Vol. 118, July, Part 1 Printed in U.SA.
THE JOURNAL OF UROLOGY
Copyright© 1977 by The Williams & Wilkins Co.
Pediatric Articles STAGHORN CALCULI IN CHILDREN FRANCIS F. BARTONE*
AND
J. H. JOHNSTON
From the Alder Hey Children's Hospital, Liverpool, England
ABSTRACT
Nineteen children who underwent extensive nephrotomies and anatrophic nephrotomies for staghorn calculi (bilateral in 4 cases) are presented. Proteus infection was the cause of the calculus in most cases. In the absence of recurrent stones, renal growth and function were excellent postoperatively. Stone recurrence was minimal if all calculi were removed and infection was controlled. Followup ranged from a few months to 13 years. Staghorn calculi, those stones that occupy a major portion of the renal pelvis and invade at least 2 major calices, are uncommon in children. There have been few reports of children with staghorn calculi treated by extensive nephrotomy. 1- 3 Herein we describe 19 children who underwent nephrotomy for staghorn calculi.
Blood pressures were recorded preoperatively in 17 cases and were normal in 16. One child had 1 or 2 readings with a diastolic of 90 mm. Hg. SURGICAL TECHNIQUE
In all cases extensive longitudinal nephrotomies were done to extract the calculi, that is an incision in the kidney parenchyma extending for at least 2 consecutive major calices in the frontal plane. The modification of anatrophic nephrotomy was used in 3 kidneys in 2 patients. In no instance was hypothermia used nor was mannitol infused. The renal pedicle was occluded completely in all instances except in those cases in which anatrophic nephrotomy was performed and the artery only was clamped. In 2 of the latter cases methylene blue was injected intravenously after occluding the posterior branch of the renal artery to delineate the proper plane as described by Glenn. 4 In 1 case the plane was found without the use of dye. (The recommended dose is 2 mg. per kg. in 1 bolus or 50 mg. per M. 2 ) 5 In young children the small size of the structures makes it difficult to enter the plane just anterior to the posterior calices but with patience it can be found.fi Calirrhaphy or calicoplasty was not necessary in any case since there were no instances of infundibular obstruction. X-rays were obtained intraoperatively in all patients to ensure that there were no residual stone fragments.
MATERIALS AND METHODS
There were 14 boys and 5 girls, ranging in age from 1 to 13 years. Of these children 14 were less than 6 years old. Four children underwent bilateral operations; hence, 23 kidneys were observed. Six patients were followed less than 2 years, 9 were followed more than 4 years, 1 was followed for 13 years and 1 was lost to followup. Only 4 children had urinary obstruction, which may have contributed to the formation of calculi. Three patients had neurogenic bladders secondary to myelomeningocele and 1 had a heavily trabeculated bladder of uncertain causation but no upper tract dilatation. One boy had a contralateral duplicated collecting system with hydronephrosis of the lower moiety. He underwent excision of this system after nephrolithotomy. Several children had mild bilateral hydronephrosis, which cleared subsequent to the nephrotomy and cure of infection. Biochemical investigation, including studies of blood and urine for calcium and phosphorous content and amino-aciduria, were all unrewarding. One patient had an abnormal hourly calcium excretion on 1 occasion, although the 24-hour level was normal. One child had defective urinary acidification but no other stigmas of renal tubular acidosis. It seems likely that the tubular defect was the result of parenchymal damage caused by the stones and infection, and was not a primary condition. The only common denominator indicated was urinary infection. Of the 19 children 18 had infected urine, including a Proteus organism being present in pure or mixed cultures in 16 cases, Escherichia coli in 2 and mixed infection in 1. The composition of the calculi was magnesium calcium ammonium phosphate in the majority of instances. The symptoms exhibited by these children varied but generally were those of upper tract infection. It was interesting that in 2 cases the calculi were diagnosed serendipitously.
RESULTS
One residual calculus and 2 recurrences were noted in 3 children and secondary nephrectomies were performed. The recurrences were true recurrences since x-rays immediately postoperatively had not revealed residual calculi. TABLE
1. Preoperative kidney size differences
Treatment
Control
9.4 7.5 9.8 8.0 9.0 12.5 12.5 Sums 68.7 Means 9.81
9.3 9.0 10.0 9.0 9.0 11.1 12.8 70.2 10.03
Spread (Paired)
Accepted for publication September 17, 1976. *Requests for reprints: Department of Urology, University of Nebraska Medical Center, 42nd and Dewey Ave., Omaha, Nebraska
(
THE JOURNAL OF UROLOGY
Copyright© 1977 by The Williams & Wilkins Co.
Pediatric Articles STAGHORN CALCULI IN CHILDREN FRANCIS F. BARTONE*
AND
J. H. JOHNSTON
From the Alder Hey Children's Hospital, Liverpool, England
ABSTRACT
Nineteen children who underwent extensive nephrotomies and anatrophic nephrotomies for staghorn calculi (bilateral in 4 cases) are presented. Proteus infection was the cause of the calculus in most cases. In the absence of recurrent stones, renal growth and function were excellent postoperatively. Stone recurrence was minimal if all calculi were removed and infection was controlled. Followup ranged from a few months to 13 years. Staghorn calculi, those stones that occupy a major portion of the renal pelvis and invade at least 2 major calices, are uncommon in children. There have been few reports of children with staghorn calculi treated by extensive nephrotomy. 1- 3 Herein we describe 19 children who underwent nephrotomy for staghorn calculi.
Blood pressures were recorded preoperatively in 17 cases and were normal in 16. One child had 1 or 2 readings with a diastolic of 90 mm. Hg. SURGICAL TECHNIQUE
In all cases extensive longitudinal nephrotomies were done to extract the calculi, that is an incision in the kidney parenchyma extending for at least 2 consecutive major calices in the frontal plane. The modification of anatrophic nephrotomy was used in 3 kidneys in 2 patients. In no instance was hypothermia used nor was mannitol infused. The renal pedicle was occluded completely in all instances except in those cases in which anatrophic nephrotomy was performed and the artery only was clamped. In 2 of the latter cases methylene blue was injected intravenously after occluding the posterior branch of the renal artery to delineate the proper plane as described by Glenn. 4 In 1 case the plane was found without the use of dye. (The recommended dose is 2 mg. per kg. in 1 bolus or 50 mg. per M. 2 ) 5 In young children the small size of the structures makes it difficult to enter the plane just anterior to the posterior calices but with patience it can be found.fi Calirrhaphy or calicoplasty was not necessary in any case since there were no instances of infundibular obstruction. X-rays were obtained intraoperatively in all patients to ensure that there were no residual stone fragments.
MATERIALS AND METHODS
There were 14 boys and 5 girls, ranging in age from 1 to 13 years. Of these children 14 were less than 6 years old. Four children underwent bilateral operations; hence, 23 kidneys were observed. Six patients were followed less than 2 years, 9 were followed more than 4 years, 1 was followed for 13 years and 1 was lost to followup. Only 4 children had urinary obstruction, which may have contributed to the formation of calculi. Three patients had neurogenic bladders secondary to myelomeningocele and 1 had a heavily trabeculated bladder of uncertain causation but no upper tract dilatation. One boy had a contralateral duplicated collecting system with hydronephrosis of the lower moiety. He underwent excision of this system after nephrolithotomy. Several children had mild bilateral hydronephrosis, which cleared subsequent to the nephrotomy and cure of infection. Biochemical investigation, including studies of blood and urine for calcium and phosphorous content and amino-aciduria, were all unrewarding. One patient had an abnormal hourly calcium excretion on 1 occasion, although the 24-hour level was normal. One child had defective urinary acidification but no other stigmas of renal tubular acidosis. It seems likely that the tubular defect was the result of parenchymal damage caused by the stones and infection, and was not a primary condition. The only common denominator indicated was urinary infection. Of the 19 children 18 had infected urine, including a Proteus organism being present in pure or mixed cultures in 16 cases, Escherichia coli in 2 and mixed infection in 1. The composition of the calculi was magnesium calcium ammonium phosphate in the majority of instances. The symptoms exhibited by these children varied but generally were those of upper tract infection. It was interesting that in 2 cases the calculi were diagnosed serendipitously.
RESULTS
One residual calculus and 2 recurrences were noted in 3 children and secondary nephrectomies were performed. The recurrences were true recurrences since x-rays immediately postoperatively had not revealed residual calculi. TABLE
1. Preoperative kidney size differences
Treatment
Control
9.4 7.5 9.8 8.0 9.0 12.5 12.5 Sums 68.7 Means 9.81
9.3 9.0 10.0 9.0 9.0 11.1 12.8 70.2 10.03
Spread (Paired)
Accepted for publication September 17, 1976. *Requests for reprints: Department of Urology, University of Nebraska Medical Center, 42nd and Dewey Ave., Omaha, Nebraska
(
