JOURNAL OF ENDOUROLOGY Volume 28, Number 6, June 2014 ª Mary Ann Liebert, Inc. Pp. 693–698 DOI: 10.1089/end.2013.0636
Transurethral and Lower Tract Procedures
Micropercutaneous Cystolithotomy in Children: Our Experience with the Transillumination Technique ˘ Mehmet Nuri Bodakci, MD, Ahmet Ali Sancaktutar, MD, Mansur Daggulli, MD, Namık Kemal Hatipoglu, MD, Haluk So¨ylemez, MD, Necmettin Penbegul, MD, Murat Atar, MD, and Yasar Bozkurt, MD
Abstract
Aim: We present our experience with micropercutaneous cystolithotripsy (mPCCL) using transilluminationguided access in children with bladder stones and evaluate the safety and efficacy of this procedure. Methods: Twelve children who underwent mPCCL for bladder stone removal in our department between January 2011 and September 2013 were included in this study. Percutaneous access was performed using the transillumination technique. The chief complaint, age and sex of the patients, stone size, operative time, complications, stone-free rate, and stone composition as determined by radiography diffraction analysis were recorded. Results: The mean age of the patients was 2.6 (1–7) years. One out of 12 patients was a girl. The mean stone size was 14 mm (7–32 mm). The mean mPCCL procedure time was 38.7 (15–65) minutes. The mean hospital stay was 1.4 (0.5–4) days. The stone-free rate after one mPCCL intervention was 91.6% and increased to 100% after two sessions of mPCCL. The notable complications were transient macroscopic hematuria in one patient, acute urinary retention in one patient, and the need for a second session of mPCCL in another patient. The stones were composed of calcium oxalate (3), ammonium acid urate (1), calcium phosphate (1), cystine (1), struvite (1), and unknown (5). Conclusion: Transillumination-guided mPCCL is a safe and effective technique, does not require the use of ionizing radiation, is technically easy, and is a minimally invasive alternative for the management of bladder stones. It has many advantages, especially in pediatric patients, such as decreased urethral injury, no need for postoperative catheter insertion in most cases, and shorter operative time.
Introduction
I
n developed countries, bladder stones are rare in adults and most commonly associated with bladder outlet obstruction, the presence of an intravesicular foreign body, or chronic infection.1 They can occur during childhood and may be caused by a protein-poor diet, particularly in developing countries, or may have the same etiologic factors as adult cystolithiasis.2 It is well known, however, that the etiology of bladder stones in the pediatric age group is complex and often multifactorial. It may be influenced by genetic or metabolic diseases and other environmental factors and hence has a high risk of recurrence.3 Therefore, appropriate treatment methods should be selected for this age group. Open cystolithotomy, transurethral cystolithotripsy (CL), shockwave lithotripsy (SWL), and percutaneous cystolithotripsy (PCCL) are used for the treatment of pediatric bladder stones. Open procedures should be the last line of treatment for pediatric cystolithiasis. Transurethral CL should be done more carefully in boys due to smaller urethral diameters and
associated concerns about iatrogenic urethral stricture. This risk is inversely related to the age of the child. For larger bladder stones, PCCL is a safe alternative with low morbidity and complication rates.4 The ‘‘all-seeing needle,’’ an optical system inside a special puncture needle, has recently demonstrated optimal renal access during percutaneous renal procedures5; however, this system may only be useful for gaining initial access. This optical system has been used for ‘‘microperc,’’ a single-step percutaneous nephrolithotomy performed with the all-seeing needle. Desai and colleagues have successfully performed this new technique in 10 cases using a 4.85F needle and have demonstrated that it is feasible and efficacious in selected cases of nephrolithiasis.6 Thereafter, Piskin and associates used this method for both renal (n = 9) and bladder (n = 2) stones successfully.7 To the best of our knowledge, there is no data in the literature about the use of the microperc technique for bladder stones except for the two patients in the Piskin et al. study. We present our experience with micropercutaneous cystolithotripsy (mPCCL) using the transillumination access
Department of Urology, Dicle University, Faculty of Medicine, Diyarbakır, Turkey.
693
694
technique in children with bladder stones. In this study, we evaluate the safety and efficacy of this procedure in children. The present study is the first original manuscript of a pediatric series that reports results of percutaneous microperc treatment in bladder stones. Patients and Methods
Twelve children who underwent mPCCL for the removal of bladder stones in our department between January 2011 and September 2013 were included in this study. This is a prospective study and was approved by the Ethical Committee of Dicle University’s medical faculty in Diyarbakır, Turkey. We included pediatric patients with all type of stones in any diameter during this period; however, we excluded patients with augmentation cystoplasty, urethral abnormality (e.g., exstrophy or spina bifida, status postoperative bladder neck reconstruction), or presence of a foreign body. The mean age of the patients was 2.6 (1–7) years. One patient was a girl. Ten children had a solitary stone while the remaining two patients had two and four bladder stones, respectively. The mean stone size was 14 mm (7–32 mm). The stone was located in the urethra in three patients who had presented with urinary retention. When the stone was located in the bladder, the most common presenting complaints included dysuria and/or frequency, intermittent and painful voiding, and/or hematuria. The stone diameter was estimated by measuring the largest diameter using plain radiography or ultrasonography. The upper urinary tract and urethra were evaluated in all patients for the presence of another stone using ultrasonography. Patients with an absence of stone fragments on plain radiographs or ultrasound were considered stone free. Preoperatively, a urine culture was performed in all patients and, if needed, antibiotic therapy was administered. The following were recorded for the study: chief complaints; age and sex of the patients; stone characteristics, such as size, number, and location of the stones; and characteristics of the procedure, including operative time, complications, and the stone-free rate. The stone composition as determined by radiography diffraction analysis was also recorded.8
BODAKCI ET AL. Percutaneous access to the bladder using the transillumination technique
The operating room lights were dimmed, and the distal tip of the cystoscope, which has its own light source, was brought to the center of the bladder and advanced toward the anterior wall of the bladder. Because the suprapubic fat tissue is thin in the pediatric age group, the border of the bladder was outlined by light from the cystoscope. This is called as positive transillumination (Fig. 1). When the cystoscope was moved toward the lateral walls of the bladder, big vessels such as arteria/vena epigastrica inferior can be seen (Fig. 2). Thus, we were easily able to determine where to puncture the full bladder so as to avoid the vascular region. A 2- to 3-mm vertical incision was made 1 or 2 cm above the pubic bone. The bladder was punctured with a 14-gauge angiocath needle (Fig. 3), as described by Penbegul and associates, for percutaneous renal access.11 The cytoscope was used to visualize the needle entering the bladder cavity and, simultaneously, urine or saline could be seen through the angiocath needle (Fig. 3). Stone fragmentation
After percutaneous access to the bladder, the 4.5F microperc system (PolyDiagnost, Pfaffenhofen, Germany) was inserted through the angiocath sheath. There is a three-way connector at the proximal part of the sheath in order to connect laser probe, scope, and irrigation. Visualization of the bladder cavity was made by a semirigid microfiber scope 0.9–
Transillumination
Transillumination is the transmission of light through tissues in the body. This technique is often used by urologists to diagnose scrotal pathologies such as a hydrocele.9 When the light energy penetrates the tissue it has different colors depending on the density and physical properties of the tissue. For example, muscle and fatty tissue is generally reflected back as an orange color while vessels are reflected back as dark purple or black. Due to this difference in color it is easy to locate veins and other tissues using this technique.10 Surgical Procedure
Initially, cystourethroscopy was performed in all cases in the lithotomy position under general anesthesia to exclude any infravesical obstruction (urethral valve or stricture) and to push a urethral stone back into the bladder. Then, using the cystourethroscopy instruments, the bladder is filled to capacity with normal saline.
FIG. 1. Using the transillumination technique, the border of the bladder can be seen easily by the light of the cystoscope.
TRANSILLUMINATION TECHNIQUE IN PEDIATRIC CASES
FIG. 2. Anterior abdominal vessels, such as the a./v. (arteria/vena) epigastrica inferior, are seen using the transillumination technique. 0.6 mm in diameter with integrated light lead (Fig. 4). After positioning the stone it was fragmented by a 276-lumen holmium:YAG laser (8 Hz [6,4 W] 0,8 J) under direct vision at a diameter
Transurethral and Lower Tract Procedures
Micropercutaneous Cystolithotomy in Children: Our Experience with the Transillumination Technique ˘ Mehmet Nuri Bodakci, MD, Ahmet Ali Sancaktutar, MD, Mansur Daggulli, MD, Namık Kemal Hatipoglu, MD, Haluk So¨ylemez, MD, Necmettin Penbegul, MD, Murat Atar, MD, and Yasar Bozkurt, MD
Abstract
Aim: We present our experience with micropercutaneous cystolithotripsy (mPCCL) using transilluminationguided access in children with bladder stones and evaluate the safety and efficacy of this procedure. Methods: Twelve children who underwent mPCCL for bladder stone removal in our department between January 2011 and September 2013 were included in this study. Percutaneous access was performed using the transillumination technique. The chief complaint, age and sex of the patients, stone size, operative time, complications, stone-free rate, and stone composition as determined by radiography diffraction analysis were recorded. Results: The mean age of the patients was 2.6 (1–7) years. One out of 12 patients was a girl. The mean stone size was 14 mm (7–32 mm). The mean mPCCL procedure time was 38.7 (15–65) minutes. The mean hospital stay was 1.4 (0.5–4) days. The stone-free rate after one mPCCL intervention was 91.6% and increased to 100% after two sessions of mPCCL. The notable complications were transient macroscopic hematuria in one patient, acute urinary retention in one patient, and the need for a second session of mPCCL in another patient. The stones were composed of calcium oxalate (3), ammonium acid urate (1), calcium phosphate (1), cystine (1), struvite (1), and unknown (5). Conclusion: Transillumination-guided mPCCL is a safe and effective technique, does not require the use of ionizing radiation, is technically easy, and is a minimally invasive alternative for the management of bladder stones. It has many advantages, especially in pediatric patients, such as decreased urethral injury, no need for postoperative catheter insertion in most cases, and shorter operative time.
Introduction
I
n developed countries, bladder stones are rare in adults and most commonly associated with bladder outlet obstruction, the presence of an intravesicular foreign body, or chronic infection.1 They can occur during childhood and may be caused by a protein-poor diet, particularly in developing countries, or may have the same etiologic factors as adult cystolithiasis.2 It is well known, however, that the etiology of bladder stones in the pediatric age group is complex and often multifactorial. It may be influenced by genetic or metabolic diseases and other environmental factors and hence has a high risk of recurrence.3 Therefore, appropriate treatment methods should be selected for this age group. Open cystolithotomy, transurethral cystolithotripsy (CL), shockwave lithotripsy (SWL), and percutaneous cystolithotripsy (PCCL) are used for the treatment of pediatric bladder stones. Open procedures should be the last line of treatment for pediatric cystolithiasis. Transurethral CL should be done more carefully in boys due to smaller urethral diameters and
associated concerns about iatrogenic urethral stricture. This risk is inversely related to the age of the child. For larger bladder stones, PCCL is a safe alternative with low morbidity and complication rates.4 The ‘‘all-seeing needle,’’ an optical system inside a special puncture needle, has recently demonstrated optimal renal access during percutaneous renal procedures5; however, this system may only be useful for gaining initial access. This optical system has been used for ‘‘microperc,’’ a single-step percutaneous nephrolithotomy performed with the all-seeing needle. Desai and colleagues have successfully performed this new technique in 10 cases using a 4.85F needle and have demonstrated that it is feasible and efficacious in selected cases of nephrolithiasis.6 Thereafter, Piskin and associates used this method for both renal (n = 9) and bladder (n = 2) stones successfully.7 To the best of our knowledge, there is no data in the literature about the use of the microperc technique for bladder stones except for the two patients in the Piskin et al. study. We present our experience with micropercutaneous cystolithotripsy (mPCCL) using the transillumination access
Department of Urology, Dicle University, Faculty of Medicine, Diyarbakır, Turkey.
693
694
technique in children with bladder stones. In this study, we evaluate the safety and efficacy of this procedure in children. The present study is the first original manuscript of a pediatric series that reports results of percutaneous microperc treatment in bladder stones. Patients and Methods
Twelve children who underwent mPCCL for the removal of bladder stones in our department between January 2011 and September 2013 were included in this study. This is a prospective study and was approved by the Ethical Committee of Dicle University’s medical faculty in Diyarbakır, Turkey. We included pediatric patients with all type of stones in any diameter during this period; however, we excluded patients with augmentation cystoplasty, urethral abnormality (e.g., exstrophy or spina bifida, status postoperative bladder neck reconstruction), or presence of a foreign body. The mean age of the patients was 2.6 (1–7) years. One patient was a girl. Ten children had a solitary stone while the remaining two patients had two and four bladder stones, respectively. The mean stone size was 14 mm (7–32 mm). The stone was located in the urethra in three patients who had presented with urinary retention. When the stone was located in the bladder, the most common presenting complaints included dysuria and/or frequency, intermittent and painful voiding, and/or hematuria. The stone diameter was estimated by measuring the largest diameter using plain radiography or ultrasonography. The upper urinary tract and urethra were evaluated in all patients for the presence of another stone using ultrasonography. Patients with an absence of stone fragments on plain radiographs or ultrasound were considered stone free. Preoperatively, a urine culture was performed in all patients and, if needed, antibiotic therapy was administered. The following were recorded for the study: chief complaints; age and sex of the patients; stone characteristics, such as size, number, and location of the stones; and characteristics of the procedure, including operative time, complications, and the stone-free rate. The stone composition as determined by radiography diffraction analysis was also recorded.8
BODAKCI ET AL. Percutaneous access to the bladder using the transillumination technique
The operating room lights were dimmed, and the distal tip of the cystoscope, which has its own light source, was brought to the center of the bladder and advanced toward the anterior wall of the bladder. Because the suprapubic fat tissue is thin in the pediatric age group, the border of the bladder was outlined by light from the cystoscope. This is called as positive transillumination (Fig. 1). When the cystoscope was moved toward the lateral walls of the bladder, big vessels such as arteria/vena epigastrica inferior can be seen (Fig. 2). Thus, we were easily able to determine where to puncture the full bladder so as to avoid the vascular region. A 2- to 3-mm vertical incision was made 1 or 2 cm above the pubic bone. The bladder was punctured with a 14-gauge angiocath needle (Fig. 3), as described by Penbegul and associates, for percutaneous renal access.11 The cytoscope was used to visualize the needle entering the bladder cavity and, simultaneously, urine or saline could be seen through the angiocath needle (Fig. 3). Stone fragmentation
After percutaneous access to the bladder, the 4.5F microperc system (PolyDiagnost, Pfaffenhofen, Germany) was inserted through the angiocath sheath. There is a three-way connector at the proximal part of the sheath in order to connect laser probe, scope, and irrigation. Visualization of the bladder cavity was made by a semirigid microfiber scope 0.9–
Transillumination
Transillumination is the transmission of light through tissues in the body. This technique is often used by urologists to diagnose scrotal pathologies such as a hydrocele.9 When the light energy penetrates the tissue it has different colors depending on the density and physical properties of the tissue. For example, muscle and fatty tissue is generally reflected back as an orange color while vessels are reflected back as dark purple or black. Due to this difference in color it is easy to locate veins and other tissues using this technique.10 Surgical Procedure
Initially, cystourethroscopy was performed in all cases in the lithotomy position under general anesthesia to exclude any infravesical obstruction (urethral valve or stricture) and to push a urethral stone back into the bladder. Then, using the cystourethroscopy instruments, the bladder is filled to capacity with normal saline.
FIG. 1. Using the transillumination technique, the border of the bladder can be seen easily by the light of the cystoscope.
TRANSILLUMINATION TECHNIQUE IN PEDIATRIC CASES
FIG. 2. Anterior abdominal vessels, such as the a./v. (arteria/vena) epigastrica inferior, are seen using the transillumination technique. 0.6 mm in diameter with integrated light lead (Fig. 4). After positioning the stone it was fragmented by a 276-lumen holmium:YAG laser (8 Hz [6,4 W] 0,8 J) under direct vision at a diameter
