Modified supine percutaneous nephrolithotomy in an 11-month-old infant

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.

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. 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 ).

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 )

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 ).