Percutaneous suprapubic cystolithotripsy for vesical calculi in children.

BACKGROUND: The majority of vesical calculi in adults can now be treated per-urethrally with the use of ultrasonic or pneumatic lithotripsy. However, the use of these devices is restricted in pediatric patients by the narrow caliber of the urethra. A percutaneous suprapubic approach to the bladder circumvents the problem of urethral caliber in these situations. PATIENTS AND METHODS: Thirty-eight children presenting with bladder stones underwent percutaneous suprapubic cystolithotripsy (PCCL) between November 1989 and April 1996. The age ranged from 1.5 to 7 years. The stone size ranged from 0.8 to 2.4 cm. Seven of these were recurrent stones, and five of the patients were female. The procedure was done under general anesthesia, and the equipment was the same as for upper tract endourology. The bladder was distended with saline and a suprapubic puncture made. The nephroscope was introduced after tract dilation and the stone removed, intact if small or after fragmentation if >1 cm. The procedure was done without fluoroscopy. A suprapubic catheter was left in for 48 hours. RESULTS: All patients had an uneventful recovery following stone removal. The average hospital stage was 3 days. Here, the access provided by percutaneous suprapubic cystostomy has been combined with the experience gained in upper-tract endourology to perform procedures that would otherwise require open operation because of nonavailability of urethral access. CONCLUSION: Extension of endourologic procedures to the lower tract reduces morbidity and hospital stay and thus the cost of treatment. Percutaneous suprapubic cystolithotripsy, in our experience, is a safe and cost-effective alternative to open surgery in children.

Endourological renal salvage in patients with calculus nephropathy and advanced uraemia.

OBJECTIVE: To document our experience with percutaneous nephrolithotripsy (PCNL) for the treatment of calculus nephropathy and advanced renal failure. PATIENTS AND METHODS: Between October 1989 and April 1996, 78 patients with calculus nephropathy (51 males and 27 females, mean age 42 years, range 16-67; mean serum creatinine level 663.8 micromol/L, range 282.8-1449.7) were treated in our department. Forty-six of the patients had bilateral upper urinary calculi, while the remaining 32 had a solitary functioning kidney obstructed by stone. Thirty-two patients had a normal urine output, 26 were oliguric and 20 presented with anuria. A preliminary percutaneous nephrostomy (PCN) was performed under local anaesthesia in 64 patients, and stone retrieved subsequently through the same nephrostomy track after improvement in their uraemic status. In the remaining 14 patients, the stones were removed at the first session. Of the 46 patients with bilateral stones, 21 underwent stone retrieval by PCNL on the contralateral side after an interval of 2-3 weeks, while 25 patients underwent simultaneous JJ stenting on the contralateral side, followed, after improvement in uraemic status, by delayed PCNL or extracorporeal shock wave lithotripsy on that side. RESULTS: There were three deaths, caused by overwhelming sepsis; 64 of the remaining 75 patients recovered well from uraemia, while 11 showed no improvement, suggesting irreversible renal damage. Complications included five patients with nonfatal sepsis and five with secondary haemorrhage. At the last follow-up 2.5-9 years after presentation, the mean serum creatinine level (271.3 micromol/L) was significantly better than the mean preoperative level. Six patients are on maintenance haemodialysis. CONCLUSIONS: It is not uncommon in developing countries for patients with urolithiasis to present with advanced uraemia caused by long-standing obstruction, almost invariably complicated by infection. A percutaneous endourological approach offers the best hope for these patients, and in our experience a significant percentage of these cases can be salvaged.

Dorsal free graft urethroplasty for urethral stricture by ventral sagittal urethrotomy approach.

OBJECTIVES: To explore the feasibility of applying a dorsal free graft to treat urethral stricture by the ventral sagittal urethrotomy approach without mobilizing the urethra. METHODS: Twelve patients with long or multiple strictures of the anterior urethra were treated by a dorsal free full-thickness preputial or buccal mucosa graft. The urethra was not separated from the corporal bodies and was opened in the midline over the stricture. The floor of the urethra was incised, and an elliptical raw area was created over the tunica on which a free full-thickness graft of preputial or buccal mucosa was secured. The urethra was retubularized in one stage. RESULTS: After a follow-up of 8 to 40 months, one recurrence developed and required dilation. CONCLUSIONS: The ventral sagittal urethrotomy approach for dorsal free graft urethroplasty is not only feasible and successful, but is easy to perform.