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L. Defidio, M. De DominicisStone sizeStone compositionStone locationAgeCongenital anomaliesSecondary anomaliesTable 1.Indications for retrograde treatment of renal stones in children≤ 2 cmRefractory to ESWLInferior calyx (lower pole)≥ 12 mthAbsence of upper obstructive pathologiesSolitary kidneyCoagulation disorderEctopic kidneycurrently urologists can benefit from the whole spectrumof stone management alternatives also in children.Although ESWL is still the most important procedure fortreating urinary stones, advances in flexible endoscopes,intracorporeal lithotripsy, and extraction instrumentshave led to a shift in the range of indications (3).The indications for retrograde treatment of the renalstone in child are showed in Table 1.According to the location of the stone the treatment canbe done with the rigid or flexible ureteroscope. The safetyand efficacy of ballistic or holmium:YAG laserlithotripsy make intracorporeal lithotriptor the treatmentof choice.Usually, a paediatric cystoscope is used to place a 5 Fropen-ended catheter to the level of the intramural ureter,and a low pressare ureteropyelogram is taken. A 0.035inch guidewire is positioned in the renal pelvis throughthe open-ended catheter and used as a safety wire duringthe procedure and for placing a ureteral catheter at theend of the procedure.The second dual flex guidewire is advanced in the ureterthrough the working channel of the 6 or 8 Fr semirigidureteroscope. The scope is then advanced between thetwo guidewires under endoscopic guidance up to thekidney.This manoeuvre allows an active dilation of the ureterfacilitating a subsequent flexible ureterorenoscopy orfragments removal. Any difficulty in negotiating theureteric orifice was resolved by rotating the instrumentatraumatically by 180° during insertion. Ureteric dilatorswere very rarely used and only when the meatus wasimpossible to negotiate.Current ureteroscopic intracorporeal lithotripsy devicesand stone retrieval technology allow for the treatment ofcalculi located throughout theintrarenal collecting system. Ifthe stone is located in theupper calyx, middle calyx orin the renal pelvis a lithotripsywith a semirigid ureteroscopeis recommended tostart. Lower pole calculi arefragmented with a 200µholmium laser fiber by a 7.5Fflexible ureteroscope.For those patients in whomthe laser fiber reduces thescope deflection, precluding are-entry into the lower polecalix, a 1.5, 1.9 or 2.2 tiplessnitinol basket is used to displace the lower pole calculusinto a more favorable position, allowing easier fragmentation(relocation technique) (4).This manoeuvre is essential to preserve the ureterorenoscope(Figure 1).The use of a ureteral access-sheath, during a flexibleureterorenoscopy, is suggested to improve the irrigantflow and visibility.The ureteral access-sheath can induce transient ureteralischemia and promote an acute inflammatoryresponse, but it also prevents potentially harmful elevationsin intrarenal pressure reducing the risk of urosepsis.It has also has the potential to improve stone-freerates by allowing passive egress or active retrieval offragments.To obtain stone fragments is essential for biochemicalanalysis. The stone composition may give significantinformation to prevent the high rate of recurrence, withdietary modification and specific therapy.Usually, a ureteral open-ended catheter is left in placeand removed in the next 24-72 h. If ureteric dilation wasused or the procedure has been complicated, a doublepigtailureteric stent is left in place for 1 week.Successful outcomes for the retrograde treatment of renalcalculi are similar to the ones obtained in the adult population(Table 2).The retrograde semirigid and flexible ureteropyeloscopy,using a small calibre ureteroscope, are a valuable techniquefor kidney stones treatment in children. Withexcellent technique and meticulous attention to details,the significant complications are rare. Reported complicationsare infrequent and generally minor. Intra-operativeureteric injuries usually consist of ureteric perforationwith the guide-wire.Table 2.Stone free rate in ureteroscopic treatment of kidney stones in child.C an n o n G M (J Endourol 2007) (5) 93% for stone < 15 mm No relocation technique33% for stone > 15 mmSmal d o n e M C (J Urol 2007) (6) 91% Mean stone size 8.3 mmM i n ev i c h E (J Urol 2005) (7) 98% Non stone size evidence54Archivio Italiano di Urologia e Andrologia 2010; 82, 1
Flexible ureteroscopy for kidney stones in childrenFigure 1.Relocation technique. Fluoroscopic sequence (a, b, c, d)of a stone relocation in a more comfortable calyx.REFERENCES1. Minevich E, Sheldon CA. The role of ureteroscopy inpediatric urology. Curr Opin Urol 2006; 16:295-8.2. Sarica K. Medical aspect and minimal invasive treatmentof urinary stones in children. Arch Ital Urol 2008;80:43-9.3. Türk C, Knoll T, Köhrmann KU. New guidelines for urinarystone treatment. Controversy or development?. UrologeA 2008; 47:591-3.4. Preminger GM, Kourambas J, Delvecchio FC, Munver R.Nitinol stone retrieval-assisted ureteroscopic managementof lower pole renal calculi. Urology 2000; 56:935-9.5. Cannon GM, Smaldone MC, Wu HY, et al. Ureteroscopicmanagement of lower-pole stones in a pediatric population. JEndourol 2007; 21:1179-82.6. Smaldone MC, Cannon GM Jr, Wu HY, et al. Isureteroscopy first line treatment for pediatric stone disease?J Urol 2007; 178:2128-31; discussion 2131.7. Minevich E, Defoor W, Reddy P, et al. Ureteroscopy issafe and effective in prepubertal children. J Urol 2005;174:276-9; discussion 279.CorrespondenceLorenzo Defidio, MDU.O.C. di Urologia Endoscopica e “Stone Center”Ospedale Cristo ReVia Delle Calasanziane, 25 - 00167 Roma, Italydefidio@tin.itMauro De Dominicis, MDU.O.C. di Urologia Endoscopica e “Stone Center”Ospedale Cristo ReVia Delle Calasanziane, 25 - 00167 Roma, Italydedominicism@aliceposta.itArchivio Italiano di Urologia e Andrologia 2010; 82, 155
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Official Journal of the SIEUN, the
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ContentsHistological evaluation of
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Page 15 and 16: ORIGINAL PAPERSurgery for renal cel
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Page 21 and 22: M. Aza, S.S. Iqbal, M.V. Muhammad,
Page 23 and 24: Archivio Italiano di Urologia e And
Page 25 and 26: The Clavien classification system t
Page 27 and 28: PRESENTATIONPercutaneous nephrolith
Page 29 and 30: Percutaneous nephrolithotomy: An ex
Page 31 and 32: PCNL in ItalyTable 1.Number and hos
Page 33 and 34: PCNL in ItalyFigure 3.Comparison be
Page 35 and 36: The patient position for PNL: Does
Page 37 and 38: PCNL: Tips and tricks in targeting,
Page 39 and 40: Tubeless percutaneous nephrolithoto
Page 41 and 42: PRESENTATIONHigh burden and complex
Page 43 and 44: High burden and complex renal calcu
Page 45 and 46: PRESENTATIONEndoscopic combined int
Page 47 and 48: PRESENTATIONHigh burden stones: The
Page 49 and 50: PRESENTATIONStone treatment in chil
Page 51 and 52: Stone treatment in children: Where
Page 53 and 54: PRESENTATIONExtracorporeal shock wa
Page 55 and 56: PRESENTATIONPercutaneous nephrolith
Page 57: PRESENTATIONFlexible ureteroscopy f
Page 61 and 62: Indications, prediction of success
Page 69 and 70: Laparoscopic and open stone surgery
Page 75: Laparoscopic and open stone surgery
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