Left renal pelvic stone with HN -2 YEARS FEMALE CHILD

2 years female child presented with vague abdominal pain and haematuria. 

No other complains. 
Urine,  RFT normal 
USG : 8 mm stone in renal pelvis  with mild HN. 
Attaching x Ray KUB. 
Kindly discuss :
How to investigate further? 
Is there is any need for further investigations? 
How to minimize radiation exposure? 
Treatment options? 

Left renal pelvic stone with HN -2 YEARS FEMALE CHILD


  • Tikenjit Mazumdar
    Tikenjit Mazumdar
    04 May 2020 02:08:23 PM

    Sir...in this case stone seems to b in pelvis..

    Investigation... IVU single plate.why I will not do?
    Though can give me information about stone and collect ing system and some functional information.in some low radition..it's will not give me HU units n extrenal kidney information.
    NCCT plus CECT..why I want this?
    It will provide me all above information with good constast of tissue.. though a bit more radiation..
    Intervention...for this 8 mm stone by decision will depend on collection ing system anatomy and HU units..
    If by hu unit it's soft stone  n favorable anatomy..my  preference will be as follows.Having said that final decision will be in consultation with parents..
    1.ESWL under GA... why? Minimal invasion.Good results in children.
    Why not? Sfr is less.needs GA..chance of pain n infection..may need axillary procedure
    2.mini pcnl...why? Very good sfr..
    Why not? Morbid procedure.. bleeding chance..Need GA
    3.RIRS...why?better sfr then eswl...stone removal through natural orifice...
    Why not?... pediatric ureter r small,not easy to pass scope.. sfr less then pcnl,n child pass small sand like fragments thought urethra..increas chance of infection due to high pressure in kidny during procedure..
    Sir correct me if I'm wrong..

  • Pankaj N Maheshwari
    Pankaj N Maheshwari
    04 May 2020 06:33:34 PM

    Issue: small calculus, not very dense, in renal pelvis

    1. Limited film IVU (documentation of anatomy & function)
    2. Urine culture
    3. Basic metabolic evaluation
    Plan of treatment: ESWL
    Would explain to parents about the options of RIRS & mini-Perc
    In view of minimally invasive ESWL and a very good possibility of stone clearance in this situation, would help them in deciding ESWL.
    Post treatment:
    1. Instruct the parents to look at urine in the diaper and try to collect fragments
    2. Look for pain or fever
    3. USG after two weeks
    On follow-up
    Treatment based on metabolic evaluation and stone analysis
    Document complete stone free status by USG at two weeks and three months.
    Document sterile urine after treatment at one month.
    Instruct parents about the risk of recurrence and need for follow-up

  • Prabir Basu
    Prabir Basu
    04 May 2020 11:33:40 PM

    Dr Pankaj Maheshwari sir , it will be very helpful if you can kindly describe the tips and tricks of doing a rirs in a such pediatric case.


  • Utsav Shah
    Utsav Shah
    05 May 2020 12:15:49 PM

    Respected Sir,

    As Pankaj sir has suggested I would prefer ESWL in this case. It might require anesthesia; however the stone is very small to justify puncturing the kidney so PCNL is ruled out. 

    However RIRS remains an option. But it needs to be prestented. Plus the technicality and expertise remain a challenge for a novice like me. 

    Hence I would prefer ESWL. 

  • Pankaj N Maheshwari
    Pankaj N Maheshwari
    05 May 2020 07:26:52 PM

    Dear Dr Basu,

    As far as the technique of RIRS in kids is concerned, it is no different than in adults. Yes, in view of the miniature anatomy and the potential risks of VUR (0-8%) and ureteral injury or stricture (about 2%) special care is needed. 

    Before procedure: document sterile urine or treat infection. 

    I give prophylactic antibiotic and continue antibiotics for about 48 hours post-op

    Pre-stenting is needed in most children.

    Place a 9.5/11.5Fr access sheath, 20-35 cm length. Long access sheath would make procedure difficult. Placement of access sheath is possible in most patients except very small kids

    Rest of the procedure standard.

    Avoid pressurized irrigation, gravity irrigation preferred. 

    DJ & PUC at the end of procedure.

    Do not exceed the time beyond 40 min of procedure time.

    My issue is where to place RIRS in day-to-day practice in kids. No treatment is without complications. ESWL is safe but has been known to cause acute injury to parenchyma and adjacent tissues. There is transient tubular dysfunction so a minimum spacing of two weeks is justified. Also all sessions of ESWL would need anaesthesia. 

    Mini-PCNL caries risk of parenchymal injury and bleeding. 

  • Prabir Basu
    Prabir Basu
    06 May 2020 04:48:04 AM

    Thank you sir.

  • Ravindra Sabnis
    Ravindra Sabnis
    07 May 2020 06:39:46 PM

    This is faintly radio opaque stone. Very likely of low HU stone. In 2 yrs old child, we have seen many times hyper uricosuria. Often we tend to see only pus cells & RBC in urine but do not pay attention to pH. if high uric acid with acidic pH, & vague symptoms - just mild tinge of blood stained urine - then this child can be candidate for medical dessolution. Just by making PH alkaline & bring uric acid normal, we have seen stone getting completely dissolved. 

    SO apart from all options discussed, this option can be kept in mind. 
    Dr. Takwani can give feedback. 

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