A 20 month old boy with kidney stones managed with Mini-perc
Master S.C. had recurrent urinary infections requiring antibiotic injections since 1 year of age. He had required multiple admissions at hospitals for antibiotic courses.
 
At 20months of age, he was referred to us with an ultrasound scan showing large stones in both kidneys. A CT scan was done to see the size and shape of the stones properly. CT scan showed the stones to be of “Staghorn” type. Staghorn literally meaning like horns of a stag- are the stones with a very complicated anatomy and they extend into sub-branches of urine collecting system within the kidneys and are as such very difficult to remove completely. In the present case as both the kidneys were involved with large stones, the management decisions were even more difficult.
The options were:
  1. Both sides open surgery : Shashank was advised surgery for removal of stones and open surgery was offered at some hospitals. Open Surgery for kidney stones especially of Staghorn variety is a really major procedure where the whole kidney has to be split open and there are high chances of major blood loss, kidney damage and other complications.
  2. Mini-Perc (also called Mini- PCNL)- Percutaneous Nephrolithotomy (PCNL or Perc) is a procedure routinely employed for such stones in adults. It entails making a direct puncture into the kidney through the back with a fine needle under radiological guidance. Through the needle a guidewire is then placed and the route to the stone is made gradually bigger to about 1cm by stepwise dilatation. Finally, a telescope called nephroscope is placed and the stone is broken down into small pieces with soundwaves or Laser and removed. Adult instruments are bigger and allow removal of large pieces. Same sized instruments if used in young children can lead to kidney damage and bleeding.
    For children a technique called – Mini-perc or Mini PCNL is recently being introduced. The size of the telescope is 12 French (adult is 20/24 Fr) and this can be easily used in small kids. The net cut on the back is less than 5mm and is safe for a developing small kidney. Larger fragments cannot be removed but Holmium Laser comes in handy in breaking these stones into really small pieces which are then removed or washed out.
Master S.C.  was taken up for Mini-perc and Holmium LASER on right side first (the side with the larger stone) at MITR healthcare Hospital, Kharghar . The surgery was completed without any blood loss and complete clearance of the stone was achieved. Shashank was discharged 3 days later withour any stitches and a small bandaid dressing on the back.
 
He remained free of any infections with minor oral antibiotics and was readmitted 3 weeks later for left side Mini-perc+ Holmium Laser. Left side kidney stones were also cleared completely and he was discharged 2 days later. More than a 3 months after second surgery, he is at home free of stones, infections and scars.
Master S.C. is one of the youngest kids in India to undergo successful Mini-perc for both sided kidney stones.
 
Ultrasound scan of right kidney showing large kidney stone Ultrasound scan of left kidney showing large kidney stone
   
CT scan in vertical axis showing stones in both kidneys CT scan in transverse section showing both sided stones
   
Operation room snapshot at MITR Hospital The child is kept in prone position for Mini-perc
   
Facts about Endourology and urinary stones in children
Endourology involves surgeries within the urinary system through the natural channels or small holes using miniaturised telescopes.
Pediatric endourology had its advent 3 decades back with availability of Pediatric cystoscopes which can be used in small infants safely.
Most common type of endourological surgeries in children are Posterior urethral valves ablation (case4), DJ stenting or for urinary stones.
Urinary stones in children are relatively uncommon and thus require thorough investigation as to find the underlying factors leading to their occurence, especially if they occur in kidney or ureter.
If the underlying cause can be identified, then medical therapy may be advisable to prevent reformation of stones. This is vital in kids as they have further 70-80 years of life ahead of them.
Small stones in kidney or ureters (<5mm) are generally passed spontaneously without any surgery, there are medicines which help in this. Rarely if the stone gets stuck in ureter it may require a Endourological Surgery in form of Uretrorenoscopy (URS).
Bladder stones can sometimes form without any underlying metabolic disorder and they are treated separately by PCCL or Cystolithotripsy.
 
 
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