was subjected first to a general examination to exclude signs of acidosis, sepsis or fluid retention. A venous blood sample was taken to determine levels of serum electrolytes, serum creatinine and blood urea. An arterial blood sample was taken to determine the level of blood gases. Abdominal ultrasound and plain urinary tract imaging were done to determine degree and level of obstruction. Patients were subdivided into three groups, A, B and C, according to the clinical findings and type of treatment. The treatment decision was based on the patient’s general condition, basic metabolic panel and stone localization. Group A included patients who were critically ill, had serum creatinine 3.5 mg/dl, blood urea nitrogen 100 mg/dl, serum potassium 7 meq/l and/or blood pH 7.1. This group was treated initially by peritoneal dialysis, followed by our standard protocol of management, in which open surgery or drainage would be chosen according to the stone level determined. Patients in groups B and C were stable with serum creatinine < 3.5 mg/dl, blood urea nitrogen < 100 mg/dl, serum potassium level < 7 meq/l and blood pH > 7.1. In group B, the obstructing stone could not be localized and patients were treated either by percutaneous nephrostomy or JJ stent. If the decision was percutaneous nephrostomy then we chose the side to operate according to the priority of infection and the more dilated pelvis. In group C, stone level was confidently determined and patients were treated by open surgery, choosing the side where there were fewer stones. Follow-up tools included urine output and basic metabolic panel. Complications were recorded for each treatment line. Time for blood chemistry to return to normal was also recorded.
All children regained normal blood urea, serum creatinine (Fig. 1) and electrolyte levels within 48 h (after one run of dialysis). Eight children (42%) in this group were relieved of anuria during dialysis due to either stone expulsion (through urethra or to the bladder) or dis-impaction. The overall complication rate was 26% (Table 1). Hypokalemia was recorded in three children (15%) and sepsis in two children (10%). Both conditions were managed by replacement therapy and antibiotics. Children with persistent anuria after dialysis (11) were managed by open pyelolithotomy in eight, internal stenting in two and percutaneous nephrostomy in one.
Group B (urinary drainage group)
Group C (open surgery group) Pyelolithotomy was done in 16 patients (69.5%) and ureterolithotomy in seven patients. Serum creatinine improved rapidly within 3 days (Fig. 1). The overall complication rate was 13% (Table 1). Secondary hemorrhage occurred in one child (4%) and was managed conservatively by blood transfusion and parental antibiotics. Other complications were minor: persistent leakage in two (8%) patients (stopped spontaneously within 6 days), low-grade fever in two (8%) patients and wound infection in two (8%) patients.
Results Fifty-four patients were included. Age ranged from 1 to 8 years. Nineteen patients (35.2%) fell in the group A category, 12 patients (22.2%) were group B and 23 patients (42.6%) were group C. All children had bilateral urinary stones.
Figure 1 Graph showing drop in serum creatinine level over time for each treatment line.
464 Table 1
M.A. Elgammal et al. Complications reported with different treatment lines.
Line of management
Major complication
Peritoneal dialysis Percutaneous nephrostomy
Hypokalemia Slippage Febrile UTI Primary hemorrhage Febrile UTI Secondary hemorrhage
Internal stenting Open surgery
Discussion Acute renal failure is the most important condition in pediatric nephrology seen in hospital practice. The causes and outcome vary from place to place and have shown changes with time. Dialysis therapy has changed the outlook for this condition somewhat; however, dialysis, especially hemodialysis, is not as easy a proposition in children at centers with limited resources and inadequate expertise [2]. Peritoneal dialysis is most often used in children with acute renal failure. It is a technically simple procedure not requiring specialized personnel. The procedure is well tolerated in the hemo-dynamically compromised child since fluid and solute removal occurs gradually over the course of the day, rather than during a short hemodialysis treatment when the risk of hypotension or dialysis disequilibrium would be much greater. Solute and fluid removal across the peritoneal membrane is efficient in children; the surface area of the peritoneal membrane correlates with the body surface area rather than the body mass, and this ratio is most favorable in infants and young children. Also, this form of dialysis is somewhat less expensive to perform [2,3]. Another advantage of peritoneal dialysis in our study was that stone expulsion (through urethra or to the bladder) or dis-impaction was encountered in 42% of children in this group, relieving of the anuria and converting the condition from an urgent to an elective one. Sepsis occurred in 10% of children under dialysis and was successfully treated using parental antibiotic therapy. Percutaneous nephrostomy has come a long way since the time of William Goodwin, who inadvertently punctured the renal pelvis attempting a translumbar aortogram [4]. Although percutaneous nephrostomy was developed using fluoroscopic guidance, ultrasound-guided procedures are now safe, easy and effective [5e7]. The procedure is usually performed when retrograde stenting is not possible, due to difficult anatomy or lack of technical expertise. Comparative studies have been carried out between percutaneous nephrostomy and retrograde ureteric stenting. Pearle et al. found no difference in clinical efficacy between the two procedures and concluded that the choice of procedure may be based on the particular circumstances of the patient and availability of facilities to carry it out [8]. A similar study however found percutaneous nephrostomy to be superior to retrograde stenting; the results demonstrated that percutaneous nephrostomy is tolerated better by patients and has less influence on the quality of
Minor complication 3 2 2 1 2 1
(15%) (33%) (33%) (16%) (33%) (4%)
Sepsis Leakage Mild hematuria Transient obstruction Difficult introduction Persistent leakage Low-grade fever Wound infection
2 2 1 3 2 2 2 2
(10%) (33%) (16%) (50%) (33%) (8%) (8%) (8%)
life than ureteral stents [9]. Mhiri and co-workers recommended percutaneous nephrostomy as an emergency measure followed by cold nephrolithotripsy, and considered it the first step of in situ treatment of the stone [10,11]. We observed a 65% complication rate in children treated by nephrostomy. As regards major complications of this procedure, primary hemorrhage occurred in 16%, tube displacement in 33%, for which re-nephrostomies had to be performed, and febrile UTI in 16%. Minor complications were post-procedure urine leak in 33%, mild hematuria in 16% and intermittent tube obstruction in 50%. clayman et al. summarized early complications inherent to fluoroscopy-guided percutaneous nephrostomy, the most common being acute bleeding requiring transfusion (<5%), failed access (<5%), adjacent organ (bowel, spleen, lung) injury (<1%) and septicemia (<1) [12]. Cochran et al. stated that risk of procedure-related sepsis is a major concern [13]. The incidence of sepsis is reported to be 0e5% [14e16], although one study showed a higher incidence of 21%. In that same study, the incidence of sepsis decreased to 9% when antibiotics were administered [13]. To our mind, primary hemorrhage was the most serious complication because the anuric kidney is edematous and congested, so the risk of cortical bleeding is high, especially with multiple punctures to access the relatively small-sized pelvi-caliceal system. As regards ureteral stenting, we observed a complication rate of 50%. Only febrile UTI was encountered as a major complication, with an incidence of 33%. Normalization of serum creatinine was reached after 5 days of the procedure. With other methods of treatment normalization of serum creatinine was reached after a maximum of 3 days. Two children in this study were not relieved of their anuria immediately after ureteric stenting. This might be due to the stents used being of narrow caliber (3e4 Fr) and therefore at risk of obstruction with ureteric edema or small clots/debris. A previous study by Li et al. compared percutaneous nephrostomy and open surgery in treating patients with post-renal acute renal failure. They concluded that percutaneous nephrostomy is preferable because of minimal trauma, less blood loss, as well as rapid recovery and better effect on recovery of renal function [17]. We think that this is true as regards adult patients, but in the pediatric population percutaneous nephrostomy may add another risk for an already critically ill child if it is complicated. The risk of anesthesia and difficulties of doing the procedure in a relatively small non-dilated kidney
Management of calculus anuria in children should be considered before taking the decision of percutaneous nephrostomy. Open surgery in our study had the lowest complication rate (13%). All children subjected to open surgery were in the group of non-critically ill children and had their stone level definitively determined by imaging study.
Conclusion Urinary diversion in children is associated with a high complication rate, while dialysis is highly effective in children rather than adults, with a lower complication rate and high incidence of spontaneous relief of anuria during peritoneal dialysis. Formal surgery in compensated children is associated with a low complication rate, with a good outcome and early recovery.
Conflict of interest All authors have no conflict of interest.
Funding No financial support or incentive has been provided for this manuscript.
Authors’ contribution All authors of this manuscript have directly participated in planning, execution, and/or analysis of this study. The contents of this manuscript have not been copyrighted or published previously. The contents of this manuscript are not now under consideration for publication elsewhere. The contents of this manuscript will not be copyrighted, submitted, or published elsewhere while acceptance by clinical Pediatric Urology Journal is under consideration. There are no directly related manuscripts or abstracts, published or unpublished, by any authors of this manuscript.
References [1] Brady HR, Brenner BM. Acute renal failure. In: Kasper DL, editor. Harrison’s principles of internal medicine. 16th ed.; 2005. p. 1644e53.
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