الفهرس 
RENAL ANATOMYOnly 14 pages are availabe for public view
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Abstract
R
enal stone disease in children is uncommon and causes a clinical management dilemma due to the size of the urinary tract in children and risk of recurrence.
The majority of renal stones are due to metabolic disorders or urinary tract infections with a consequently high lifetime risk of recurrence (Wah et al., 2013).
In the past, open surgery was the only treatment modality available to children, despite its related morbidities. New technologies have been offered for the management of renal stone disease in children. In 1986, extracorporeal shockwave lithotripsy (ESWL) was first introduced in children and it is now used as the first-line treatment for children presenting with renal stones (Newman et al., 1986). However, ESWL is usually not suitable for a large stone burden, such as a ‘‘Staghorn’’ stones, and sometimes ESWL fails to fragment some stones with very high density, which would then indicate surgical intervention. Percutaneous nephrolithotomy (PCNL) is a well-established technique in adults (Woodside et al., 1985).
PCNL was first described in children by Woodside et al. in 1985. Acceptance of the procedure for treatment of renal calculi in pediatric patients was delayed because the authors used adult instruments and there was great concern about the deleterious effects of these large instruments on small pediatric kidneys.
Then, development of new instruments, technical improvement and presence of endourologists with considerable experience in percutaneous surgery allowed widespread acceptance of PCNL for treating renal calculi in children.
The current indications of PCNL in pediatric patients included large, complex, staghorn stones and those who are contraindicated to undergo ESWL or failed ESWL treatment.
Preoperative radiological investigation of choice was NCCT using low dose protocols to reduce radiation exposure. Antibiotic prophylaxis is recommended and the procedure must be performed by an experienced team including endourologist, anesthiologist, nurses and technicians.
Percutaneous renal access is recommended to start at the posterior axillary line and enter the kidney through the top of a posterior calyx. Then dilatation of the tract is performed by many techniques as serial dilatation , single step technique and balloon dilation .
Intra-renal manipulations and lithotripsy should be performed in intelligent and delicate movements to achieve maximum stone clearance without high morbidity. Post-operative care and medications are as important as the operative steps.
Complications of PCNL include bleeding , postoperative fever and others . Among these complications, fever was the most common and bleeding was the most dangerous.
The range of complication rates is very wide (1.2% - 60%). To reduce the complications of traditional PCNL and its significant morbidity, Jackman introduced the Mini PCNL technique using an instrument with 12-Fr rigid nephroscope and 15 Fr sheath in 2001. Then, Desai and his colleagues described the ultra mini PCNL (UMP) technique where the tract dilatation is 11 Fr.
With the recent advances in technology and development of miniature endourological instruments, the reported stone-free rates of PCNL for children in recent large series are satisfactory and ranged from 59 % to 97.2%.
This study aimed to assess safety and efficacy of PCNL in the treatment of renal stones more than 15 mm in children aged 2-14 years and included 40 patients who were divided into 2 groups
group A aged 2-6 years was managed by mini PCNL
group B aged 7-14 years was managed by standard PCNL
All cases were investigated preoperatively by non contrast enhanced CTUT
Stone clearance rate , operative time, perioperative complications, need to analgesia and length of hospital stay were reported.
Success was defined as complete stone clearance or non significant (≤ 4mm), non obstructing residual fragments.
group A achieved complete stone clearance by 88.9 % while group B achieved complete stone clearance by 95.5 %
No major complications were reported , so PCNL is a safe and effective procedure for management of renal stones in children, with accepted stone clearance rates and postoperative morbidity in addition to short hospital stay.