Bilateral renal pelvic stone with bilateral HN

3 years male child presented with vague abdominal pain and haematuria. 

No vomiting,  no fever. 
Counts,  creatinine normal. 
Attaching USG and IVP images for review. 
Please discuss treatment options. 
And both the side at a time or one by one? 

Bilateral renal pelvic stone with bilateral HN Bilateral renal pelvic stone with bilateral HN Bilateral renal pelvic stone with bilateral HN Bilateral renal pelvic stone with bilateral HN


  • Ramesh Babu
    Ramesh Babu
    01 May 2020 08:02:14 AM

    Most likely its a metabolic issue. Needs workup later.

    I would do one side at a time. PCNL in stages. (Bigger side- stag one may opt for open surgery also)

  • Dr. Anil Takvani
    Dr. Anil Takvani
    01 May 2020 08:08:40 AM

    Thanks Sir. 

    Can you please explain staged? 
    You mean to say first PCN and than PCNL? 
    Which side you are thinking for open? 
    Can we attempt ESWL,  as results of ESWLaregood in paediatric patients 

    01 May 2020 08:14:09 AM

    Very good case for discussion sir..

    I think pcnl one by one.
    Easier one first as both kidney's look equally functioning and child may not be able to say which is more symptomatic side.
    Some analysis and metabolic work up once stone free is deemed.

  • Ramesh Babu
    Ramesh Babu
    01 May 2020 08:41:12 AM

    A CTKUB would have given more info.

  • Dr. Anil Takvani
    Dr. Anil Takvani
    01 May 2020 08:45:14 AM

    Dr.  Kaushal,  

    Agree we discussed stone analysis and metabolic work up. 
    But because of lockdown,  right now it is not possible as Junagadh has no facilities. 
    What kind of metabolic work up you are proposing? 

  • Jaideep Mahajani
    Jaideep Mahajani
    01 May 2020 08:50:01 AM

    Patient does need metabolic work up, but certainly needs clearance first. 

    Concidering age, I will prefer PCNL in two stage. In first sitting, bilateral PCN; followed by PCNL after 2-3 days. Advantage is, you are reducing chances of bleeding on either side. PCNL in pre existing track becomes very safe and easy.

  • Ravindra Sabnis
    Ravindra Sabnis
    01 May 2020 10:03:35 AM

    X-Ray KUB is not all that clear. Are we talking bilateral PUJ stones? Appear to be smaller size stones on both sides

    Nice case it can generate discussion on several aspects 
    1) Such symptoms & uSG shows - stone at PUJ, thick kidney, normal Cr, what should be next investigations - Whether conventional IVP, whether CT IVP, NCCT. USG & DTPA. 
    2) What could be treatment options - ESWL, PCNL, Observation? 
    3) What metabolic studies to be done - when? 
    My answers are following 
    1) I can avoid doing conventional IVP - it does not pick up several concomitant stones (USG not so sensitive to pic them up) plain KUB is children has problem of gas & can never be as clear to see details. I would prefer NCCT - which will pick up all stones , it will give HU , Low dose NCCT is also adequate enough, which will reduce radiation. 
    2) Treatment options will depend upon - what is size, what is HU. this appears small stobe at PUJ with mod HN on both sides with thick paranchyma. ESWL can be good option in children. if not miniperc/MIPXS will good be option which will clear stone at one go 
    3) Serum parameters of metabolic work should be done at this time only. Often children have high uric acid - if radioluscent stones. High Ca can give suspicious of parathyroid , urine metabolic work can be delayed till stones are cleared. In high uric acid , radioluscent, low HU stones, can be treated with medical therapy. xyluric & mentaining PH of urine alkaline. we have cases where uric acid stones have dissolved completely by such treatment 
    This is only my opinion. Others can share their experience. 

  • Dr. Anil Takvani
    Dr. Anil Takvani
    01 May 2020 11:43:18 AM

    Thanks Sir, 

    Yes we are talking bilateral pelvic stone. 

  • Utsav Shah
    Utsav Shah
    01 May 2020 12:31:31 PM

    Respected Anil Sir,

    As discussed above by stalwarts, NCCT might be a better option. 
    I would like to do metabolic work up - Sr uric acid, Sr calcium, Sr PTH, 24 hour urinary metabolites(which is indicated in children having stones; and especially for this Pt as he has B/L calculi). 

    In this COViD era, I would like to proceed with U/L PCNL on one side(where he is more symptomatic or where I can give better clearance) followed by ESWL on the other side. 
    Role of ESWL shud not be forgotten as it still finds a place in ALL guidelines. 

    Thank you sir. 

  • Pankaj N Maheshwari
    Pankaj N Maheshwari
    01 May 2020 01:07:12 PM

    Very interesting case Anil.

    I would agree on most points mentioned above:
    CT would be better for evaluation but in view of the risks of radiation exposure to the child, i would prefer the low dose CT protocol. Even ultra-low dose CT can be done but that can miss smaller calculi (<3mm). As we would expect this child to have recurrences in his life time, radiation exposure care is vital. 

    Metabolic evaluation is vital and would be based on the stone analysis

    ESWL is a good option in children as fragment clearance in kids is very good but in view of bilateral obstruction, i would not consider ESWL in this child. 

    I would choose Mini-PCNL in this child. I would not do a staged PCNL rather would plan for bilateral single session PCNL. Obviously would tackle the second side only if the first side goes very smooth. Both sides seem to have an easy puncture as system is dilated hence I could choose any side. I may choose left side first as that side stone appears larger of the two sides. Would not place a stent unless absolutely essential. 

    This child would need an advice for regular follow-up once stone free.

  • Chandra Singh J
    Chandra Singh J
    01 May 2020 10:09:58 PM

    In addition to the above, extensive counseling of the parents is vital, in view of the high likelihood of recurrence. I assume the stone is not satisfactorily radio-opaque, for assessing response to ESWL. So my choice will be a mini PCNL after CT, one side at a time. Which side first will depend upon the CT.

  • Dr. Anil Takvani
    Dr. Anil Takvani
    02 May 2020 07:39:46 AM

    On both the sides stone seen very clearly in C arm.  

    As anaesthesia requires for ESWL, why not ESWL in situ or after stenting on right side first as in 45 minutes image contrast is not filled up in right ureter?
    Left can be delt little later seeing response on right side.

  • Ramesh Babu
    Ramesh Babu
    02 May 2020 09:41:32 AM

    ESWL is likely to need more than one sitting. In children that means several GAs with risks and cognitive development issues of mutiple GAs in a kid.  

    PCNL may clear all in one go. But CT is preferable to decide which side first

    Larger bulk PCNL (stent both sides) after a few wks tackle otherside (dont stent this time). Thats just two GAs

  • Dr. Isteaq Shameem
    Dr. Isteaq Shameem
    02 May 2020 04:22:06 PM

    Dr Isteaq Shameem

    Low dose NCCT should be preferred as rightly pointed out by Prof Sabnis sir. IVU in children is not always clear due to bowel gas. Depending upon stone size and HU ESWL/PCNL in two separate sittings can be done. One should not forget the role of ESWL especially in Children. Ureteral accomodating capacity in children is amazing following ESWL even in bigger stone
    One should also take account of recurrence since child is only 3 yrs old
    Regarding Metabolic evaluation stone analysis and other classical investigations should follow after stone clearance
    Thank you all

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