UROLOGY - CASE REPORT

Management of multiple stones in a single session usingminimally invasive methods in infants with renal failure:renal salvage

Ahmet Ozturk • Selcuk Guven • Mesut Piskin •

Mehmet Kilinc • Jale Celik • Mehmet Arslan

Received: 11 March 2010 / Accepted: 24 August 2010 / Published online: 17 September 2010

� Springer Science+Business Media, B.V. 2010

Abstract The goal in the treatment of stone disease

causing infantile obstructive uropathy is to obtain a

quick resolution of the obstruction using the least

invasive treatment modality available and rendering the

patient stone-free, if possible. Two infants with bilateral

kidney stones, the first of whom also had ureteral stone,

were referred to our clinic with acute renal failure and

were treated successfully in a single session using

minimally invasive methods. In this report, we discuss

the management of these two cases, aged 9 and

26 months, which resulted in favorable outcomes.

Keywords Simultaneous bilateral percutaneous

nephrolithotomy � PCNL � Infant � Renal failure �Ureteroscopic lithotripsy � Single session

Introduction

Obstructive uropathy inducing renal failure warrants

immediate intervention. It has been shown that it is

not only the relief of obstruction, but also the removal

of calculi that contributes to the improvement in renal

function in patients with azotemia from calculus

disease. Hence, an aggressive approach is warranted

to clear stones from patients who present with

calculus nephropathy and azotemia [1, 2].

In contrast with management in adults, surgical

treatment in pediatric stone disease in a growing

kidney requires a more cautious approach due to the

long-term outcomes and significant recurrence rates.

Children carry a higher risk of the metabolic and

infectious causes of stone disease [3]. The objectives

of treatment in stone disease causing infantile

obstructive uropathy are a quick resolution of the

obstruction and total clearance of stones, if possible,

using the least invasive treatment modality.

Two infants with bilateral kidney stones, the first

of whom also had ureteral stone, were referred to our

clinic with acute renal failure and were treated

successfully in a single session using minimally

invasive methods. We present herein the management

of these two cases, notable with respect to their young

ages of 9 and 26 months.

Patients and methods

Case 1

A 9-month-old male infant was admitted to our

emergency department with anuria, nausea and

A. Ozturk � S. Guven (&) � M. Piskin �M. Kilinc � M. Arslan

Department of Urology, Selcuk University Meram

Medical School, 42080 Akyokus, Konya, Turkey

e-mail: selcukguven@selcuk.edu.tr

J. Celik

Department of Anesthesiology, Selcuk University

Meram Medical School, Konya, Turkey

123

Int Urol Nephrol (2012) 44:3–6

DOI 10.1007/s11255-010-9832-6

vomiting. Serum blood urea nitrogen (BUN) and

creatinine were to 107 and 2.8 mg/dl, respectively, on

admission. Renal ultrasound, plain film and comput-

erized tomography (CT) demonstrated bilateral renal

stones and a right ureteral stone (Fig. 1). The stones

were 20 and 15 mm in diameter on the right, 11 mm

on the left and 10 mm in the right ureter (Table 1).

Urgent treatment was decided.

Endourologic technique

The procedure was started with lithotomy position,

and rigid cystoscopy (10 F) was performed to place a

working wire. The right ureter was followed with a

7.5 F pediatric semirigid ureteroscope (STORZ,

Tuttlingen, Germany), and a 1-cm stone in the

middle ureter was disintegrated with pneumatic

lithotripter. Fragmented stones were extracted with

a basket. Immediately thereafter, 3 F ureteral cathe-

ters were placed in both ureters. The patient was then

placed in the prone position. The genitalia were

covered with lead protection (panel). A mixture of

methylene-blue and opaque substance was flashed

through the right ureteric catheter, and the collecting

system was punctured posterior to the calyx. Dilata-

tion was done using Amplatz sheath up to 20 F. The

Fig. 1 Preoperative CT (a), preoperative plain film (b), postoperative plain film (c), postoperative IVU (d)

Table 1 Patient

characteristics and

operative and postoperative

factors

Age Case 1 Case 2

9 months 26 months

Stone size and location Right kidney (20 mm, 15 mm) Right kidney (12 mm)

Left kidney (11 mm) Left kidney (15 mm)

Right ureter (10 mm)

BUN/creatinine, on admission 107/2.8 (mg/dl) 114/4.7 (mg/dl)

Intervention Right ureteroscopic lithotripsy Right PCNL

Right PCNL Left PCNL

Left PCNL

Total fluoroscopy time 150 s 65 s

BUN/creatinine postop 12 h 17/0.35 (mg/dl) 19/0.7 (mg/dl)

BUN/creatinine postop 24 h 15/0.4 (mg/dl) 16/0.7 (mg/dl)

Metabolic evaluation Cystine Mixed calcium

4 Int Urol Nephrol (2012) 44:3–6

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11-mm pelvic stone was disintegrated with pneumatic

lithotripter, and the stone pieces were extracted with

forceps. Residuals were monitored with fluoroscopy,

and antegrade pyelography was performed to evalu-

ate the collecting system. Then, a 10 F Foley

nephrostomy tube was placed. In the course of

removing the left kidney stone, fluoroscopy was used

for 10 s. After disintegration of both stones in the

pelvis with pneumatic lithotripter, they were

extracted with forceps (Fig. 1). Extraction of all

stones was verified with fluoroscopy and antegrade

pyelography. On the right side, a 10 F Foley catheter

was placed as nephrostomy tube (Fig. 2). In the

course of removing the right kidney stone, fluoros-

copy was used for 140 s. Blood BUN and electrolyte

levels returned to normal on the 1st postoperative day

(Table 1), and ureteral catheters placed in the course

of the procedure were extracted on the same day.

Nephrostomy drainage was clear in the postoperative

period, and the drain was removed on the 2nd

postoperative day. Although there were not any

residual stones determined fluoroscopically at the

end of the operation, 8 mm in diameter lower calyces

stone was determined on follow-up plain film and

renal ultrasound. As it is inconvenient to keep

percutaneous nephrostomy catheter in a 9-month-

old infant, we waited for the decision of the family

concerning SWL or 2. PNL and removed the

nephrostomy catheter. The patient was discharged

uneventfully on the 5th postoperative day. A residual

stone was being followed in this patient. The DMSA

scintigraphy detected no new scarring or loss of renal

function on the postoperative 4th week.

Case 2

A 26-month-old male infant was admitted to our

emergency department with abdominal pain, nausea

and vomiting. Serum BUN and creatinine were 114

and 4.7 mg/dl, respectively, on admission. Plain film

and renal ultrasound demonstrated right and left renal

stones of 12 and 15 mm in diameter, respectively.

Simultaneous bilateral percutaneous nephrolithotomy

(PCNL) was performed as in Case 1, and a 12-mm

stone on the right and a 15-mm stone on the left were

disintegrated with pneumatic lithotripter and

extracted with forceps. Fluoroscopy was used for

20 s on the right and 45 s on the left. Blood BUN and

electrolyte levels returned to normal on the 1st

postoperative day. Postoperative follow-up was

uneventful, and the patient was discharged on the

postoperative 5th day (Table 1).

Discussion

Reports confirming the efficacy and safety of PCNL

and ureteroscopy in children have been published in

recent years, and use of these minimally invasive

methods in children have been attempted, though

widespread use has been slower and more cautious to

develop than in adults [3, 4]. The first reports regarding

the safety of PCNL or ureteroscopy in children were

related to school-aged children whose bodily dimen-

sions were close to those of adults [5–7]. Ensuing

studies have suggested the applicability of PCNL and/

or ureteroscopy in every age group [8–11]. However,

to date, studies emphasizing the best possible clear-

ance rates with the least invasive treatment in infants

with advanced azotemia are lacking.

The reports related with bilateral PCNL in children

are scarce. Salah et al. [12] first evaluated the results of

13 children (average age: 8 years) with bilateral kidney

stones and reported the advantages of simultaneous

bilateral PCNL as reduced psychological stress, one

cystoscopy and anesthesia, less medication, and a

shorter hospital stay and convalescence, with consid-

erable savings in cost. The youngest patient in their

study was 3 years old. Samad et al. [13] later evaluated

results in the very young child, children with anatom-

ically abnormal kidneys, children with impaired renal

function and children with bilateral renal stones

undergoing simultaneous bilateral PCNL. They argued

Fig. 2 Bilateral PCNL and ureteroscopic lithotripsy were

performed, and 10 F Foley catheters were used as nephrostomy

tube

Int Urol Nephrol (2012) 44:3–6 5

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that none of these factors should be considered as

relative contraindications. Furthermore, the results of

bilateral PCNL in Samad’s group were comparable to

those of Salah’s study. Although these two studies give

information about bilateral PCNL in children and the

effectiveness of unilateral PCNL in children with renal

failure, there were no data in those studies about urgent

endourological treatment of bilateral kidney stones

also associated with ureteral stone causing obstructive

uropathy in an infant.

The noteworthy data in our cases were that both of the

children who underwent simultaneous bilateral PCNL

were infants, and their clinical course recovered dramat-

ically. Also, remarkable was the successful application of

bilateral PCNL and ureteroscopy in a single session in

such a young infant with renal failure (9 months).

Renogram with 99mTc-DMSA in first patient detected

no new scarring or loss of renal function.

These findings suggested that simultaneous bilat-

eral PCNL could be applied safely in infants.

Furthermore, percutaneous procedures are accepted

as an excellent treatment modality in the presence of

obstructive uropathy [14–16], it has been shown that

it is not only the relief of obstruction but also the

removal of calculi that contributes to the improve-

ment in renal function in patients with azotemia from

calculus disease [14, 17]. We also preferred treatment

with minimally invasive methods instead of provid-

ing a palliative drainage in infants with renal failure

secondary to stone disease.

It should be kept in mind that the lifetime possibility

of repeat procedures is high in children affected by

stone disease. Use of minimally invasive methods in

children, even in the very young, can be as effective

and safe as in adults. The application of simultaneous

bilateral PCNL and ureteroscopy, if required, with

emphasis on the best possible clearance rates using the

least invasive treatment, can also provide a treatment

rather than only a palliative drainage in infants with

renal failure secondary to stone disease. Also, these

children could have been stabilized with cystoscopy

and internal stenting with transfer if the necessary

equipment and experience are not available.

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