Abstract
Nephrolithiasis is less common in children and is rare in newborns. The evaluation and management strategies for renal stones in infants are not clear. Recently, supine percutaneous nephrolithotomy (PCNL) has gained attention, but data on its feasibility and safety in infants are limited. We report a case of supine PCNL in an infant, focusing on its feasibility and benefits.
Keywords: Infant nephrolithiasis, Supine PCNL
1. Introduction
Managing nephrolithiasis in infants presents significant challenges, as there are no distinct guidelines for managing renal stones in this age group. Recently, there has been a shift towards performing PCNL in the supine position.1 However, there is a scarcity of literature on the feasibility and safety of supine PCNL in infants. Here, we present a case of an 11-month-old female infant undergoing supine PCNL at our center.
2. Case presentation
An 11-month-old female baby presented with complaint of excessive crying for 3 months. There was no history of cystinuria, hyperoxaluria, primary hyperparathyroidism, inflammatory bowel disease (IBD), cystic fibrosis, or premature birth. Additionally, there was no family history of renal stones or consumption of high oxalate, protein, or calcium-rich foods. Preoperative urinalysis showed a urine pH of 6.4, and absence of uric acid crystals. Serum uric acid and serum calcium level was within normal level. An ultrasound followed by CT scan of abdomen and pelvis, revealed a right renal pelvic calculus measuring 16.2 x 6.9 mm (Fig. 1).
Fig. 1.
Non-contrast CT scan showing a calculus in right renal pelvis of size 16.2 x 6.9 mm.
As we have extensive experience in performing supine PCNL in adults, we planned to do supine PCNL in this patient. The patient was placed in Barts “flank-free” modified supine position. Posterior axillary line, 12th rib and illiac crest was marked pre-operatively (Fig. 2)
Fig. 2.
Pre-operative picture of 11-months infant in Barts “flank-free” modified supine position. Posterior axillary line, 12th rib and illiac crest marking was done preoperatively.
Cystoscopy was done using 6 Fr paediatric cystoscope and a 4Fr ureteric catheter was introduced. Then, a retrograde pyelogram was done. Puncture was done with 18G needle, targeting the middle calyx in 0° and the depth was adjusted with C-arm in 30° cranial tilt. Puncture was confirmed to be in the calyx by the free flow of urine. Serial dilatation was performed with 8 Fr to 14 Fr fascial dilators, followed by placement of 16Fr metallic amplatz sheath. A 12 Fr nephroscope was used for visualization of the stone. Stones were fragmented with a thulium fiber laser(Fig. 3).
Fig. 3.
(a) Intraoperative picture of C-arm monitor showing mid calyx approach of PCN needle on well visualized renal calyces following fluoroscopy. (b) PCN needle in situ following puncture of right midpole calyx showing free flow of urine. (c) 16 Fr metallic amplatz seath in situ. (d) Lithotripsy in process using Thulium fibre laser as an energy source.
Stone clearance was confirmed endoscopically, after which 3Fr 16cm DJ stent was placed. No nephrostomy tube was placed. 6 Fr foley's catheter was placed for bladder drainage. (Video 1)
Total time taken for the PCNL was 52 mins (from insertion of ureteric catheter to end of the procedure). Post operative period was uneventful. Foley's catheter was removed on second postoperative day. DJ stent removal was done after 4 weeks. Ultrasonography done on the same day revealed no residual calculus. Biochemical analysis of the stone showed it is a mixture of uric acid dihydrate (85 %) and uric acid monohydrate (15 %). A complete metabolic workup did not reveal any abnormalities.
3. Discussion
Despite the increasing prevalence of renal stone disease in the pediatric population, its occurrence among infants remains rare.2,3 Recently, there has been a notable rise in performing PCNL in the supine position in adults. This approach offers several benefits: improved cardiopulmonary management by anesthesiologists, especially in obese patients, reduced intrarenal pressure, easier fragment removal due to gravity, decreased radiation exposure to the surgeon, shorter operative times, and the ability to conduct Endoscopic Combined Intrarenal Surgery (ECIRS) and Simultaneous Bilateral Endoscopic Surgery (SBES).4,5 However, there is a lack of literature supporting the use of supine PCNL in infants under one year of age.
In our case, due to the large size of the stone, we opted for supine PCNL, achieving complete stone clearance with a single mid-calyx access. The advantages observed included no need to change the position, reduced overall operative time, and easier fragment washout due to gravity.
Only a few published studies are available regarding the feasibility and safety of supine PCNL in children. Gamal et al. evaluated supine PCNL in paediatric age group and reported an initial success rate of 92.5 % in 27 children. The youngest patient in the study was 2.5 years.6 Vaddi et al. has reported a case of 9-month-old infant who underwent supine PCNL, which is probably the youngest age of child reported in the literature so far.7
While PCNL is a recognized treatment for large stones in infants, supine PCNL in infants has not been commonly reported. Familiarity and training in adult supine PCNL could make it a viable alternative to traditional prone PCNL, even in infants. This case highlights the feasibility, safety, and benefits of supine PCNL in infants.
4. Conclusion
Supine PCNL, rarely performed in infants due to the technical challenges and associated risks, was meticulously planned and executed by our multidisciplinary team. This case highlights that supine PCNL can be safely and effectively performed even in infants.
CRediT authorship contribution statement
Prajwal Paudyal: Writing – review & editing, Writing – original draft, Supervision, Methodology, Formal analysis, Data curation, Conceptualization. Anup Karki: Data curation, Conceptualization. Anil Subedi: Data curation. Devendra Bist: Writing – original draft. Ashish Lal Shrestha: Writing – review & editing.
Ethics approval and consent for publication
Written informed consent for publication was given by the patient. Ethics approval from the institutional review board was not applicable. Consent for publication and use of images for scientific purposes was given by the patients mother.
Availability of data and materials
Not applicable.
Funding
None.
Conflicts of interest statement
There are no conflicts of interest.
Acknowledgement
The authors would like to thank the staff of the operation room and the general ward staffs of Kathmandu Medical College and Teaching Hospital, Kathmandu for providing support and helping the management of the patient.
Footnotes
Supplementary data related to this article can be found at https://doi.org/10.1016/j.eucr.2025.103024.
Appendix A. Supplementary data
The following is the supplementary data related to this article:
References
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Supplementary Materials
Data Availability Statement
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