Minimal access surgery in the management of pediatric urolithiasis

Purpose: In contrast to adult patients, a relatively large number of open surgical procedures are still needed in the treatment of urolithiasis in children. Since almost all open surgical techniques may be reproduced by minimal access surgery (MAS), there is a rationale to apply the latter in the management of pediatric urolithiasis. Our study aimed to assess the feasibility and outcome of MAS in the treatment of pediatric urinary calculi. Materials and methods: The charts of patients with urolithiasis submitted to MAS between 1994 and 2007 were retrospectively reviewed. The inclusion criteria were contraindication for and failure of lithotripsy or endourology techniques. Demographic data, lithiasis characterization (location, dimension, composition), predisposing factors (anatomic or metabolic) and surgical approach (technique and outcome) were evaluated. Results: Fifteen consecutive patients (eight girls, seven boys) with a median age of 108 months (range: 10e297) were elected for MAS. Eleven (73%) children had associated urogenital malformations and three (20%) presented metabolic abnormalities. A total of 17 procedures were performed laparoscopically: three nephrolithotomies (one transperitoneal, two by retroperitoneoscopy), four pyelolithotomies (retro), three ureterolithotomies (trans) and seven cystolithotomies (suprapubic approach). Five patients underwent concomitant correction of urological anomalies (three calyceal diverticula, one obstructive megaureter, one ureteropelvic junction obstruction). Complete removal of calculi was accomplished in 14 (82%) procedures. There were two perioperative complications (one intraperitoneal vesical perforation and one perivesical urinoma). At a median follow up of 4 years (range: 1 month to 11 years), four patients have developed recurrence. Conclusions: Minimal access surgery is an effective and safe approach for urolithiasis in children who are not candidates for minimally invasive modalities. Individualized application of different techniques may solve virtually all cases. In selected cases, the role of MAS as firstchoice therapy deserves consideration.