Division of Paediatric Urology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, UP, -226014 , India.
Division of Paediatric Urology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, UP, -226014 , India.
J Pediatr Urol. 2022 Jun;18(3):312.e1-312.e5. doi: 10.1016/j.jpurol.2022.03.017. Epub 2022 Mar 28.
Minimal invasive approach is the current standard of care in the management of pediatric renal calculi. Current guidelines are clear with extra corporal shock wave lithotripsy (ESWL) and percutaneous nephrolithotomy (PCNL) for stone size less than and greater than 20 mm respectively. Although retrograde intrarenal surgery (RIRS) is well established in adults but literature on its role, safety and efficacy in children is sparsely available.
To share our experience of RIRS and its outcome in a pediatric population in both primary and residual calculi of size less than 20 mm.
We retrospectively analysed data of children who underwent RIRS for either primary or residual renal calculi from January 2017 to January 2021. Children less than 5 years underwent passive ureteric dilatation with stenting preoperatively. A7.5 Fr flexible ureteroscope with an access sheath was used in all cases while performing RIRS. All the patients had a stent left in situ at the end of the procedure. Data including stone burden, number of sittings, operative time, stone-free rate (SFR) and grade of post procedural complications were analysed with appropriate statistical methods.
A total of 20 patients were included in this study. The median age at presentation was 9 years ranging from 9 months to 18 years. Eight patients (40%) presented with primary renal calculi and underwent RIRS directly while the rest of the 12 (60%) had residual calculi following other procedures like SWL, PCNL before undergoing RIRS. Seven patients (35%) had congenital renal anomalies. The mean stone size and operating time (OR) was 12.6 ± 3.2 mm 84.5 ± 7.2 min respectively. The post-procedural complications were seen in 4 (20%) patients in the form of Grade-1 modified Clavein classification in 3 and Grade 2 in 1 patient. The 100% stone-free rate was achieved in 80% of the cases after first attempt.
In the present series, RIRS was effective in both the types of stones (primary and residual) less than 20 mm in size, showing 100% stone free rate with maximum of two attempts. Choosing age based optimised passive ureteric dilation led to injury free access for RIRS. Overall complications remained with in low grades and are comparable to current literature. Limitations of the study include small cohort, retrospective study and the need of three anaesthesia procedures in children under 5 years of age.
RIRS is safe and effective in children with a renal stone(s) less than 20 mm and it has a high success rate in term of achieving stone free status in both primary and residual calculi.
微创方法是目前治疗小儿肾结石的标准方法。目前的指南明确规定，对于小于 20 毫米的结石，采用体外冲击波碎石术（ESWL）和经皮肾镜碎石术（PCNL）治疗；对于大于 20 毫米的结石，采用经皮肾镜碎石术（PCNL）治疗。虽然逆行肾盂内手术（RIRS）在成人中已经得到很好的建立，但其在儿童中的作用、安全性和疗效的文献资料很少。
分享我们在小儿人群中使用 RIRS 治疗小于 20 毫米的原发性和残余结石的经验及其结果。
我们回顾性分析了 2017 年 1 月至 2021 年 1 月期间因原发性或残余肾结石接受 RIRS 的儿童患者的数据。5 岁以下的儿童在术前进行被动输尿管扩张和支架置入。所有病例均采用 7.5Fr 柔性输尿管镜和鞘管进行 RIRS。所有患者在手术结束时均留置支架。使用适当的统计方法分析结石负荷、手术次数、手术时间、无石率（SFR）和术后并发症分级等数据。
本研究共纳入 20 例患者。中位年龄为 9 岁，年龄范围为 9 个月至 18 岁。8 例（40%）为原发性肾结石，直接行 RIRS 治疗；其余 12 例（60%）在接受 RIRS 前，曾接受过 SWL、PCNL 等其他治疗，有残余结石。7 例（35%）存在先天性肾畸形。平均结石大小和手术时间（OR）分别为 12.6±3.2mm 和 84.5±7.2min。术后并发症 4 例（20%），其中 3 例为改良 Clavein 分级 1 级，1 例为 2 级。首次尝试后，80%的病例达到 100%的无石率。
在本系列中，RIRS 对大小小于 20 毫米的两种类型结石（原发性和残余性）均有效，首次尝试的无石率达到 100%，最多尝试两次。根据年龄选择优化的被动输尿管扩张可实现无创伤性的 RIRS 入路。总体并发症处于低级别，与目前的文献资料相当。本研究的局限性包括：样本量小、回顾性研究、5 岁以下儿童需要进行 3 次麻醉。
RIRS 治疗小儿肾结石（小于 20 毫米）是安全有效的，在原发性和残余结石中均具有较高的结石清除率。
