Laparoscopic Surgery in Pediatric Upper Tract Urolithiasis: An Alternate Modality.

INTRODUCTION: Incidence of pediatric urolithiasis has increased over the last few decades. Procedures such as extracorporeal short wave lithotripsy, percutaneous nephrolithotripsy, and ureterorenoscopic lithotripsy are not widely available for pediatric age group in many developing countries. It is desirable that advantages of minimally invasive surgery be offered to selected cases with urolithiasis.
MATERIALS AND METHODS: All patients with pediatric upper tract urolithiasis managed laparoscopically from January 2015 to April 2020 were retrospectively reviewed.
RESULTS: A total of 38 patients were included. The mean age of the patients was 8 ± 2.85 years. Thirty-four patients (renal and upper ureteric) were managed through retroperitoneal approach, while those with lower ureteric calculi (n = 4) were approached transperitoneally. A total of eight patients required conversion to open technique. The stone clearance rate was 79% by laparoscopic approach alone. There were no procedure-related complications.
CONCLUSION: Our study suggests that laparoscopic management for pediatric upper tract urolithiasis is a radiation-free, single-time curative treatment and is feasible in centers where facilities for other endoscopic procedures are unavailable. Copyright:

INTRODUCTION

The incidence of pediatric urolithiasis has increased over the last few decades. The prevalence rates in the developing countries are reported to be as high as 15% in children under 15 years of age.[1] Extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotripsy (PCNL), and ureterorenoscopic lithotripsy (URSL) are procedures of choice in the management of urinary tract stones both in adults and children. However, open surgery is still widely practiced in developing countries due to nonavailability of these facilities, expertise, and the inability of patients from far-flung areas to reach tertiary care centers where these facilities are available.[1] Facilities and expertise for pediatric laparoscopic surgery are now available in a larger number of centers in developing countries. Hence, it is desirable that selected cases be offered advantages of minimally invasive surgery instead of open surgery in the absence of other endoscopic modalities. We present our experience with laparoscopic management of upper tract urolithiasis in children.

MATERIALS AND METHODS

All patients of pediatric urolithiasis managed laparoscopically from January 2015 to April 2020 at our institute were included in this report. Retrospectively collected data on laparoscopic approach, duration of surgery, blood loss, conversion to open procedure, and stone clearance rates were analyzed. First author was the primary surgeon in all these cases. Preoperative workup included routine hematological investigations, urine analysis, and ultrasonogram of the abdomen. Intravenous pyelogram was performed in all patients to delineate the pelvicalyceal anatomy. Computerized tomography (CT) scan could be done in only six cases due to cost factor. Stone clearance was checked peroperatively by using C-arm and postoperatively by plain X-ray abdomen before discharge.

Retroperitoneal approach to renal and upper ureteric stones

The children were placed in lateral kidney position. Three ports were placed. A 10-mm camera port was placed between the 12th rib and iliac crest in the posterior axillary line. Two 5-mm ports were placed – one in the renal angle and another in the superomedial to anterior superior iliac spine. The renal pelvis was cleared posteriorly and incised obliquely, avoiding the pelviureteric junction. In difficult cases, incision was extended into one of the calyces. Stone was gently manipulated out. A glove-finger was used as a retrieval bag. Stone was placed in it to be taken out at the end of the procedure. A Double-J stent (DJ) was placed if the pyelotomy incision extends into the calyces. The renal pelvis was closed with 5-0 polyglactin suture. A perinephric drain was left in place via the camera port. Complete stone clearance was confirmed during surgery by matching the shape and number of stones retrieved with those on preoperative imaging studies, and further confirmation was done by peroperative C-arm imaging.

Transperitoneal approach to lower ureteric stones

The patient was placed in 45° lateral position with the ipsilateral side up. Three ports were placed. A 10-mm camera port was placed at umbilicus. Two 5-mm ports were placed according to position of the ureteric stone using the triangulation method. The overlying colon was reflected off the ureter. The ureter was gently grasped just above the stone. An incision was made in the ureter over the stone; the stone was extracted and placed in a glove finger which was retrieved at the end of the procedure. A DJ stent was placed through the ureterotomy and ureterotomy closed with a few interrupted 5-0 polyglactin sutures. The glove finger with the stone was retrieved through the camera port.

RESULTS

A total of 38 (28 male and 10 female) patients, with a mean age of 8 ± 2.5 years (range 5–12 years), underwent laparoscopic procedure for urolithiasis. Flank pain was the most common symptom (22/38). Hematuria with flank pain was present in eight patients (21.05%). Thirty-two patients had single calculi, of which seven had staghorn renal calculi. Retroperitoneal access was used in 34 patients. Four patients with lower ureteric calculi underwent transperitoneal laparoscopic ureterolithotomy. The mean duration of surgery for laparoscopic pyelolithotomy was 85 ± 30 min [Table 1]. Conversion to open procedure was required in eight cases. Four of these had multiple pelvicalyceal stones, three patients had large impacted staghorn pelvicalyceal stone, and one case had dense perirenal adhesions [Table 2]. None of the cases required blood transfusion during surgery. The mean hospital stay was 4.2 ± 2 day (2–10 days). The stone clearance rate was 79% by laparoscopic approach alone. Complete stone clearance could be achieved in all the cases within single general anesthesia (i.e., including the cases converted to open procedure).

Table 1

Clinical profile of patients and operative details

Parameters	Renal stones	Ureteric stones
Age (years)	8±2.5	9±1.5
Sex (male:female)	2.3:1	5:0
Number of stones
Single	28	4
Multiple	5	1
Symptomatology, n (%)
Pain	18 (54.5)	4 (80)
Pain and hematuria	7 (21.2)	1 (20)
Hematuria	8 (24.2)
Approach, n (%)
Transperitoneal	0	4
Retroperitoneal	33 (100)	1
Duration of surgery (min)	85±30	80±15
Hospital stay (days)	4.2±2	2-3
Peroperative blood loss (ml)	30±10.3	8±2

Table 2

Comparison of patients characteristics in those managed laparoscopically with those requiring conversion

	Laparoscopic (n)	Converted (n)
Site of stone
Renal	25	8
Upper ureteric	1	0
Lower ureteric	4	0
Number of stones
Single	28	4
Multiple	2	4
Staghorn	4	3
Peripelvic adhesion	20	1
Renal pelvis
Dilated	22	3
Nondilated	8	5

DISCUSSION

Similar to adults, ESWL, PCNL, URSL, and now retrograde intrarenal surgery are considered to be the procedures of choice for the management of pediatric urolithiasis in developed countries. Laparoscopic or open surgery is reserved for cases with failure of these procedures or in cases with malformed or ectopic kidneys.[1] However, in the developing countries, other factors such as cost of the procedures, availability of these facilities, and expertise also determine the choice of procedures for the management of pediatric urolithiasis. Laparoscopic surgery is preferable in these setting. There are some studies describing laparoscopic approach in adults, but very few studies describing use of laparoscopy in children with urolithiasis are available in English literature.[23456] Apart from the known advantages of laparoscopy such as shorter hospital stay and better cosmesis as compared to open surgery, it is a radiation-free procedure with complete stone clearance under single anesthesia. Soltani et al. reported stone clearance rate of 100% in laparoscopic pyelolithotomy.[2] Similar results were noted by Gaur et al.[7] Landa-Juárez et al. have used a combination of laparoscopy and pyeloscopy with lithotripsy and achieved a stone-free rate of 92.8% with single procedure.[8] In the present study, the stone clearance rate was 79% by laparoscopic approach alone. Patients in whom stones could not be retrieved were converted to open procedure, and the complete clearance was achieved under single anesthesia. With laparoscopic approach, the chances of residual fragments are minimal. In endoscopic surgeries, residual fragments are a major concern in pediatric patients. Residual fragments that are considered clinically insignificant residual stone fragments in adults cannot be neglected in children.[9] Most of the studies available in pediatric urolithiasis describe transperitoneal approach, may be because it allows more space and greater freedom of movement.[261011] In author's view, retroperitoneal approach provides direct access to the urinary tract and the chances of postoperative adhesive obstruction are minimal as there is no breach in the peritoneal cavity. There are less chances of vascular injury when dealing with intrarenal pelvis and in cases requiring extended pelvic incisions. Al-Hunayan et al. in their study recommended retroperitoneal approach over transperitoneal approach for laparoscopic pyelolithotomy.[11] Valla performed laparoscopic pyelolithotomy in three cases using retroperitoneal approach and reported that this approach is feasible and safe in pediatric population if performed by well-trained surgeons.[12] Limited data are available regarding complications of laparoscopic management. Various complications reported are urinoma formation, omental prolapse, and bleeding.[4]

In our series, we see that most of the cases that were converted to open procedure had either multiple pelvicalyceal stones or large impacted staghorn stones associated with nondilated renal pelvis [Table 2]. Hence, laparoscopic pyelolithotomy is now avoided in patients with staghorn calculus, especially in non/minimally dilated pelvicalyceal system, and in patients with multiple stones and calyceal stones. We now offer laparoscopic pyelolithotomy/ureterolithotomy only in cases with single renal pelvic stones/ureteric stones. Retroperitoneal approach is our preferred approach for renal pelvic and upper ureteric stones, and transperitoneal approach is preferred for lower ureteric stone. However, a randomized control studies including larger number of patients are required to validate our inferences.

CONCLUSION

Our study suggests that a single renal pelvis and single/multiple ureteric stones can be managed laparoscopically in pediatric population. Laparoscopic management is a radiation-free, single-time curative treatment and is feasible in centers where facilities for other endoscopic procedures are unavailable. However, a proper case selection is prudent to achieve good results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.